Regular Psychiatric Care Research Articles

Mobile Mental Health Units in Heraklion Crete 2013–2022: Progress, Difficulties and Future Challenges

Mobile mental health units (MMHUs) have been proposed as an effective model to serve the mental health needs of remote underserved areas. In 2013, the Department of Psychiatry, University of Crete, started a pilot MMHU to cover the needs of remote rural areas of the Heraklion Prefecture. The main objectives were early detection, prevention and therapy of patients with severe psychiatric disorders, without access to regular psychiatric care. In addition to regular visits to primary care health centers, a community support network was established. During this 10-year period, the MMHU has evaluated 3343 patients and performed 19,935 visits. The most frequent diagnoses are depression and anxiety (52.7%) whereas psychosis and bipolar disorders are the third (12.7%) and fifth most frequent diagnoses (4.7%). Half of the patients with depression/anxiety were older than 65 years and one third were living alone. Furthermore, the first visit with the MMHU of severely mentally ill was about 15 years later from the self-reported onset of psychotic symptoms. We discuss how to improve our ability to detect and intervene earlier in patients with severe mental illness, and how to address effectively, both pharmacologically and psychosocially, the depression and loneliness of older individuals living in small remote communities.

High Security Settings in Flanders: An Analysis of Discharged and Long-Term Forensic Psychiatric Patients.

BackgroundTwo Forensic Psychiatric Centres (FPC) were implemented the last decade in Flanders in Ghent (2014) and Antwerp (2017). FPCs are forensic institutions for forensic psychiatric patients with a high recidivism risk and a high security need. The objective of FPCs is to create a care process with sufficient flow (from high to lower forms of security), and transitions (from specialized forensic care to regular psychiatric care).AimsTo examine the characteristics of the high security population in FPCs, treatment length, number of discharges, and discharge locations and to determine the profile of long-term patients within an FPC.MethodsA retrospective file study of an admission cohort of 654 patients admitted to FPC Ghent or FPC Antwerp was conducted. Sociodemographic, clinical, judicial and risk characteristics were analyzed. Bivariate analyses were used to test the difference between two groups: the group that was discharged to a lower security level vs. the group of long-term patients.ResultsMost patients had psychosis and personality disorders, while comorbidity was also high. Judicial histories were extensive, with many sexual index offenses. During a 6-year follow-up period, the number of referrals back to prison was low. Nearly a third of the population was discharged to a setting with a lower security level. Long-term patients typically presented with more personality disorders, higher psychopathy traits and higher risk scores and were more frequently subjected to coercive measures during treatment.ConclusionsThe Flemish FPC population is characterized by a high proportion of sex offenders as well as a high proportion of personality-disordered patients. It is this last group, and the group with elevated psychopathy traits, who remain for longer than expected and is difficult to resocialize. This study further highlights the need for clear criteria to assess the conditions of these long-term patients in Flanders.

Initial Low Levels of Suicidal Ideation Still Improve After Cognitive Behavioral Therapy for Insomnia in Regular Psychiatric Care.

Insomnia disorder is highly prevalent, and has been identified as a risk factor for many psychiatric problems, including depression, suicide ideation and suicide death. Previous studies have found that cognitive behavioral therapy for insomnia (CBT-I) reduce depression and suicidal ideation in samples with high levels of suicidal ideation. This study aims to investigate associations of CBT-I with suicidal ideation in a sample of 522 patients primarily seeking internet-delivered treatment for insomnia in regular psychiatric care. The sample had high pretreatment insomnia severity levels and a relatively high level of comorbid depression symptoms. Suicidal ideation levels were relatively low pretreatment but still improved significantly after CBT-I. Contrary to previous findings, the strongest predictor of changes in suicidal ideation were improvements in depressive symptoms, rather than improvements in insomnia. We conclude that suicidal ideation may not be a major problem in these patients primarily seeking treatment for insomnia, despite comorbid depressive symptoms, but that suicidal ideation still improves following CBT-i. Considering the increased risk for patients with untreated insomnia to develop depression, this finding is of interest for prevention of suicidal ideation.

Unmet mental health needs in the general population: perspectives of Belgian health and social care professionals

BackgroundAn unmet mental health need exists when someone has a mental health problem but doesn’t receive formal care, or when the care received is insufficient or inadequate. Epidemiological research has identified both structural and attitudinal barriers to care which lead to unmet mental health needs, but reviewed literature has shown gaps in qualitative research on unmet mental health needs. This study aimed to explore unmet mental health needs in the general population from the perspective of professionals working with vulnerable groups.MethodsFour focus group discussions and two interviews with 34 participants were conducted from October 2019 to January 2020. Participants’ professional backgrounds encompassed social work, mental health care and primary care in one rural and one urban primary care zone in Antwerp, Belgium. A topic guide was used to prompt discussions about which groups have high unmet mental health needs and why. Transcripts were coded using thematic analysis.ResultsFive themes emerged, which are subdivided in several subthemes: (1) socio-demographic determinants and disorder characteristics associated with unmet mental health needs; (2) demand-side barriers; (3) supply-side barriers; (4) consequences of unmet mental health needs; and (5) suggested improvements for meeting unmet mental health needs.ConclusionsFindings of epidemiological research were largely corroborated. Some additional groups with high unmet needs were identified. Professionals argued that they are often confronted with cases which are too complex for regular psychiatric care and highlighted the problem of care avoidance. Important system-level factors include waiting times of subsidized services and cost of non-subsidized services. Feelings of burden and powerlessness are common among professionals who are often confronted with unmet needs. Professionals discussed future directions for an equitable mental health care provision, which should be accessible and targeted at those in the greatest need. Further research is needed to include the patients’ perspective of unmet mental health needs.

Special Phenomena in Rorschach Protocols in Patients Diagnosed with Schizophrenia.

The Rorschach method has been proved as an effective tool for personality dynamics assessment, as well as for identify psychopathological patterns, especially with regard to the dissociation of consciousness, which makes it relevant in the context of schizophrenia. The aim of this study was to contribute to the evaluation of the so-called special phenomena in Rorschach protocols in patients diagnosed with schizophrenia. The sample consisted of ten patients previously diagnosed with ICD-10 F20 who were hospitalised in the Federal District, Brazil, in the Centre for Living and Psychosocial Care (Life Mansion). The participants were chosen in the free choice form by the lead researcher. All were under regular psychiatric care and used medication continuously to treat the illness. Data were analysed according to the interpretative principles of Bruno Klopfer's theoretical and clinical approach. It was found eight fixed special phenomena in the schizophrenic patients' responses to Rorschach tests. All patients responses showed the following special phenomena: confabulation; contamination; named colour; self-referential ideation; referential ideation; looking at the back of the card; perseveration and position response. Normal patients did not present high frequency and intensity of special phenomena in their respective protocols. Taken together, this clinical study supports the conclusion that the Rorschach technique is an important tool for the evaluation of schizophrenic patients.

Conventional Cognitive Behavioral Therapy Facilitated by an Internet-Based Support System: Feasibility Study at a Psychiatric Outpatient Clinic

BackgroundCognitive behavioral therapies have been shown to be effective for a variety of psychiatric and somatic disorders, but some obstacles can be noted in regular psychiatric care; for example, low adherence to treatment protocols may undermine effects. Treatments delivered via the Internet have shown promising results, and it is an open question if the blend of Internet-delivered and conventional face-to-face cognitive behavioral therapies may help to overcome some of the barriers of evidence-based treatments in psychiatric care.ObjectiveWe evaluated the feasibility of an Internet-based support system at an outpatient psychiatric clinic in Sweden. For instance, the support system made it possible to send messages and share information between the therapist and the patient before and after therapy sessions at the clinic.MethodsNine clinical psychologists participated and 33 patients were enrolled in the current study. We evaluated the usability and technology acceptance after 12 weeks of access. Moreover, clinical data on common psychiatric symptoms were assessed before and after the presentation of the support system.ResultsIn line with our previous study in a university setting, the Internet-based support system has the potential to be feasible also when delivered in a regular psychiatric setting. Notably, some components in the system were less frequently used. We also found that patients improved on common outcome measures for depressive and anxious symptoms (effect sizes, as determined by Cohen d, ranged from 0.20-0.69).ConclusionsThis study adds to the literature suggesting that modern information technology could be aligned with conventional face-to-face services.

Assessment of diagnostic information and quality of working alliance with clients diagnosed with personality disorders during the mental health intake

Background: A primary purpose of diagnostic systems is to improve care, yet, little is known about how providers use it routine clinical care.Aims: We investigated specific DSM-IV personality disorders (PDs) diagnostic information therapists collected during intake visits and the association between a therapist PD diagnosis and clients’ and therapists’ reports of the quality of working alliance during the intake.Method: A total of 122 intakes (n = 34, 27.9% were diagnosed with PD) in four community mental health clinics in Israel were audiotaped. Immediately following the intake, clients and therapists completed the working alliance inventory (WAI). Independent clinicians coded the intakes using an information checklist.Results: Despite the relatively high prevalence of PD in regular psychiatric care, very limited PD diagnostic information was directly assessed during the intake. Therapists evaluated the quality of the working alliance when they saw a client they diagnosed with PD as significantly lower than the rating of a client without a PD, while the clients’ ratings did not differ as a result of their diagnosis.Conclusions: Therapists do not collect sufficient explicit diagnostic information to base their PD diagnostic decisions. Yet, the presence of PD diagnosis affects their rapport with their clients as early as the intake.

1153 – Effectiveness and health economic evaluation of internet-based cognitive behavioural therapy in regular psychiatric care

Introduction Anxiety disorders are highly prevalent and among the leading causes of the global disease burden. Cognitive behaviour therapy (CBT) is an effective treatment, but demand is high and resources to deliver CBT are scarce. Embracing new technologies to meet these growing needs, there is an emergent evidence base of the efficacy of internet-based CBT (ICBT). Objectives Evaluating (1) treatment effects, (2) cost-effectiveness and (3) cost-utility of ICBT for panic disorder. Aims To evaluate clinical effectiveness and health economics of ICBT for patients within regular psychiatric care. Methods Longitudinal analysis of 570 patients diagnosed with panic disorder that have been treated between 2007 and 2012 at an ICBT unit within regular psychiatric care. The ICBT was therapist-guided and lasted for three months. Clinical outcome measures were improvements in symptom severity and health related quality of life. Economic outcome measures were direct and indirect costs and incremental cost-effectiveness ratios (ICER). Results Analyses of treatment outcome suggest significant reductions in primary symptoms of panic disorder and that ICBT is an economically and clinically effective treatment for panic disorder leading to improvement of symptom severity and quality of life for these patients. Conclusions The findings of this study can aid decision makers when considering options of evidence-based treatment delivery formats within psychiatric care.

Emotion recognition in pictures of facial affect: Is there a difference between forensic and non-forensic patients with schizophrenia?

Background and Objectives: Abundant research has demonstrated that pa- tients with schizophrenia have difficulties in recognizing the emotional content in facial ex- pressions. However, there is a paucity of studies on emotion recognition in schizophrenia patients with a history of violent behavior compared to patients without a criminal record. Methods: Emotion recognition skills were examined in thirty-three forensic patients with schizophrenia. In addition, executive function and psychopathology was assessed. Results were compared to a group of 38 schizophrenia patients in regular psychiatric care and to a healthy control group. Results: Both patient groups performed more poorly on almost all tasks compared to controls. However, in the forensic group the recognition of the expression of disgust was preserved. When the excitement factor of the Positive and Negative Syndrome Scale was co-varied out, forensic patients outperformed the non-forensic patient group on emotion recognition across modalities. Conclusions: The superior recognition of disgust could be uniquely associated with delinquent behavior.

Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial

BackgroundInternet administered cognitive behaviour therapy (CBT) is a promising new way to deliver psychological treatment, but its effectiveness in regular care settings and in relation to more traditional CBT group treatment has not yet been determined. The primary aim of this study was to compare the effectiveness of Internet-and group administered CBT for panic disorder (with or without agoraphobia) in a randomised trial within a regular psychiatric care setting. The second aim of the study was to establish the cost-effectiveness of these interventions.MethodsPatients referred for treatment by their physician, or self-referred, were telephone-screened by a psychiatric nurse. Patients fulfilling screening criteria underwent an in-person structured clinical interview carried out by a psychiatrist. A total of 113 consecutive patients were then randomly assigned to 10 weeks of either guided Internet delivered CBT (n = 53) or group CBT (n = 60). After treatment, and at a 6-month follow-up, patients were again assessed by the psychiatrist, blind to treatment condition.ResultsImmediately after randomization 9 patients dropped out, leaving 104 patients who started treatment. Patients in both treatment conditions showed significant improvement on the main outcome measure, the Panic Disorder Severity Scale (PDSS) after treatment. For the Internet treatment the within-group effect size (pre-post) on the PDSS was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group effect sizes were low and treatment effects were maintained at 6-months follow-up. We found no statistically significant differences between the two treatment conditions using a mixed models approach to account for missing data. Group CBT utilised considerably more therapist time than did Internet CBT. Defining effect as proportion of PDSS responders, the cost-effectiveness analysis concerning therapist time showed that Internet treatment had superior cost-effectiveness ratios in relation to group treatment both at post-treatment and follow-up.ConclusionsThis study provides support for the effectiveness of Internet CBT in a psychiatric setting for patients with panic disorder, and suggests that it is equally effective as the more widely used group administered CBT in reducing panic-and agoraphobic symptoms, as well as being more cost effective with respect to therapist time.Trial registrationClinicalTrials.gov NCT00845260

Quality of Life in a Population of Dutch Prisoners with Mental Disorders: Relations with Psychopathological, Social, Demographical, Judicial and Penitentiary Factors

Little research is done on the impact of psychopathology in prison settings as expressed in outcome measures such as Quality of Life (QOL). The aim of the present study was to examine the QOL of Dutch male prisoners with mental disorders and to compare their QOL with the QOL of three reference groups: the general Dutch population (GDP), psychiatric outpatients, and prisoners without mental disorders. Also, the QOL of the reference group of prisoners without mental disorders was compared with the QOL of the other reference groups. An additional aim was to investigate possible relationships between the QOL of the study population and psychopathological, social, demographic, judicial and penitentiary factors. The QOL of the study population (N = 71) was measured with the WHOQOL-Bref. In addition, psychopathological, social, demographic, judicial and penitentiary data were collected. The QOL of the study population was worse compared with the QOL of the GDP and prisoners without psychopathology but better than the QOL of the psychiatric outpatients. Within the study population, the impact of DSM-IV-TR Axis I and II disorders on experienced QOL was of a similar negative magnitude. Correlations between substance dependence or abuse, social and demographic variables, judicial/penitentiary variables and QOL were small or absent. Psychopathological factors explained the major part of the known QOL variance of the study population. The relatively good QOL of the imprisoned patient group, in comparison to the QOL of the outpatient group, leads to the recommendation to implement elements of the detention regime in regular psychiatric care.

An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting

Panic disorder with or without agoraphobia (PD/A) is common and can be treated effectively with selective serotonin reuptake inhibitor (SSRI) medication or cognitive–behaviour therapy (CBT). However, the lack of access to CBT services has motivated the development of self-help approaches requiring less therapist contact. A novel treatment modality in this field, showing efficacy in several randomized trials but until now not evaluated within the context of regular psychiatric care, is Internet-based treatment. The aim of the present study was to evaluate the effectiveness of Internet-based CBT for patients in a psychiatric setting. Twenty consecutively referred patients with PD were included in the study. A structured clinical interview with a psychiatrist was conducted for inclusion, as well as at post-treatment and at the 6-month follow-up. The treatment consisted of a 10-week CBT-based self-help programme, including minimal therapist support by e-mail. At post-treatment, 94% of patients no longer met DSM-IV criteria for PD (82% at 6-month follow-up). The within-group effect sizes (for the main outcome PDSS; Panic Disorder Severity Scale) were Cohen's d=2.5 (pre- to post-treatment) and 2.8 (pre-treatment to follow-up), respectively. The proportion of responders on the PDSS was 75% at post-treatment and 70% at 6-month follow-up. The results supports earlier efficacy data on Internet-based CBT for PD and indicates that it is effective also within a regular psychiatric setting. However, a larger randomized controlled trial should be conducted, directly comparing Internet-based CBT with traditionally administered CBT within such a setting.

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.

Development and function of the psychiatric crisis and emergency service in Mannheim

The setting up of a psychiatric emergency and crisis service during the years 1974 to 1980 in Mannheim forms part of the evolvement of a central psychiatric overall care programme with emphasis on patients residing in the same region, that is to say, close to the psychiatric facilities; within this framework, the role played by the emergency service is preferably of an auxiliary and additional nature, over and above the already existing regular care facilities. Since the emergency and crisis service forms a part of a regular psychiatric care network, its principal functions are: 1. First diagnosis and, in connection therewith, the decision whether 2. acute intervention in an existing crisis should be effected within the emergency service, or 3. whether further treatment must be instituted with a psychiatric or internistic or social partner of the emergency service. The emergency service has to look after an increasing proportion of patients with severe mental disturbances who are seen by the emergency service in moments of extreme crisis (high rate of attempted suicides) or in acute severe relapses, and who are normally also looked after by the regular psychiatric services. Over and above, the emergency service has to look after a special small group of patients not covered by any other psychiatric service on account of their social disorganisation , frequently also because they are addicts. As should be expected, there is an almost continuous drop in the referral to the psychiatric service, the farther away the patients live from the seat of the emergency service. This, however, applies in a very similar manner to the regular outpatient services and also to the entire psychiatric care available to the residents of Mannheim.