Showing papers in "Epidemiologia E Psichiatria Sociale-an International Journal for Epidemiology and Psychiatric Sciences in 2009"

What is a randomised controlled trial

Abstract: Method Fifty-seven parents randomised to I0 weeks ofex~erimental Habilitation programmes for intellectual disability are primitive in developing countries (Heron & Myers, 1983). Resources to develop specialist care are scarce in these nations. One compensatory option for this deficit is to facilitate the primary care-giver to take on the role of therapist (McLoughlin, 1992), because parents are the focus of intervention (Myreddi, 1992). Parental attitude influences the development and training of the developmentally disabled child (Beckett-Edwards, 1994) and is a dynamic adaptational process subject to change (Gallimore et al, 1993). Changes in and control therapy were assessed using parental attitude occur with intervention the Parental Attitude Scale towards the (Bruiner & Beck, 1984; Sameroff & Managementof Intellectual DisabilityThe 1990). Interventions with parents are varpreand post-intervention measurements ied (Girimaii, 19931, including a model were done by a single-blinded rater and with an O ~ ~ O r m n i t y raise questions and discuss problems over a period of time (Stecompared. phens & Wyatt, 1969; Cunningham et al, Results The intervention group had a 1993). This randomised-controlled ma1 evalustatistically significant increase in the ates the efficacy of Interactive Group outcome scores and clinical improvement psychoeducation (IGP) in changing attiin the total parental attitude score, tudes towards children with intellectual orientation towards child-rearing, disability.

The global burden of mental disorders : An update from the WHO World Mental Health (WMH) Surveys

Abstract: Aims - The paper reviews recent findings from the WHO World Mental Health (WMH) surveys oil the global burden of mental disorders. Methods - The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders. Results - The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4-6.8% in half the countries, 2.3-3.6% in one-fourth, and 0.8-1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions in the WMH data. Adult mental disorders are found to be associated with such high role impairment in the WMH data that available clinical interventions could have positive cost-effectiveness ratios. Conclusions - Mental disorders are commonly Occurring and often seriously impairing in many countries throughout the world. Expansion of treatment could be cost-effective from both employer and societal perspectives.

Long-term lithium treatment in the prevention of suicidal behavior in bipolar disorder patients.

Abstract: We reviewed available research findings, including meta-analyses on effects of lithium-treatment associated with rates of suicidal behavior in bipolar disorder or unipolar major depressive disorder patients, and for comparisons of lithium to mood-stabilizing anticonvulsants. Data from meta-analyses consistently indicate marked reductions of suicidal behavior and mortality during long-term treatment with lithium salts in bipolar disorder patients, and possibly also in unipolar, recurrent major depressive, perhaps even more effectively than with anticonvulsants proposed as mood-stabilizers. Suicidal risk is frequently associated with dysphoric-agitated symptoms, anger, aggression, and impulsivity-all of which may respond better to treatment with lithium or other mood-stabilizing medicines than to antidepressants. In these conditions, antidepressant treatment may not provide a beneficial effect on risk of suicidal thoughts and perhaps attempts, particularly in juveniles, whereas, lithium, perhaps even more than anticonvulsants, seems to be remarkably effective in the preventing suicidal behavior. The mechanism of action is not well defined and may be associated with either a prevention of mood recurrences or a more specific "antisuicidal" activity.

Eating disorders and obesity: two sides of the same coin?

Abstract: The eating disorders anorexia and bulimia nervosa have traditionally been regarded as entirely separate from obesity. Eating disorders have been regarded as Western culture-bound syndromes, arising in societies with excessive emphasis on weight, shape and appearance, and best treated by psychological therapies, in particular cognitive behavioural therapy or family-based interventions. In contrast, obesity has been considered a medical illness with metabolic and genetic origins, and thought to be best treated by mainstream medicine, involving dietary, drug or surgical treatment. We believe that this polarisation is fundamentally flawed, and research and treatment of both types of disorder would be better served by greater appreciation of the psychosocial components of obesity and the biological and genetic components of eating disorders. There are similarities in phenotype (such as excessive attempts at weight control, binge eating behaviours) and in risk factors (such as low self-esteem, external locus of control, childhood abuse and neglect, dieting, media exposure, body image dissatisfaction, weight-related teasing and shared susceptibility genes). One example of shared genetic risk is the brain-derived neurotrophic factor (BNDF) gene, in which the valine allele of the Val66Met amino acid polymorphism predisposes to obesity, whereas the methionine allele predisposes to eating disorders. Thus the evidence suggests that these disorders will have both shared and distinct susceptibility factors; some will predispose to both types of disorder, some will push in opposite directions, and some will separate them.

Economic evaluation of a crisis resolution service: a randomised controlled trial.

Abstract: AIMS: The use of specialised services to avoid admission to hospital for people experiencing mental health crises is seen as an integral part of psychiatric services in some countries The aim of this paper is to assess the impact on costs and cost-effectiveness of a crisis resolution team (CRT) METHODS: Patients who were experiencing mental health crises sufficient for admission to be considered were randomised to either care provided by a CRT or standard services The primary outcome measure was inpatient days over a six-month follow-up period Service use was measured, costs calculated and cost-effectiveness assessed RESULTS: Patients receiving care from the CRT had non-inpatient costs pounds sterling 768 higher than patients receiving standard care (90% CI, pounds sterling 153 to pounds sterling 1375) With the inclusion of inpatient costs the costs for the CRT group were pounds sterling 2438 lower for the CRT group (90% CI, pounds sterling 937 to pounds sterling 3922) If one less day spent as an inpatient was valued at pounds sterling 100, there would be a 995% likelihood of the CRT being cost-effective CONCLUSION: This CRT was shown to be cost-effective for modest values placed on reductions in inpatient stays

Stressful and intrusive life events preceding first episode psychosis

Abstract: Aim – To test the hypothesis that stressful life events, in particular intrusive events, would cluster before the first onset of psychosis. Method – Forty-one patients with first episode psychosis were interviewed with the Life Events and Difficulties Schedule to assess events in the year before the onset of illness. Events were rated contextually on timing, independence, threat, and intrusiveness. Within-patient group clustering was evaluated, and the patient group was compared with two general population surveys from London. Results – Events were very frequent in the year before the onset of psychosis. Stressful and intrusive events were more common in the three months before onset compared with the previous nine months, although few analyses reached conventional statistical significance. Threatening and intrusive events were much more frequent in patients than in the comparison groups. First episode psychosis patients were strikingly more likely to report an intrusive event in the three months before onset (OR=17.1, 34% v 3%), and also showed an excess between three months and one year before onset (OR=8.1, 11% v 3%). Conclusions – Events may trigger many cases of first episode psychosis. The effect emerges several months before onset, particularly if the events are intrusive. This has both theoretical and clinical implications.Declaration of Interest: DR was supported by a UK Medical Research Council studentship. The authors have no conflicts of interest in writing this paper.

The role of psychopharmacology in suicide prevention.

Abstract: The potential role of psychopharmacology in suicide prevention is often minimised. This may to some extent reflect that few medication trials have specifically focussed on prevention of suicidal behaviour--indeed this outcome is often not reported in trials. However, there is reasonably strong evidence that lithium may reduce risk of suicide, the postulated mechanism being a specific effect on aggression. Evidence is lacking with regard to any protective effect of other mood stabilizers. Clozapine may reduce suicidal behaviour in patients with schizophrenia, with reduction of affective symptoms being a possible explanation. The role of antidepressants in relation to suicide risk is highly controversial, especially in children and adolescents. It is unclear whether minor tranquillizers or hypnotics can assist in suicide prevention, although they can reduce the anxiety symptoms that may occur during initial treatment with SSRI antidepressants. It is also uncertain whether psychopharmacology has a role in preventing suicidal behaviour in people with personality disorders. Despite the limitations of the evidence we contend that suicide risk should be an important factor in deciding when and what to prescribe.

Information systems for mental health.

Abstract: The use of information systems and computer science applications in the health sector is now entrenched and widespread. In mental health services there are the typical applications of information systems concerning administrative, clinical and research issues, as well as innovative applications concerning diagnostic procedures, self-help, communication and delivery of psychotherapy.

Family burden in bipolar disorders: results from the Italian Mood Disorders Study (IMDS).

Abstract: Aims – To explore: a) the burden of care, and the professional and social support in relatives of patients with bipolar disorders; b) the psychosocial interventions provided to patients and their families by Italian mental health centres. Methods – 342 outpatients with a bipolar disorder and their key-relatives were randomly recruited in 26 Italian mental health centres, randomly selected and stratified by geographical area and population density. Family burden was explored in relation to: a) patient's clinical status and disability; b) relatives’ social and professional support; c) interventions received by patients and their families; d) geographical area. Results – In the previous two months, global functioning was moderately impaired in 36% of the patients, and severely impaired in 34% of them. Twenty-one percent of patients attended a rehabilitative programme, and 3% of their families received a psychoeducational intervention. Burden was higher when patient's symptoms and disability were more severe, the relatives had poorer psychological support and help in emergencies by the social network, and the family lived in Southern Italy. Differences in family burden in relation to geographical area disappeared when psychosocial interventions were provided. Conclusion – This study highlights the need to increase the availability of rehabilitative interventions for patients with bipolar disorders and of psychological support for their families, especially in Southern Italy.

The implementation of mental health information systems in developing countries: challenges and opportunities.

Abstract: The aims are to examine the challenges and opportunities in the implementation of mental health information systems (MHIS) in developing countries as suggested by the World Health Organization (WHO) and explored by Gulbinat et al. (2008). Special recommendations for developing countries are: 1) MHIS should be linked to the general medical information system; 2) there is need for adoption, adaptation and validation of preferably self-administered instruments that are appropriate for different levels within the health care system; 3) developing countries must adopt innovative and "unconventional" approaches through utilization of community members, traditional doctors/healers and mid-cadre health workers, in addition to general doctors, for the delivery of mental health services.

Dissecting the many genetic faces of schizophrenia.

Abstract: . Recent genome-wide association studies in schizophrenia have provided strongest evidence for association and this strengthened when the affected phenotype included bipolar disorder suggesting that genes may not always associate with operationalised diagnostic entities. Several further large Genome Wide Association (GWA) studies on schizophrenia are under way and identified and replicated further loci in well-powered cohorts. The last 2 years have also witnessed an explosion of interest in human Copy Number Variants (CNVs). Deletions recently identified in schizophrenia (1q21.1; 2p16.3; 15q11.2; 15q13.3) have also been most recently found in further neurodevelopmental diseases. Thus, a significant fraction of individuals with neurodevelopmental diseases including schizophrenia carry CNVs and many will be defined as "genomic disorders" in the coming years. These findings could represent a decisive step towards understanding the causes of this severe mental disorder as well as developing new potential treatments. There is new hope that these new avenues will help understanding the neurobiology of schizophrenia in more depth leading to the development of new innovative diagnostic tools and therapies as was the case after the discovery of rare APP and presenilin 1 and 2 mutations in Alzheimer's disease.

Interhemispheric communication in schizophrenia

Abstract: matter tract, mostly composed by both myelinated and unmyelinated fibres, connecting the two cerebral hemispheres. The CC can be divided into different sections: rostrum, genu, body, isthmus and splenium (Aboitiz, 1992). Myelinated fibres predominate in the midbody and the splenium while unmyelinated fibres are more numerous in the rostrum and the genu. The callosal fiber disposition approximately reflects brain topography: the anterior sections connect the frontal lobes, the median sections connect temporal and parietal regions, and the posterior sections link occipital areas (Pandya et al., 1971). This traditional picture, however, which has been obtained mainly through studies in non-human primates has been partly modified by modern diffusion tensor imaging studies in humans (Hofer & Frahm, 2006). The CC matures after birth through adolescence and into early adulthood (Giedd et al., 1996; Keshavan et al., 2002) and is involved in different cognitive processes such as sensory-motor integration, attention, language, arousal and memory (Brambilla et al., 2005). Its size has been shown to be associated with handedness, sex (i.e., greater splenium in females and greater genu in males, Dubb et al., 2003; Shaywitz et al., 1995) and cerebral laterality (i.e., inverse correlation between callosal connectivity and brain lateralization in males; Aboitiz, 1992; Luders et al., 2003), and age (Ota et al., 2006; Sullivan et al., 2002) Specifically, age-related callosal degeneration has been detected by a diffusion tensor imaging (DTI) study (Ota et al., 2006) in the sub-regions that connect areas which are thought to be vulnerable to normal aging: the genu, rostral body, and isthmus (Good et al., 2001; Resnick et al., 2003; Sullivan et al., 2001). This result replicated post mortem findings of callosal degeneration in rostral body, anterior midbody and isthmus (Aboitiz et al., 1996). In particular, the CC has been shown to be crucial in determining inter-hemispheric transfer time (IHTT) of visuomotor information. IHTT can be assessed with the Poffenberger paradigm (Poffenberger 1912; Marzi, 1999) or by using cortical evoked potentials (EPs). Both techniques are based on the callosal crossing of visual information which is required when simple visual stimuli are presented extra-foveally to the hemifield contralaterOutcome reporting bias in clinical trials

Clinical challenges in the assessment and management of suicidal behaviour in patients with bordeline personality disorder.

Abstract: Self-injurious and suicidal behaviours are highly prevalent in patients with borderline personality disorder (BPD) and the risk of completed suicide is high. Borderline patients often present with heterogeneous clinical pictures and widespread comorbidity complicating clinical assessments and management. This calls for increased efforts in systematic evaluation and monitoring of self-harming and suicidal behaviours; these behaviours should be addressed actively as high priority treatment targets. Early drop-out is common for BPD patients in treatment but is possible to counteract by fostering a strong therapeutic relationship through adopting a realistic, but consistent and supportive approach carefully avoiding reinforcement of suicidal behaviours. Suicidal crises should primarily be managed in an outpatient setting giving priority to keeping the patient safe adopting a safety plan procedure, while helping the patient as quickly as possible to return emotionally to a more acceptable level of arousal and mental functioning. Pharmacological treatments should primarily be used for management of comorbid conditions, but may possibly also be helpful when used to reduce specific symptoms such as anger, hostility and impulsivity. There is currently a range of different integrated short-term and long-term psychological treatments in different stages of development and some of them have been shown to be efficacious in reducing suicidal behaviours; notably dialectical behaviour therapy and mentalization-based therapy.

The contribution of epidemiology to defining the most appropriate approach to genetic research on schizophrenia.

Abstract: Psychosis is thought to have a strong genetic component, but many efforts to discover the underlying putative schizophrenia genes have yielded disappointing results. In fact, no strong associations emerged in the first genome-wide association studies in psychiatry and weakly observed associations were not related to the candidate genes identified in previous studies. These partially successful findings may be explained by the fact that genetic research in psychiatry suffers from confounding issues related to phenotype definition, the considerable degree of phenotypic variability and diagnostic uncertainty, absence of specific neuropathological features and environmental influences. To make progress it is first necessary to deconstruct psychosis based on symptomatology, and then to correlate particular phenotypes with genetic variants. Moreover, it is time to conduct studies that define persistent aspects of the schizophrenic profile that are more likely to represent an underlying biological pathogenesis, as opposed to fluctuating symptoms that are possibly environmentally mediated. In fact, progress in understanding the etiology of schizophrenia will depend upon the availability of good measures of genetic liability as well as relevant environmental exposures during critical periods of an individual's life. If environmental and/or genetic factors are not precisely measured, it is impossible to study their independent effects or interactions.

Superiority, equivalence or non-inferiority?

Abstract: One of the most important critical decision to be taken when designing a randomized controlled trial (RCT) in clinical psychopharmacology is the choice of the comparator. This choice is crucial because it affects many issues related to both internal and external validity. The aim of a RCT may be to establish efficacy in absolute terms, against an inert treatment (usually a placebo), or to establish efficacy with respect to another treatment (also known as comparator), a trial may be designed to demonstrate that the new drug is superior to the control intervention or, by contrast, that the new drug is similar to the control intervention in terms of, say, symptoms' reduction. Three kinds of RCTs may be designed: Superiority trials, Equivalence studies, Non-inferiority studies.

Strange bedfellows: economics, happiness and mental disorder.

Abstract: SUMMARY. Aim – The high economic and social costs associated with the ‘common mental disorders’, and the need to scale up appropriate care services, are now widely recognized, but responses vary from country to country. In Britain, a current government initiative to promote psychological therapy is driven both by economic pressures and by research on the factors of happiness, or life-satisfaction. This article provides a short critical review of the project. Method – A health policy analysis, with regard to problem definition; objectives; sources of information; criteria for evaluation; impact on existing services, and comparison with alternative strategies. Results – The new programme, Improving Access to Psychological Therapies (IAPT), aims to expand treatment services by training 3,600 ‘psychological therapists’ in cognitive behavioural therapy (CBT), which they will then apply in the wider community. This service, with an initial budget of £173 million, will provide treatment for depression and chronic anxiety from local centres across the country. The programme is intended to pay for itself by reducing incapacity costs. Closer examination, however, raises questions concerning the project’s theoretical basis, logistics and research methodology, and casts doubt on its advantages over alternative approaches. Conclusions – The IAPT project is ill-designed to achieve its objectives and unsuitable as a model for treatment and care of the common mental disorders in other countries. An alternative strategy, based on closer integration of community mental health and primary health care, should be tested and on previous experience seems likely to prove more cost-effective. Declaration of Interest: None.

Why internal and external validity of experimental studies are relevant for clinical practice

Abstract: In randomised controlled trials (RCTs) there are two types of validity: internal validity and external validity . Internal validity refers to the extent to which the observed difference between groups can be correctly attributed to the intervention under investigation. In other words, it is the extent to which the design and conduct of the trial eliminate error. Internal validity might be threatened by two types of errors: systematic error (also called bias ) and chance error (also called random error or statistical error ) (Keirse & Hanssens, 2000. Systematic error, or bias, may be the consequence of erroneous ways of collecting, analysing and interpreting data. This may produce differences between treatments that are not real, with an overestimation or an underestimation of the true beneficial or harmful effect of an intervention (Juni et al. , 2001). In RCTs there are four types of bias: selection bias (when the groups differ in baseline characteristics because of the way participants are selected), performance bias (when the care provided to the trial participants differs systematically between the experimental and control group), detection bias (when there are systematic differences in outcome assessment), and attrition bias (when the loss of participants from the study systematically differs between the experimental and control group). By contrast, chance error, or statistical error , is due to outcome variability that may arise by chance alone. Studies with small sample sizes are more likely to incur in this type of error than studies with large sample sizes. Thus, the risk of random error may be minimised by recruiting sufficiently large samples of patients.

Is the exposure to antidepressant drugs in early pregnancy a risk factor for spontaneous abortion? A review of available evidences.

Abstract: SUMMARY. Aim – To review studies conducted to establish the risk of spontaneous abortion (SA) in women exposed to antidepressant drugs (ADs) during early pregnancy. Methods – By using different search terms, PubMed, Toxline, EMBASE, PsychINFO, and the Cochrane library databases were searched from January 1980 to March 2008, to identify studies assessing the risk of SA in women exposed to different classes of ADs during the first trimester of pregnancy. Results – Ten studies over 21 identified were selected for the analysis. All were performed prospectively and included as control group unexposed women, or exposed to non-teratogenic drugs or to placebo. In seven studies a depressive episode was specified as the reason for which the drug was prescribed, while the time of exposure was in nine. Conclusions – Only three studies over ten selected reported a significant association between an increased rate of SAs and early pregnancy exposure to some ADs. Many methodological flaws in the study design were found in all studies considered. Given this background and a lack of strong evidence on this issue, further prospective and better designed studies are needed to assess the risk of SA in pregnant women exposed to ADs against the risk of an untreated maternal depression. Declaration of Interest: None.

What people with schizophrenia think about the causes of their disorder

Abstract: AIMS To describe what users with schizophrenia think about the causes of their disorder. METHODS In each of the 10 participating Italian mental health centres, 25 users with schizophrenia were consecutively recruited and asked to complete the Users' Opinions Questionnaire (UOQ). RESULTS 150 out of 198 respondents mentioned at least one social cause for their mental disorder, and 114 reported exclusively social causes. Family conflicts were the most frequently reported social cause (21%), followed by traumas (20%), work and study difficulties (17%), and psychological disturbances (17%). Ten percent of the respondents mentioned biological causes. Biological causes were more frequently reported by users who were aware of their diagnosis of schizophrenia, whereas social causes by those who just knew they suffered from a psychosis. Difficulties in social relationships were more frequently pointed out by respondents with an earlier onset of the illness and a higher number of compulsory admissions in the previous 12 months. These users expressed more scepticism about the usefulness of the treatments they received, and perceived a greater social distance. CONCLUSIONS Users' beliefs about the causes of their disorder should be taken into account by psychiatrists in order to improve their working alliance with them.

The interaction between genetics and epidemiology: the puzzle and its pieces.

Abstract: I tre Editoriali in questo numero di EPS mirano ad esemplificare le potenzialità dell’interazione fra genetica ed epidemiologia, non solo nell’ambito della ricerca in psichiatria ma anche per la pratica clinica. La pratica clinica attuata in maniera ottimale richiede la capacità di mettere in atto trattamenti individualizzati che tengono conto delle migliori evidenze che derivano da un insieme di informazioni riguardanti gli aspetti che causano o interferiscono con l’insorgenza ed il decorso dei disturbi psichici. Queste informazioni possono essere considerate le tessere di un puzzle e, in qualche modo, la ricerca scientifica può essere considerata il tentativo di mettere assieme le tessere di questo puzzle senza conoscere la figura illustrata sul coperchio della scatola (Hough & Ursano, 2006). Occorre mettere al posto giusto parecchie tessere prima di riuscire in qualche modo a comprendere la figura. E, nell’ambito della ricerca, queste tessere corrispondono spesso ai dati ottenuti con diversi approcci e metodologie. Una delle sfide dei ricercatori è immaginare quali siano i pezzi mancanti prima di averli in mano. Per far questo non occorre solo avere in mente la forma che dovrebbero avere queste tessere, ma occorre anche tener conto della plausibilità dell’immagine che esse andrebbero a formare. In alcuni casi, la qualità della ricerca può essere giudicata proprio da come una tessera si integra nel puzzle e si collega con le altre tessere. Molti quesiti scientifici non ancora risolti possono essere indagati solo mediante indagini multidimensionali, in modo da mettere al posto giusto tessere di diversa tipologia. E meno si sa di un puzzle, più sono le tessere di cui abbiamo bisogno. A noi pare che questo esempio metta in luce alcune delle sfide prioritarie che debbono essere affrontate quando si intende indagare l’interazione fra scienze biologiche e sociali e, specificatamente, il ruolo dell’interazione fra genetica ed epidemiologia nella comprensione dei disturbi psichici. I tre Editoriali presentati in questo numero di EPS hanno l’obiettivo di rispondere a tre quesiti principali, ciascuno di questi può essere considerato una tessera di un The aim of the three Editorials published in this issue of EPS is to discuss the potential of the interaction between genetics and epidemiology, not only for psychiatric research but also for clinical practice. Optimal clinical practice can be considered the capacity to design treatments based on the best available knowledge of a puzzle that comprises the factors that cause and interfere with the onset and course of mental disorders. Research is then the process by which pieces of that puzzle are assembled without having the benefit of the box-top picture of the completed puzzle; it takes many separate pieces of the “puzzle” to reach an understanding of the entire scene (Hough & Ursano, 2006). These pieces represent different types of data, often obtained using diverse approaches and techniques. The challenge of the researcher is to imagine each of the missing pieces before actually having them in hand. In solving puzzles, the shape of the pieces is not the only limitation that needs to be satisfied; one must also ensure that the final picture has to make sense. In some instances, the quality of the research is judged by the number of ways a piece of data integrates into and coalesces the rest of the puzzle. The multidimensionality of scientific enquiries makes it essential that as many different pieces of the puzzle as possible are obtained. The more that is unknown about the puzzle, the more pieces one needs. In our opinion, this example is emblematic of the key challenges that we face when addressing the interplay between biological and social sciences, and specifically the interplay between genetics and epidemiology in the understanding of psychiatric diseases. The three Editorials in this Issue of EPS answer to three principal questions, all of which are “pieces” of a puzzle whose “box-top picture” is unclear: i) how genetics and clinical epidemiology research can interact to sharpen our understanding of the phenotype of mental disorders, and, perhaps, help to yield more reliable classifications of mental disorders;

Mental health care of children and adolescents in Serbia: past steps and future directions.

Abstract: Child and adolescent psychiatry (developmental psychiatry) is a relatively young and new discipline. With the advancement of clinical knowledge, research, education and professional activities, this field is continually being enriched and is a challenge for mental health professionals. It was developing in Serbia for the past fifty years and now represents a separate professional discipline which encompasses specific diagnostic procedures, treatment, prevention, rehabilitation and research of disorders of emotional, social and cognitive development of children and adolescents.

Suicide prevention strategies and mental disorders

Abstract: Nel corso dei secoli la complessità del fenomeno del suicidio ha costantemente attratto l’attenzione di filosofi, teologi, medici, sociologi e artisti. Nonostante questo interesse universale, la possibilità di controllare e prevenire tale fenomeno continua ad essere un obiettivo ambizioso e difficile, ancora molto lontano dall’essere raggiunto. Nel presente numero di Epidemiologia e Psichiatria Sociale, tre editoriali discutono la possibilità di attuare interventi farmacologici e non farmacologici che possano avere un impatto positivo sul rischio di suicidio. I tre contributi indicano con chiarezza alcuni aspetti centrali. Primo, il burden associato al suicidio è immenso. Secondo alcune stime dell’OMS, il suicidio è tra le prime 10 cause di morte in ogni Paese, e una delle prime tre cause di morte nella popolazione tra i 15 e 35 anni (World Health Organization, 2000). Il suicidio ha, inoltre, smisurate implicazioni psicologiche e sociali. Si stima che, in media, ogni evento abbia delle ripercussioni su almeno sei persone. Se poi esso avviene in ambito lavorativo o scolare, le ripercussioni possono coinvolgere centinaia di persone. Secondo, c’è una forte relazione tra suicidio e malattia mentale. Vi sono evidenze raccolte sia in Paesi in via di sviluppo che in Paesi sviluppati che indicano una prevalenza di problemi psichici dell’80% nelle casistiche di suicidi portati a compimento. Terzo, la rilevanza del suicidio in quanto indicatore di esito negativo non è confinata ad una malattia mentale specifica o ad uno specifico gruppo di condizioni cliniche ma, al contrario, riguarda in modo trasversale un’ampia gamma di situazioni psicopatologiche: è stato stimato che il rischio lifetime sia del 6-15% nelle patologie affettive, del 7-15% nell’alcolismo, del 4-10% nella schizofrenia. Nei pazienti con disturbi di personalità, il rischio è comparabile a quello presente nelle patologie affettive, anche se è spesso sottostimato in quanto mascherato da condotte e da comportamenti auto-lesivi, auto-mutilanti e auto-distruttivi. Il quarto aspetto, essenziale, che emerge dai contributi, è forse il più disturbante: nonostante alcuni interSuicide is a serious and complex phenomenon that has attracted the attention of philosophers, theologians, physicians, sociologists and artists over the centuries. Despite of this wide interest, its prevention and control represent difficult and ambitious goals that are still far from being achieved. In the present issue of Epidemiologia e Psichiatria Sociale three Editorials discuss the possibility of implementing pharmacological and non-pharmacological intervention strategies that may have a positive impact on the risk of suicide. Some bare facts can clearly be distilled from these contributions. First, the burden of suicide is substantial. According to WHO estimates, suicide is among the top 10 causes of death in every country, and one of the three leading causes of death in the 15 to 35-year age group (World Health Organization, 2000). The psychological and social impact of suicide on the family and society is immeasurable. On average, single suicide intimately affects at least six other people. If a suicide occurs in a school or workplace it has an impact on hundreds of people. Second, there is a strong relationship between suicide and mental disorders. Studies from both developing and developed countries have consistently shown an overall prevalence of mental disorders of around 80% in cases of completed suicide. Third, the relevance of suicide as an outcome is not confined to a specific mental disorder or to a minority of clinical entities, but it cross-sectionally encompasses a wide range of conditions: the lifetime risk of suicide in people with mood disorders has been estimated at 6-15%; in alcoholism, 7-15%; and in schizophrenia, 4-10%. In patients with personality disorders the risk of suicide has been shown to be comparable to the risk of suicide in affective disorders but, regrettably, it is often underestimated because it may be masked by the presence of one or more of a range of low lethality selfdestructive behaviours. The fourth bare fact is possibly the most disappointing one: despite the beneficial effect that some pharmacological and non-pharmacological interventions may have only a few clinical trials have

Innovations in the utilization of health information technology in psychiatric services.

Abstract: There is ever-increasing activity in applying information technology to various areas of healthcare, including mental health. Examples of innovations include applications in screening, treatment, clinical decision support, communication and coordination, telemedicine, Internet-based education and services, public health research, training and education, and bioinformatics. Issues and challenges include protection of privacy, managing narrative free text, assessing the reliability of information found online, and mitigating impact on clinical workflow. While many of the innovations described will not be fully realized until national information systems reach a larger scale, many are having a positive impact on mental healthcare today.

Employment status, aspirations and perceptions of support amongst psychiatric service users in Pavia, Italy.

Abstract: Aims – To describe the employment status of people using mental health service in Pavia, Italy; to explore their employment aspirations and perceptions of support to achieve these; and to test the feasibility of working with service users as researchers. Method – Face to face interviews carried out by two service user researchers with a consecutive sample of 200 service users attending the local psychiatric outpatient department using a translated version of a questionnaire developed for previous UK surveys. Results – A higher proportion of survey participants (42.5%) were in paid work compared to the UK, but 62.4% of those in work were dissatisfied with their employment. Amongst unemployed participants, 65.2% were interested in gaining employment but only 29.3% were receiving support to do so. Support was mainly limited to referral on to a generic disability organisation. The service user researchers carried out the survey to a high standard and reported benefits from undertaking the work. Conclusions – The results indicate a need in Pavia for specialist employment support using the Individual Placement and Support approach. Further development of service user involvement in research is indicated.

Outcome reporting bias in clinical trials.

Abstract: Randomised controlled trials (RCTs) are designed and powered to measure one single outcome, called primary outcome (Sibbald & Roland, 1998; Barbui et al., 2007). The primary outcome is the pre-specified outcome of greatest clinical importance and is usually the one used in the sample size calculation (Accordini, 2007). In addition to the primary outcome, RCTs may have several other outcomes, called secondary outcomes. In contrast with the analysis of the primary outcome, the analysis of secondary outcomes and its interpretation may be complicated by at least two factors: 1) the trial may not have enough statistical power to detect differences (so it is possible to incur in a type II error, that is failing to see a difference that is present);2) increasing the number of secondary outcomes generates the problem of multiplicity of analyses, that is the proliferation of possible comparisons in a trial (and increasing the number of comparisons increases the possibility to incur in a type I error, that is detecting significant differences by chance). For all these reasons, the results of the analysis of primary outcomes is considered less susceptible to bias than the analysis of secondary outcomes.

Twin studies in psychotic disorders.

Abstract: etiology of major psychoses, particularly schizophrenia and bipolar disorder. Nevertheless, little is known about the nature and extent of the specific genetic contribution to disease liability (Kendler et al., 1993; Danese, 2008). Twin studies can provide crucial insights regarding the etiology of sub-threshold and clinical psychosis, and represent an extraordinarily powerful design to establish the role of genes and environment both in the expression of a trait (e.g., development of a disease) and in the co-expression of multiple traits (e.g., comorbidity of multiple diseases). By comparing the correlation for a trait between genetically identical monozygotic (MZ) twins with that between dizygotic (DZ) twins who represent full sibs, and assuming that MZ twins share relevant environmental exposures to the same extent as DZ twins (‘equal environments assumption’), it is possible to estimate the contribution of genetic factors (“heritability”) and environmental influences to the expression of the trait. Furthermore, when multiple phenotypes are studied, cross-twin/cross-trait correlation (i.e., between a given phenotype in a twin and another phenotype in his/her cotwin) in MZ and DZ twin pairs provides information on genetic or environmental influences common to the phenotypes (genetic or environmental correlation between the phenotypes), which could play a role in their coexpression (Boomsma et al., 2002; Spector et al., 2000). The potential of the twin design enormously increased after the implementation of population-based registries of data on twins in several countries (Busjahn & Hur, 2006), including Italy (Fagnani et al., 2006; Stazi et al., 2002). A large body of twin studies aimed at unraveling the genetic and environmental architecture of major psychoses and psychotic symptoms. Although results vary Twin studies in psychotic disorders

Per una storia dell'affidamento dei malati psichiatrici alle famiglie: Towards a history of the family care of psychiatric patients

Abstract: Summary Inserting adults with psychic problems into families has recently been practiced in various European countries and also in Italy, where some mental health departments support such families. Beyond the well known story of Gheel, the etero and omofamily care of psychiatric patients has a forgotten history. Methods – On the basis of unexplored and exceptionally rich sources from the archives of the asylums in Florence, as well as of the Province di Florence, which funded assistance to the mentally ill – this research focuses on the subsidized “domestic custody” of hundreds of psychiatric patients, who had already been institutionalized. Beginning in 1866, outboarding was supported by the provincial administration in Florence with the collaboration of the asylum medical direction. Results – In the late 19th C. and in the early 20th C. prestigious psychiatrists sought alternatives to the institutionalisation. These alternatives involved varied participants in a community (the patients and their families, the administrators and the medical specialists, the neighborhood and the police). The families played a special role that historians of the psychiatry exclusively dedicated to the insane asylums have not really seen. Conclusions – The role of the families in the interaction with the psychiatric staff is not, even on a historiographical level, simply an additional and marginal chapter of the practices and of the culture of the mental health. These archival evidence contradicts some common places on the past of the Italian psychiatry before 1978, and provokes new reflections of possible relevance to the present.

[Quality of life of relatives of patients with obsessive-compulsive disorder: relation to family accommodation and other socio-demographic and clinical characteristics]

Abstract: Numerosi studi hanno confermato che la qualità di vita dei pazienti con disturbo ossessivo-compulsivo (DOC) è compromessa rispetto alla popolazione generale in numerose dimensioni (Moritz et al., 2005; Eisen et al., 2006; Stengler-Wenzke et al., 2006a; Didie et al., 2007; Norberg et al., 2008). La vita del paziente non è tuttavia l’unica a subire l’impatto del disturbo. Diversi studi hanno analizzato la particolare situazione dei familiari dei soggetti con DOC individuando le aree di funzionamento maggiormente compromesse dal vivere quotidianamente e prendersi cura di tale tipo di pazienti (Magliano et al., 1996; Black et al., 1998; Gururaj et al., 2008), ma solo due di essi hanno utilizzato strumenti specifici per la valutazione della qualità di vita (Stengler-Wenzke et al., 2006b; Albert et al., 2007). Entrambi gli studi hanno concluso che la qualità di vita dei familiari sani di pazienti con DOC è maggiormente compromessa; tra i fattori predittivi di maggiore compromissione sono emersi la gravità della sintomatologia ossessivo-compulsiva, l’età avanzata dei familiari, il sesso femminile, l’essere genitore piuttosto che coniuge e il grado di coinvolgimento del familiare nei sintomi O/C del paziente (misurato con la Family Accommodation Scale). Entrambi gli studi, tuttavia, soffrono di alcuni limiti metodologici, quali la mancata considerazione di variabili legate al paziente (Stengler-Wentzke et al., 2006b) o l’esiguità del campione indagato (Albert et al., 2007). Obiettivo del presente studio è: 1) verificare, in un campione indipendente e più ampio, se la qualità di vita dei familiari di pazienti con DOC è compromessa rispetto alla popolazione generale italiana; 2) individuare le caratteristiche socio-demografiche e cliniche di pazienti e familiari che predicono tale compromissione, con particolare attenzione al coinvolgimento diretto dei familiari nei sintomi.

Panic agoraphobic spectrum in psychiatrically healthy subjects: impact on quality of life.

Abstract: Several studies have evaluated the quality of life (QOL) in patients with Panic Disorder (PD). For instance, the Epidemiological Catchment Area Study (ECA) assessed the quality of life (QoL) using the subjective evaluation of health, psychosocial functioning and financial status as parameters (Regier et al., 1984). Among the general population, people with PD or panic attacks reported a low level of physical health in 35% of cases and a low degree of mental health in 38% of cases, similarly to people suffering from Major Depressive Disorder (29% and 39% respectively), but more frequently than the in individuals not affected by any disorder (24% and 12% respectively). Furthermore, 27% of patients with PD were in need of some form of social or financial support in contrast to 16% of people suffering from depression and 12% of unaffected people. The National Comorbidity Survey (NCS) (Magee et al., 1996) found serious interference in activities in 27% of agoraphobic patients. For instance, the agoraphobic subjects reported an average of 1.1 days of work lost in the previous month due to their psychopathology. Several Authors have studied the relationship between PD and a worse quality of life and/or a worse ability to function. In a review on the topic, Mendlowicz & Stein (2000) provided an integrated view of the issue of quality of life in patients with anxiety disorders and concluded that the existing studies almost uniformly show a marked impairment of quality-of-life and psychosocial functioning in individuals with anxiety disorders. However, as noted by the Authors above, “despite the growing number of studies undertaken during the past 15 years, the investigation of quality of life in individuals with anxiety disorders is still in its infancy.” Rucci et al. (1993) evaluated the prevalence of subthreshold psychiatric disorders in primary care and their association with the patients health perception, disability in daily activities and psychological distress Subjects with subthreshold disorders reported levels of psychological distress, disability in daily activities and perceived health comparable to those of patients with full-fledged ICD-10 disorders. Despite the scientific and clinical importance of the topic, relatively few studies have evaluated the prevalence and impact of subthreshold affective disorders in general (Schotte & Cooper, 1999) and panic symptoms in particular (for instance Bellini & Galverni, 2003) in non psychiatric populations. Moreover, the literature on the relationship between sub-threshold or residual PD and quality of life is scant. To this end, we decided to investigate the impact of panic-agoraphobic “spectrum” on the quality of life of subjects who did not meet the criteria for a full blown PD. We adopted the definition of “spectrum” developed by Cassano and colleagues (Cassano & Pini, 2000; Rucci & Maser, 2000), which refers to a dimensional view of psychopathology that includes a broad array of manifestations of the target disorder, including its most severe symptoms as well as a range of more subtle features related to the core condition, which may include temperamental traits, prodromal indicators, or residual symptoms. Although they are frequently associated with specific DSM-IV disorders, these conditions are also found in individuals who have never met full DSM-IV diagnostic criteria. Our hypothesis for this study was that the presence of subthreshold panic-agoraphobic symptomatologies in otherwise healthy individuals would significantly impair the quality of life despite the absence of a full-blown PD diagnosis.

Use of mental health services and unmet needs for socially-at-risk Spanish children and adolescents.

Abstract: Abstract Reported one-year prevalence of service use due to mental disorders in children and adolescents from the general population varies according to country, organization of services, and services considered. Among factors associated with use of services, the literature lists parental and school personnel's perception of problems, having a psychiatric diagnosis (especially externalizing), symptom severity, comorbid disorders, functional impairment, family burden, family environment or being a boy (Cabiya et al., 2006; Farmer et al., 2003; Sayal, 2004). A better understanding of these factors may help to optimize access to services of children needing help.