Standardization of the Maristán Scale of Informal Care in people with schizophrenia and other psychoses

OBJECTIVE

No instrument has been developed and validated across cultures to measure the degree of support provided by informal carers to people with schizophrenia. We aimed to develop such a measure.

METHOD

The Maristán Scale of Informal Care was developed directly from the views of patients with schizophrenia in six countries. Face-to-face interviews were carried out with participants and 103 were repeated after 30 days. Principal Axis Factoring followed by Promax rotation evaluated the structure of the scale. Horn's parallel combined with bootstrapping determined the number of factors. Cronbach's alpha estimated the scale's internal consistency and intra-class correlation its test-retest reliability.

RESULTS

A total of 164 interviews were undertaken, 103 with re-test. The Horn's Parallel Analysis and the analysis of the Promax rotation revealed one factor. Cronbach's alpha was 0.89. Intra-class correlation coefficient was 0.56 (95% CI 0.42-0.68) and this increased to 0.64 (95% CI 0.51-0.75) after removing two outlying values. Patients from Argentina recorded the lowest scores (poor informal support/care).

CONCLUSION

The Maristán Scale of Informal Care is a reliable instrument to assess the degree of support provided by informal carers to people with schizophrenia across cultures. A confirmatory factor analysis is needed to evaluate the stability of its factor structure.

Spiritual and religious beliefs as risk factors for the onset of major depression: an international cohort study

BACKGROUND

Several studies have reported weak associations between religious or spiritual belief and psychological health. However, most have been cross-sectional surveys in the U.S.A., limiting inference about generalizability. An international longitudinal study of incidence of major depression gave us the opportunity to investigate this relationship further.

METHOD

Data were collected in a prospective cohort study of adult general practice attendees across seven countries. Participants were followed at 6 and 12 months. Spiritual and religious beliefs were assessed using a standardized questionnaire, and DSM-IV diagnosis of major depression was made using the Composite International Diagnostic Interview (CIDI). Logistic regression was used to estimate incidence rates and odds ratios (ORs), after multiple imputation of missing data.

RESULTS

The analyses included 8318 attendees. Of participants reporting a spiritual understanding of life at baseline, 10.5% had an episode of depression in the following year compared to 10.3% of religious participants and 7.0% of the secular group (p<0.001). However, the findings varied significantly across countries, with the difference being significant only in the U.K., where spiritual participants were nearly three times more likely to experience an episode of depression than the secular group [OR 2.73, 95% confidence interval (CI) 1.59–4.68]. The strength of belief also had an effect, with participants with strong belief having twice the risk of participants with weak belief. There was no evidence of religion acting as a buffer to prevent depression after a serious life event.

CONCLUSIONS

These results do not support the notion that religious and spiritual life views enhance psychological well-being.

Predicting onset of major depression in general practice attendees in Europe: extending the application of the predictD risk algorithm from 12 to 24 months

BACKGROUND

PredictD is a risk algorithm that was developed to predict risk of onset of major depression over 12 months in general practice attendees in Europe and validated in a similar population in Chile. It was the first risk algorithm to be developed in the field of mental disorders. Our objective was to extend predictD as an algorithm to detect people at risk of major depression over 24 months. Method Participants were 4190 adult attendees to general practices in the UK, Spain, Slovenia and Portugal, who were not depressed at baseline and were followed up for 24 months. The original predictD risk algorithm for onset of DSM-IV major depression had already been developed in data arising from the first 12 months of follow-up. In this analysis we fitted predictD to the longer period of follow-up, first by examining only the second year (12-24 months) and then the whole period of follow-up (0-24 months).

RESULTS

The instrument performed well for prediction of major depression from 12 to 24 months [c-index 0.728, 95% confidence interval (CI) 0.675-0.781], or over the whole 24 months (c-index 0.783, 95% CI 0.757-0.809).

CONCLUSIONS

The predictD risk algorithm for major depression is accurate over 24 months, extending it current use of prediction over 12 months. This strengthens its use in prevention efforts in general medical settings.

Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain

BACKGROUND

The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care.

METHOD

A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI).

RESULTS

Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain.

CONCLUSIONS

The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

An international risk prediction algorithm for the onset of generalized anxiety and panic syndromes in general practice attendees: predictA

BACKGROUND

There are no risk models for the prediction of anxiety that may help in prevention. We aimed to develop a risk algorithm for the onset of generalized anxiety and panic syndromes.

METHOD

Family practice attendees were recruited between April 2003 and February 2005 and followed over 24 months in the UK, Spain, Portugal and Slovenia (Europe4 countries) and over 6 months in The Netherlands, Estonia and Chile. Our main outcome was generalized anxiety and panic syndromes as measured by the Patient Health Questionnaire. We entered 38 variables into a risk model using stepwise logistic regression in Europe4 data, corrected for over-fitting and tested it in The Netherlands, Estonia and Chile.

RESULTS

There were 4905 attendees in Europe4, 1094 in Estonia, 1221 in The Netherlands and 2825 in Chile. In the algorithm four variables were fixed characteristics (sex, age, lifetime depression screen, family history of psychological difficulties); three current status (Short Form 12 physical health subscale and mental health subscale scores, and unsupported difficulties in paid and/or unpaid work); one concerned country; and one time of follow-up. The overall C-index in Europe4 was 0.752 [95% confidence interval (CI) 0.724-0.780]. The effect size for difference in predicted log odds between developing and not developing anxiety was 0.972 (95% CI 0.837-1.107). The validation of predictA resulted in C-indices of 0.731 (95% CI 0.654-0.809) in Estonia, 0.811 (95% CI 0.736-0.886) in The Netherlands and 0.707 (95% CI 0.671-0.742) in Chile.

CONCLUSIONS

PredictA accurately predicts the risk of anxiety syndromes. The algorithm is strikingly similar to the predictD algorithm for major depression, suggesting considerable overlap in the concepts of anxiety and depression.

Implementing a national case-management training program in Portugal

Introduction

In Portugal, a new National Mental Health Plan has been launched with the following objectives: equal access to care, decentralisation of mental health services and integration of mental health services in the general health services. In order to change the operational model for mental health teams, a case-management training program has been launched by the Ministry of Health.

Objectives

This study aims to evaluate: a)

Methods

The study was carried out at 36 public mental health services in mainland Portugal. The professionals attended a case management course (SAMHSA procedures), in which they were trained by means of guidelines, demonstrative audios, scenarios and role-playing. The assessment was conducted with a questionnaire addressing logistics, program content, acquisition of skills, usefulness and overall satisfaction.

Results

135 professionals from the whole country have been involved. The trainees’ acquisition of competences was found rather satisfactory. Results of the training were impressive regarding satisfaction and motivation of the trainees (69% were highly satisfied). Dimensions such as organization (35% highly satisfied, 52% satisfied), program content (41% highly satisfied, 43% satisfied), practical skills gaining (35% highly satisfied, 58% satisfied) and usefulness (58% highly satisfied, 31% satisfied) were also very well rated.

Conclusions

Of upmost relevance, it was possible to implement a case management training program at a national level, with no particular difficulties. The impact of courses on trainees was overall impressive.

Differences in clinical and needs assessment between inmates with high versus low risk of suicide

Introduction

Drugs addiction, suicide and mental health disorders are the major problems of inmates health. In Portugal the suicide is the second cause of death and is increasing in a panorama of general decreased mortality in prisons.

Objectives

To characterize and compare the inmate population with high versus low risk of suicidality, according several variables including the needs for care.

Methods

A descriptive study of a non-probabilistic sample constituted by all male inmates referenced to a forensic psychiatric clinic in Lisbon region, during a year (April 2009–2010), was performed. The data was collect from user and professional interviews and user file. The instruments, besides a specific questionnaire, includes MINI; BPRS and the Camberwell Assessment of Need, Forensic Version (CANFOR). The suicide risk was defined by C section from MINI and defined as a dichotomic variable: null/low or moderate/high suicide risk.

Results

The sample was composed of seventy nine inmates (median age 36). Major depression was the only diagnostic significantly associated with suicide risk. There was a significant association between moderate/high risk of suicide and the unmet needs rated by users in psychological distress, safety to self, drugs and company domains and unmet needs rated by staff in daytime activities, psychological distress, safety to self and drugs domains.

Conclusion

The suicide prevention is a crucial issue in prisons. The assessment of suicide risk, psychiatric care and care delivery in unmet needs domains may have a positive impact in self harm and suicide incidence.

Whole-body measurements at Ipen, Brazil

The intake of radioactive material by workers can occur in the radiopharmaceuticals production or during the handling of these in the medical fields (nuclear medicine). The workers who work in areas where exposures are significant are routinely monitored to demonstrate that the workers are receiving adequate protection from internal contamination. Direct measurements of whole-body and thyroid contents provide an estimate of the activity value of these radionuclides in the potentially exposed workers. The whole-body measurements of the workers, trainees and visitors are routinely performed by the In Vivo Monitoring Laboratory (LMIV) of the Energy and Nuclear Research Institute (IPEN/CNEN-SP). The frequency of measurements is defined by the Radioprotection Service (SRP) and the Dose Calculation Group of IPEN. During the period 2006-2007, 2500 measurements had been carried in workers who develop tasks related to the production of radiopharmaceuticals. The activity value of the radionuclides and the workers' tasks relationship had been evaluated.

A six-panel PCR of both plasma and blood for EBV-DNA as tumor marker for nasopharyngeal carcinoma patients treated in the United States

e17014

Background: Studies of plasma from nasopharyngeal carcinoma (NPC) patients from endemic regions demonstrate that circulating DNA derived from EBV may be used as a tumor marker, but data from non-endemic regions or in whole blood are limited. Methods: ViraCor Laboratories (Lee's Summit, MO) performed PCR for EBNA, EBER, and LMP on both plasma and whole blood of 11 NPC patients undergoing therapy at the Hospital of the University of Pennsylvania. Results were correlated with disease status via review of chart records and imaging reports. Results: 7 of 11 patients tested were positive for circulating EBV derived DNA. 2 patients were treated with induction chemotherapy with suppression to 0 copies of circulating DNA for all plasma measures, but not whole blood measures (LMP 0, EBER 100 and EBNA 200 copies for one patient and LMP 100, EBNA 100 and EBER 300 copies for the other). The first of these patients remains free of disease but the other retains a large mass believed to be active disease, but which has not grown over 8 months following therapy. 5 patients, including the 2 patients treated with induction therapy, were treated with chemoradiotherapy. PCR following therapy was negative on all plasma measures for the 4 patients who remain free of disease (at intervals of 7, 12, 13 and 16 months). 2 of these patients retained low-level EBV on at least 1 whole-blood measure–1 for EBNA alone (100 copies) and the other for both EBER and EBNA (300 and 100 copies). 2 patients were treated for metastatic disease. 3 episodes of progression were all accompanied by increases in plasma EBV (EBNA from 13,700 to 21,100 with EBER 1600 to 9400 and EBNA 1800 to 2200 to 3000 with EBER 100 to 100 to 500). Conclusions: This pilot data on a population treated in the United States is consistent with larger data sets obtained in endemic regions demonstrating that EBV is an effective tumor marker for prognosis and to follow therapy. It is the first to demonstrate greater specificity of plasma measures over whole blood measures, and it raises the hypothesis that whole blood measures may be more sensitive. Further prospective study is warranted in non-endemic populations both to validate the measure and to facilitate translational research into biologic factors driving the behavior of these tumors.

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is Feigned Psychosis a Pathway to Schizophrenia?

Factitious disorders (FD) are characterized by intentional production of either physical, psychological or mixed symptoms that mimic various clinical syndromes, with no apparent advantage for the individual concerned other than allowing him to assume the sick role. Large body of work has been accumulated on FD, but the majority of published data deal with the physical variant of the disease, with comparable few reports on psychiatric FD. Although there are many different presentations for psychiatric FD, the factitious psychosis subset justifies particular attention. Factitious psychosis may be prodromic of a genuine chronic psychosis, usually in the context of a personality disorder. Published data shows Munchausen psychosis, a severe subset of FD psychosis, with a prevalence of 0.25% of all inpatient admissions and global FD psychosis attaining 4.1% of all diagnosed psychoses, generally with a poor prognosis.

The scantiness of studies on the subject of psychiatric FD and factitious psychosis in particular, despite its significant prevalence, coupled with the fact that its recognition embarks on a radically different approach compared with the physical variant, stresses the need for case reporting.

We present four clinical cases with discussion of the underlying pathology and outcome, and a systematic review of the literature of FD psychosis case reports. This is followed by further discussion addressing the recognition of factitious psychosis, its etiological contributing factors, management, effects on staff and diagnostic criteria.