Psychiatric Contact Research Articles

Antidepressant Treatment Outcomes of Psychogenic Movement Disorder

Psychogenic movement disorder (PMD) is a subtype of conversion disorder. We describe the outcomes of a series of PMD patients following antidepressant treatment. Twenty-three outpatients with chronic PMD, diagnosed using Fahn and Williams' criteria, underwent psychiatric assessment. The patients were referred for assessment and management from January 2003 to July 2004. Fifteen agreed to be treated with antidepressants. Patients received citalopram or paroxetine; those who did not respond after 4 weeks of taking an optimal dose were switched to venlafaxine. Concurrently, 3 had supportive psychotherapy, and 1 had family intervention. Assessments included the DSM-IV-based Mini-International Neuropsychiatric Interview and scales measuring depression, anxiety, and motor and global severity. Eighteen patients (78%) had at least 1 Axis I diagnosis in addition to the somatoform diagnosis, and 3 (13%) had somatization disorder. Five (22%) had previous psychiatric contact. Nine (39%) had previously been treated with antidepressants, but only 4 (17%) had adequate trials. No significant differences existed in patient characteristics between treated and untreated groups. Among treated patients, Montgomery-Asberg Depression Rating Scale scores improved from baseline (p < .01). Two treated subgroups were identified: 10 patients (67%) had primary conversion disorder, of whom 8 had marked motor and global improvements with 7 complete remissions, and 5 (33%) had primary hypochondriasis, somatization disorder, or probable factitious disorder/malingering, of whom none improved. All of the patients with primary conversion disorder had a current or previous depressive or anxiety disorder compared with 40% (N = 2) of the patients with additional somatoform diagnoses. Our preliminary findings suggest that chronic PMD with primary conversion symptoms and with recent or current depression or anxiety may respond to antidepressants. Further well-designed studies, now under way, are required to confirm these findings.

High-Risk-Kinder für Schizophrenie eine Übersicht

Since the early 1950s high-risk studies have systematically investigated the offspring of schizophrenics. The majority of high-risk children had schizophrenic mothers, to a lesser degree schizophrenic fathers and even more seldom schizophrenic siblings. Family studies revealed that disturbances from the so called spectrum - also play a role for the genetic proliferation of schizophrenic diseases. High-risk studies must be carefully planned for an extremely long future. Schizophrenic mothers are difficult co-workers. The drop-out rate is high. Scientists investigating healthy children are confronted with criticism from the public. Last but not least after many years of follow-up one wishes to have taken into consideration scientific means that were not available at the beginning of the study. Notwithstanding these hardships high-risk studies at various centres all over the world have meanwhile been going on for several decades, the former children have become grown-ups, have reached and passed the critical age for schizophrenia outbreak and a vast amount of data have been collected and contribute to our knowledge of the disease. Already at a very young age high-risk children of schizophrenia differ in many aspects from their low-risk peers: physically, mentally, behaviourally and in the ways they are being brought up. They are underweight, show physical abnormalities, reach important developmental stages later in life, are inclined to isolate themselves, are more depressed, have worse school-careers, show more forensic problems and have an early history of psychiatric contacts. Terms like pandevelopmental retardation or pandysmaturation have become common to describe the problem. - Growing up with a schizophrenic mother has many disadvantages for these children. Schizophrenic mothers are often socially marginalised, they show less empathy, understanding and spontaneity, their educational style has been described as poorer, the family climate is chaotic, neglect and physical abuse are not infrequent. High-risk children have a tendency to make themselves invisible. - Among the high-risk population one does also find children that are especially gifted, talented and creative, with rich fantasies and later on successful as adults. Much is known about risk factors that eventually might lead to the outbreak of the disease, though many of them being unspecific: all irregularities, disturbances and problems during pregnancy, birth and childhood have a positive correlation with later schizophrenia, the earlier they happen and the more severe they are, the greater the risk. Traumata during the 6th gestational month seem to bear most unfortunate consequences. -Cultural, social and familial factors have also some impact on later schizophrenia. Father's age over 55 at the time the children are born is considered unfortunate, such as an early outbreak of mother's disease, cannabis-abuse of the mother and a mother's body-mass index of over 30. Families with a high level of disturbed communication (i.e. conflicts between parents and children, lack of empathy, breaches in inner familial communication, a narrowing milieu and problems with borders) seem to contribute to the outbreak of schizophrenia in the offspring. Some knowledge is available about protective factors. Major interest focussed on environmental influence, detrimental as well as protective.

Court-based psychiatric assessment: Case for an integrated diversionary and public health role

This article describes a follow-up study of 232 individuals who underwent psychiatric assessment by a Criminal Justice Mental Health Team (CJMHT) in 2001/2002, and also draws upon in-depth interviews conducted with 26 of the cohort. At assessment many people are identified with substance misuse problems, as homeless and with a history of psychiatric contact but in the main their problems are of insufficient severity to merit diversion to psychiatric hospital. The study mapped service contact, housing and offending in the 12 months following assessment and compared this to the 12 months prior to assessment, and found increased levels of service contact but also increased levels of offending and no decrease in homelessness. Thus assessment by the CJMHT brought few discernible advantages for the majority of clients. This was also the perception of the 26 clients who were interviewed. Their own perceptions of their lifestyle and the support that they deemed most valuable are described to identify means of enhancing the efficacy of court assessment.

Telepsychiatry in Emergency Consultations: A Follow-Up Study of Sixty Patients

The objective was to investigate how telepsychiatry works in the assessment of psychiatric emergency patients. Sixty consecutive patients referred to the acute open ward having their first psychiatric contact through the videolink with the psychiatrist on duty. Only minor technical problems occurred. The results suggest both acceptance and satisfaction on the part of patients and staff with new technology, instead of waiting for a consultation or traveling to see a psychiatrist in face-to-face meeting. Telepsychiatry seems to be suitable for the assessment of psychiatric emergency patients, and satisfactory for patients and staff alike.

Smoking During Pregnancy and the Risk for Hyperkinetic Disorder in Offspring

Maternal smoking during pregnancy may increase the risk for behavioral disorders. The aim of this study was to investigate the association between smoking during pregnancy and hyperkinetic and attention-deficit/hyperactivity disorder in the offspring in a large population-based study. This study was designed as a nested case-control study. Data were obtained from Danish longitudinal registers and included 170 children with hyperkinetic disorder and 3765 population-based control subjects, who were matched by age, gender, and date of birth. Potential confounders, including newborn characteristics, socioeconomic status, and family history of psychiatric illnesses, were evaluated by conditional logistic regression analyses. Women who smoked during pregnancy had a 3-fold increased risk for having offspring with hyperkinetic disorder compared with nonsmokers. Socioeconomic factors and history of mental disorder in the parents or siblings seemed to confound the result to some extent (adjusted relative risk: 1.9; 95% confidence interval: 1.3-2.8). Adjustment for parental age or exclusion of children with low birth weight (<2500 g), preterm delivery (<37 weeks completed gestation), and Apgar scores <7 at 5 minutes revealed no changes in the results. Also, excluding children with conduct disorders or comorbid disorders revealed no change in the results. Our results showed an increased risk for hyperkinetic disorder in children of mothers who smoked during pregnancy. This could not be explained by newborn characteristics, parental socioeconomic status, family history of psychiatric hospitalizations or contact as outpatients, conduct disorders, or comorbidity.

Re: Psychiatric Diagnosis and Suicide

The paper of Bertolote, Fleischmann, De Leo, and Wasserman (Crisis, 2004, 25:147–155) is a potentially influential review of psychiatric diagnosis and suicide, as it purports to present data that diminish the importance of the treatment of mental disorders, particularly depression, in suicide prevention. However, it has a number of flaws that should be acknowledged before necessarily accepting their conclusions. From the methodological point of view one can not simply add the numbers of suicides from widely varying studies to arrive at valid data in terms of general population or psychiatric inpatient suicides. For example, subjects taken from a series of persons who have jumped from bridges or who have died by suicide in underground railways are hardly likely to be representative of a broader general sample of suicides in the community. Furthermore, the three largest studies from the UK, Denmark, and Israel, which comprised over 75% of what the authors referred to as general population suicides, were actually suicides of persons who had had psychiatric contact. Indeed, not only were many of those persons psychiatric inpatients at the time of death, but the authors of the UK study reported that their large sample comprised less than 25% of the total UK suicides. It is probable that psychotic illnesses were more likely to be represented in such psychiatric samples, therefore biasing the results. Bertolote et al. have also confined their analysis to traditional psychological autopsy-type data and have ignored more recently available population attributablerisk research, such as that from Denmark (Qin, Agerbo, & Mortensen, 2003), which allows for the relative importance of various contributing factors to be estimated. That research demonstrated clearly that psychiatric illness sufficiently severe to lead to hospitalization is of overwhelming importance in suicide at the broad population level, and that psychosocial issues such as being on a pension, having a low income, or being unemployed are of far lesser importance. The authors have also stated that they were interested in looking at the geographical origin of the published research, but those two studies from non-Western countries comprised only 216 subjects, or 1.4% of the total, and, therefore, one must be particularly cautious in considering that the overall results would apply to other nonWestern countries. The authors have suggested that strategies should not be “focusing exclusively on the identification and treatment of depression,” but I am not aware of any broad international programs that have been so focused, although there have been regional programs that have done so and that show promise in suicide reduction. The authors have also not distinguished the approaches to suicide prevention that may be appropriate in one country as opposed to another. The focus on mental illness, and in particular depression, is probably the most appropriate approach in developed countries, as many of the psychosocial stressors that may be more amenable to social manipulation have already been addressed. However, for countries with very high suicide rates, clearly addressing psychosocial factors will hold more promise in terms of reducing suicide. This has been illustrated in a model that integrates the role of biological and psychosocial factors contributing to suicide (Goldney, 2003), where it was postulated that there is a base rate of suicide caused by intractable, biologically based, mental disorders, albeit with a contribution from psycho-social stressors, but the relative importance of biological factors diminishes as suicide rates increase. There is a need to delineate more clearly the relative importance of psychiatric illness and psychosocial factors, not only in individual countries, but also in specific regions within countries where there may be unusually high suicide rates. The lumping together of disparate

Does socioeconomic status affect the use of community‐based psychiatric services? A south Verona case register study

To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service. An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study. Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups. The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

Patients with Affective Disorders Admitted to Maximum Secure Care (1999-2003)

The State Hospital, Carstairs, is a special secure psychiatric facility for Scotland and Northern Ireland. This study describes the background, illness and offence (where appropriate) characteristics of 25 patients admitted between 1999 and 2003 with a diagnosis of any affective disorder. Patients were, on average, 37 years old and had a lengthy history of psychiatric contact. Patients with an affective disorder were more likely to be admitted under civil proceedings, following a transfer from hospital, as opposed to being admitted under criminal procedure. Sixty per cent were discharged to prison, court or local hospitals within one year of their admission to special secure care. Significant violence during an episode of mania or hypomania (even in the presence of psychotic symptoms) appears rare. Recurrent unipolar depression resistant to first and second line treatments in women, and lithium withdrawal mania in male bipolar patients were the most common clinical problems. Treatments aimed at reducing co-morbid substance misuse, and improving compliance with mood stabilisers, appear important in managing this patient group.

Offence and offender characteristics among two groups of Finnish homicide offenders with schizophrenia: Comparison of early- and late-start offenders

Offence and offender characteristics were analysed among 109 Finnish persons with schizophrenia who were accused of a homicide between the years 1983 and 2002. Distinguishing characteristics between two groups were examined: early starters, who present antisocial behaviour before the onset of schizophrenia, were compared with late starters, who first offend after the onset of mental disorder. The results suggest that the offence characteristics of early- and late-start offenders with schizophrenia differ only modestly. However, several significant differences between the groups were found in the offender characteristics. Behaviour problems and psychiatric contacts in childhood were more common among early-start offenders with schizophrenia. The findings are discussed with regard to investigative work and the criminal justice system.

Identification in 2 independent samples of a novel schizophrenia risk haplotype of the dystrobrevin binding protein gene (DTNBP1).

Recent research suggests that variation in the gene encoding dystrobrevin binding protein (DTNBP1) confers susceptibility to schizophrenia. Thus far, no specific risk haplotype has been identified in more than 1 study. To confirm DTNBP1 as a schizophrenia susceptibility gene, to identify and replicate specific risk and protective haplotypes, and to explore relationships between DTNBP1 and the phenotype. Genetic association study based on mutation detection and case-control analysis. All subjects were unrelated and ascertained from general (secondary care) psychiatric inpatient and outpatient services. The Cardiff, Wales, sample included 708 white subjects from the United Kingdom and Ireland (221 females) who met DSM-IV criteria for schizophrenia and were individually matched for age, sex, and ethnicity to 711 blood donor controls (233 females). Mean +/- SD age at first psychiatric contact for cases was 23.6 +/- 7.7 years; mean age at ascertainment was 41.8 +/- 13.5 years. The Dublin, Ireland, sample included 219 white subjects from the Republic of Ireland who met DSM-III-R criteria for schizophrenia or schizoaffective disorder and 231 controls. The mean age of the Irish cases was 46.0 +/- 8.5 years; mean age at first psychiatric contact was 25.2 +/- 12.4 years. Evidence for association between the DTNBP1 locus and schizophrenia. In the Cardiff sample, there was no evidence for association with previously implicated haplotypes but strong evidence for association with multiple novel haplotypes. Maximum evidence was found for a novel 3-marker haplotype (global P<.001), composed of 1 risk haplotype (P =.01) and 2 protective haplotypes, 1 common (P =.006) and 1 rare (P<.001). Specific risk and protective haplotypes were replicated in the Dublin sample (P =.02,.047, and.006, respectively). The only phenotypic variable associated with any haplotype was between the common protective haplotype and higher educational achievement (P =.02, corrected for multiple tests). DTNBP1 is a susceptibility gene for schizophrenia. Specific risk and protective haplotypes were identified and replicated. Association with educational achievement may suggest protection mediated by IQ, although this needs to be confirmed in an independent data set.

Emergency department management and outcome for self-poisoning: a cohort study

Self-poisoning in adults is an important public health problem across the world, but evidence to guide psychological management is lacking. In the current cohort study we wished to investigate whether aspects of routine Emergency Department management such as receiving a psycho-social assessment, or being referred for specialist follow up, affected the rate of repetition of self-poisoning. The study was carried out in four inner city hospitals in Greater Manchester, United Kingdom, over a 5-month period. We used hospital information systems and reviewed the case notes of every patient presenting to the Emergency Department to identify prospectively all adult patients presenting with deliberate self-poisoning. Data regarding the Emergency Department management of each episode were collected. The Manchester and Salford self-harm database was used to determine the number of individuals who went on to repeat self-poisoning within 6 months of their index episode. During the recruitment period 658 individuals presented with self-poisoning. Traditional risk factors for repetition such as substance dependence, psychiatric contact, and previous self-poisoning were associated with a greater likelihood of receiving a psycho-social assessment or being referred for specialist follow-up. Ninety-six patients (14.6%) repeated self-poisoning within 6 months of their index episode. After adjustment for baseline demographic and clinical characteristics and hospital, receiving a psycho-social assessment was not associated with reduced repetition but being referred for specialist follow-up was [adjusted hazard ratio for repetition (95% CI): 0.49 (0.25 to 0.84), P=.01]. We found that being referred for active follow-up after self-poisoning was associated with a reduced risk of repetition. The implications of this finding are discussed. Further studies using both cohort and randomized controlled study designs will help inform management strategies for patients who poison themselves.

Childhood sexual abuse predicts poor outcome seven years after parasuicide

There is substantial empirical research linking borderline personality disorder with prolonged mental instability and recurrent suicidality. At the same time, a growing body of observations links borderline personality disorder to sexual abuse and other forms of abuse and trauma in childhood. The aim of this study was to investigate among patients admitted for parasuicide the predictive value for outcome 7 years after the parasuicide of a diagnosis of borderline personality disorder compared to the predictive value of a history of childhood sexual abuse. Semi-structured interviews were conducted at the time of the index parasuicide, with follow-up interviews 7 years later. In addition, information was collected from medical records at the psychiatric clinic. A logistic regression analysis was used to assess the specific influence of the covariates borderline personality disorder, gender and reported childhood sexual abuse on the outcome variables. Univariate regression analysis showed higher odds ratios for borderline personality disorder, female gender and childhood sexual abuse regarding prolonged psychiatric contact and repeated parasuicides. A combined logistic regression model found significantly higher odds ratios only for childhood sexual abuse with regard to suicidal ideation, repeated parasuicidal acts and more extensive psychiatric support. The findings support the growing body of evidence linking the characteristic symptoms of borderline personality disorder to childhood sexual abuse, and identify sexual abuse rather than a diagnosis of borderline personality disorder as a predictor for poor outcome after a parasuicide. The findings are relevant to our understanding and treatment of parasuicide patients, especially those who fulfil the present criteria for borderline personality disorder.

Gender, Estrogen, and Schizophrenia

Most of the evidence to support an association between estrogen and psychosis is indirect and comes from clinical studies of gender differences in schizophrenia and from studies of fluctuating levels of psychopathology in different phases of the menstrual cycle. Our data, as well as those of other investigators, suggest a significantly later age at onset of schizophrenia in women than in men. There is somewhat more direct evidence from animal studies indicating that estrogen modulates dopamine systems in a manner similar to neuroleptics, although there are some inconsistencies in the literature. Few studies have examined the effects of estrogen administration in conjunction with neuroleptics on psychotic symptoms. We present a case report of a postmenopausal woman with schizophrenia who had an improvement in positive symptoms with estrogen replacement therapy. Long-term double-blind treatment studies are needed to investigate the effects of estrogen on psychotic symptoms in women with schizophrenia.

Do Violent Offenders With Schizophrenia Who Attack Family Members Differ From Those With Other Victims?

Do violent offenders with schizophrenia who attack family members differ from those with other victims? Data on individual background factors were collected on all male offenders of violent crimes who for their first time were subject to forensic psychiatric evaluation in Sweden between 1992 and 2000 and were diagnosed with schizophrenia. In addition to descriptive data for the whole sample, analyses were made in order to identify possible characteristic factors for offenders who targeted family members. In comparison to offenders with other victims, the findings indicate an earlier onset of mental illness, in terms of that they were more likely to have interrupted their schooling at an earlier stage, were more likely to have had psychiatric contacts in childhood, to be younger when first compulsorily admitted to psychiatric inpatient treatment, and they were also younger when they committed the index crime. The findings suggest the need to address the possibility of violent behavior within the family when managing patients with major mental disorders.

Psychiatric features of seriously life-threatening suicide attempters: A clinical study from a general hospital in Japan

Objective: Although attempted suicide is one of the strongest predictors of completed suicide, few Japanese studies have described psychiatric differences between those who attempt suicide by overdose (OD) and those who use more violent methods (MV). Methods: A total of 22 consecutively admitted MVs were compared to 78 ODs. All patients were referred for psychiatric evaluation during the same 3-year period. Results: The MV group was predominantly male (68%), whereas the OD group was predominantly female (72%). Using DSM-IV criteria, depressive disorders were most common in both groups, followed by psychotic disorders. The OD group had significantly more borderline patients. Contrary to previous reports, prior psychiatric contact was low in the MV group. MVs were more likely to complain of financial problems and to retain a definite wish to die after the attempt. Conclusions: This study identified meaningful differences between the two groups of patients who attempted suicide.

Psychiatric Treatment in Prison: A missed opportunity?

National Health Service Executive guidelines require psychiatric services to maintain links with prisoners previously subject to the Care Programme Approach (CPA) and to participate in discharge planning. We are unaware of previous studies assessing the involvement of general psychiatric services with patients in prison or prisoners' perceptions of their needs. Consecutive referrals to a prison psychiatric liaison service over a three-month period were screened for previous psychiatric contact. Half of those interviewed reported previous psychiatric contact. Two-thirds were in contact with services at the time of detention. One-third believed services knew of their imprisonment. Ninety-three per cent believed they would require psychiatric support after release. Few patients received input from general psychiatric services during imprisonment despite a high level of perceived need. Improved liaison would help facilitate both care in prison and discharge planning in the spirit of CPA and the government directive.

Traumatic injuries of children and adolescents--are they associated with psychiatric contacts?

Our aim was to investigate whether a large number of hospital visits by children and adolescents because of injuries are associated with psychiatric treatments and subsequent suicides. We examined the case records of 250 randomly chosen patients, 156 (62%) boys and 94 (38%) girls, out of 2306 outpatients who were 0-16 years old and had been treated because of traumatic injuries in Oulu University Hospital in 1984 and were alive in 1997. Boys with seven or more accidents had had psychiatric treatments more commonly than did boys with fewer accidents (39% vs. 8%). In addition, the case records of the patients who had died before the end of 1997 out of the 2306 patients were examined. Twenty-one (0.9%) patients (20 males and one female) had died, and seven (0.3%) of them had committed suicide. The traumatically injured male patients had a twofold suicide rate compared to the national average. The researchers also re-coded the causes of death from the death certificates. There seems to be a tendency to interpret adolescent suicides as accidental, as one of the seven registered suicides (14%), but six of the seven re-coded suicides (86%) had occurred before the age of 20.

An Assessment of Suicide in an Urban VA Medical Center

This study characterizes those patients of an urban VA Medical Center (VAMC) who had committed suicide. A cause-of-death search of the 1,075 veterans from the VAMC's case rolls who died during 1998 was conducted. For confirmed and suspected suicides, a chart review was conducted, noting psychiatric history and recent contact with the VAMC. Nineteen patients were either confirmed or suspected suicides. Few of these patients had made recent contact with the VAMC, although the majority of them had received psychiatric services from the VA at some time. The proportion of deaths due to suicide was similar in African American and White patients. Rates of suicide were elevated, primarily because of the high proportion of patients receiving psychiatric treatment. Elderly suicides were less likely to have had psychiatric services or previous psychiatric diagnoses than were younger suicides. Patients with past contact with psychiatric services may be especially at risk of suicide, particularly as contact with these services diminishes. Elderly patients in medical settings with undiagnosed or undertreated psychiatric disorders are also likely to have elevated risk for suicide. These findings demonstrate the importance of acknowledging that risk factors for suicide are specific to sites or populations; this information can be used in allocating resources for developing site-specific strategies for prevention.

Service utilisation and costs of first-contact patients in a community psychiatric service in Italy

This study describes service utilisation under routine clinical activity and the costs of providing mental health care for 24 months for the whole population of 330 subjects who had first contact with the Magenta Community Mental Health Centre during one year. The mean age of patients was 42.5 years, and 61% were females. According to ICD 10 criteria, 7% were diagnosed as having schizophrenia, 22% mood disorders, 37% neurotic disorders, 15% personality disorders and 19% other diagnoses. The clinical routine activity was monitored for 24 months from the first contact for each patient. The mean cost for a schizophrenic patient is more than double that of other patients. In-patient activity and community services accounted, respectively, for 49.7% and 50.3% of the total costs. Total health care costs per patient differ widely according to whether patients had been hospitalised during the observation period. Patients with a previous psychiatric contact and a longer duration of illness were more costly than the other patients. Multiple regression analysis was used to assess the association between all the individual variables and costs. For the whole population, the model explains 50% of the cost variation. Higher treatment costs were positively associated with the presence of previous psychiatric contacts and referral to the CPS by other sources than a general practitioner, and negatively associated with age.

Specialist service use following psychiatric emergency presentation: an 18-month follow-up study.

The aim of the present study was to identify the subsequent use of specialist psychiatric services by a group of 170 individuals referred as psychiatric emergencies. Hospital and community mental health team (CMHT) records and databases were used to identify specialist contact in an 18-month follow-up period. Out of the total of 170 people, 169 were traced. The majority (60.9%) had had some specialist psychiatric contact in the follow-up period. Those with severe mental health problems formed a minority of presenters, but were heavy users of services. Coverage by CMHT services was insufficient to prevent crisis in many cases. Improved access to broader community services is needed for those with life crises. This study suggests some important gaps in coverage by wider mental health services, which the current mental health agenda goes some way towards addressing.