Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

Background.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

Methods.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

Results.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

Conclusions.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Trauma and suicidality in war affected communities

Purpose

The aim was to assess whether experiences of war trauma remain directly associated with suicidality in war affected communities when other risk factors are considered.

Materials and methods

In the main sample 3313 participants from former Yugoslavia who experienced war trauma were recruited using a random sampling in five Balkan countries. In the second sample 854 refugees from former Yugoslavia recruited through registers and networking in three Western European countries. Sociodemographic and data on trauma exposure, psychiatric diagnoses and level of suicidality were assessed.

Results

In the main sample 113 participants (3.4%) had high suicidality, which was associated with number of potentially traumatic war experiences (odds ratio 1.1) and war related imprisonment (odds ratio 3) once all measured risk factors were considered. These associations were confirmed in the refugee sample with a higher suicidality rate (10.2%).

Discussion and conclusions

Number of potentially traumatic war experiences, in particular imprisonment, may be considered as a relevant risk factor for suicidality in people affected by war.

Prenatal and Perinatal Factors in Autism Spectrum Disorders–a Case Control Study of a Serbian Sample

Introduction

Autism spectrum disorders (ASD) are complex psychiatric disorders, with both genetic and environmental factors implicated in their etiology. Recent studies suggest the prenatal and early postnatal genesis of ASD, therefore, understanding the effect of environmental risk factors could be important for prevention and treatment of ASD.

Aims

The aim of this study was to determine the association of prenatal factors and perinatal complications with ASD.

Methods

Our study included 102 subjects with ASD (80% boys) aged 9.35 ± 5.85, and 107 age and sex matched healthy controls (77% boys). For the diagnosis of ASD, we used the ICD-10 criteria and Autism Diagnostic Interview-Revised (ADI-R). A questionnaire regarding prenatal and perinatal factors/complications was administered to all subjects.

Results

Logistic regression model of having autism vs. being a control subject included gender, age, maternal and paternal age at birth, pregnancy order, smoking in pregnancy, number of medication during pregnancy (mostly tocolytics, antihypertensives, antiarrhythmics), and early postnatal complications (mostly prematurity, low birth weight, hyperbilirubinaemia). The model was significant, explaining about the third of variance, with number of medication during pregnancy and having an early postnatal complication as significant predictors.

Conclusions

Our study has shown a significant association of specific prenatal and perinatal factors and ASD, even after controlling for other potential confounding variables. Identifying specific risk factors is important for prevention of ASD. It is also the first step in defining basis of the gene–environment interaction mechanism, which might enable development of an individualised therapeutic approach for this group of disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The INTERPRET-DD study of diabetes and depression: a protocol

AIM

People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe.

METHOD

INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated.

RESULTS

Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use.

CONCLUSIONS

Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression.

Child is father of the man: child abuse and development of future psychopathology

Available epidemiological data indicate that the abuse of children within families is a very common phenomenon, and is still on the rise. Among others, abuse includes direct physical and emotional violence to the child, as well as the indirect emotional trauma of witnessing interparental violence. These early trauma experienced within the context of the family can influence the development of the child's personality as well as predispose towards the development of mental disorders in adulthood. There are some important factors influencing the occurrence of abuse, or the conditions predisposing it: certain parental personality traits appear to be instrumental, and the presence of individual psychopathology of parents is also connected with different forms of family dysfunction as a system, representing a variable which is interpolated in the quality of parenthood as the most important factor that determines long-term consequences on children and possible future psychopathology. The complex but tangible effects of parents' personality traits on the psychological development of children may contribute to the transgenerational transmission of abuse and violence. The phenomenon of domestic violence and abuse can be described from the perspective of the psychological and systemic theoretical postulates. According to systemic theory and practice, dysfunctional communication in the family is a significant predictor for domestic violence. Characteristics of dysfunctional communication include low levels of verbal expressiveness and emotional responsiveness, low tolerance to criticism and its interpretation as a threat or intimidation, and consequently increased anxiety and subsequent escalation of an argument into violence. Overall it seems that there may be a complex connection between parental personality and family interaction patterns, leading to dysfunctional communication which further amplifies the detrimental characteristics of family dynamics, and eventually escalates to violence. According to one theory, there may be a degree of transgenerational transmission of these communication patterns in children who have been victims of violence, thus propagating the conditions for violence, this time perpetrated by the victims themselves. Therefore there is a pressing need for prevention, perhaps through psychoeducation for parents or through early detection and treatment of traumatized children and adolescents, in the hope that the transgenerational vicious cycle of violence may be broken.

Course of post-traumatic stress disorder following war in the Balkans: 1-year follow-up study

BACKGROUND

Prevalence rates of post-traumatic stress disorder (PTSD) following the experience of war have been shown to be high. However, little is known about the course of the disorder in people who remained in the area of conflict and in refugees. Method We studied a representative sample of 522 adults with war-related PTSD in five Balkan countries and 215 compatriot refugees in three Western European countries. They were assessed on average 8 years after the war and reinterviewed 1 year later. We established change in PTSD symptoms, measured on the Impact of Events Scale - Revised (IES-R), and factors associated with more or less favourable outcomes.

RESULTS

During the 1-year period, symptoms decreased substantially in both Balkan residents and in refugees. The differences were significant for IES-R total scores and for the three subscales of intrusions, avoidance and hyperarousal. In multivariable regressions adjusting for the level of baseline symptoms, co-morbidity with depression predicted less favourable symptom change in Balkan residents. More pre-war traumatic events and the use of mental health services within the follow-up period were associated with less improvement in refugees.

CONCLUSIONS

Several years after the war, people with PTSD reported significant symptom improvement that might indicate a fluctuating course over time. Co-morbid depression may have to be targeted in the treatment of people who remained in the post-conflict regions whereas the use of mental health services seems to be linked to the persistence of symptoms among refugees.

A case of pregabalin intoxication

Pregabalin, or S-(+)-3-isobutylgaba, is a lipophilic analogue of GABA. Although pregabalin is structurally related to GABA, it is inactive at GABA receptors and does not appear to mimic GABA physiologically. Pregabalin is a potent ligand for the alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system. It is currently being licensed for epilepsy, neuropathic pain, and generalized anxiety disorder. There are few case reports that have demonstrated safety of pregabalin in case of intoxication. We report here a case of pregabalin toxicity with a moderate pregabalin concentration that was successfully managed with conservative treatment only. The case report describes a 54-year-old man who was treated with pregabalin for generalized anxiety disorder. After having experienced a significant stress on a job the patient ingested huge amount of pregabalin (4,2 r) together with bromazepam (21 mg) and chlorimipramine (125 mg). On presentation he was conscious and alert with a stable condition of cardiovascular and respiratory systems. The serum pregabalin concentration was 20.8 mg/L but the patient did not have any signs of toxicity. Thanks to his good and stable somatic condition the patient was managed with supportive treatment only. Although anecdotal, our case report points toward safety of pregabalin following deliberate self-poisoning. Our observation is in accordance with the recent international literature underlining that pregabalin was listed as the drug ingested in only 1% of fatalities, usually in combination with other drugs.

Mental health promotion: guidance and strategies

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

Stress and personality

Stress is an adaptation reaction of living organisms in response to internal or external threats to homeostasis. It is considered as a complex defence mechanism representing the final endpoint of numerous dynamic and interconnected factors of biological, psychological and social nature. Stress is not a simple, stimulus-response reaction, but the interaction between an individual and the environment, involving subjective perception and assessment of stressors, thus constituting a highly personalized process. Specific inherited characteristics, early experience in life, and particular, learned cognitive predispositions make individuals more or less susceptible to the effects of stressors. Resilience and vulnerability to stressors as well as intensity of stress response are greatly dependable on age, gender, intelligence, and numerous characteristics of personality, such as hardiness,locus of control, self-efficacy, self-esteem, optimism, hostility (component of type A personality)and type D traits (negative affectivity and social inhibition). To understand the relation between personality and stress, it is essential to recognize the impact of individual differences in the following four aspects: (1) choice or avoidance of environments that are associated with specific stressors, challenges or benefits, (2) way of interpreting a stressful situation and evaluating one's own abilities and capacities for proactive behaviour so as to confront or avoid it, (3) intensity of response to a stressor,and (4) coping strategies employed by the individual facing a stressful situation. Studies have recorded considerable consistency in coping strategies employed to confront stressful situations, independentlyof situational factors and in connection with permanent personality and temperamental traits,such as neuroticism, extraversion, sense of humour, persistence, fatalism, conscientiousness, andopenness to experience. Positive affect has been associated with positive reappraisal (reframing) ofstressful situations, goal-directed problem-focused coping, using spiritual or religious beliefs to seekcomfort, and infusion of meaning into the ordinary events of daily life in order to gain a psychologicaltime-out from distress. Characteristics of a resilient personality are: ability to cope in stressful situations,continuing engagement in activities, flexibility to unexpected changes in life, ability to seeksocial support, perceiving stress as a challenge - a chance for growth and development rather than athreat to life, taking care of one's body, living in harmony with nature, optimism and sense of humour,work and love, developing spiritualism and seeking true sense. The tolerance threshold is individual.However, even persons with mature and integrated personalities exposed to prolonged stress mayexperience failure of their adaptive capacities and psychological or somatic decompensation. Duringthe last years, Life Skills Education has become the focus of particular attention. Educational programsaim at developing the capacities for critical thinking, analyzing and problem-solving, buildingof self-confidence, confronting various negative pressures imposed by the environment, improvingself-assessment, developing communication and social adjustment skills, and gaining control overstressors and one's own affective and behavioral response. Finally, special programs for individualvulnerable population groups (teenagers, elderly persons, patients with AIDS, addictions, etc.) havebeen introduced so as to strengthen their ability to handle specific stressful situations.

Psychotropic medication use in children and adolescents in an inpatient setting

Medication can be an effective part of treatment for several psychiatric disorders of childhood and adolescence but its use should be based on a comprehensive psychiatric evaluation and treatment plan. The aim of this study was to evaluate psychotropic medication use for children and adolescents treated as inpatients and to compare it with principles of rational pharmacotherapy, thus identifying possible downsides of current practices and pointing a way towards safer and more efficient practices. This is a descriptive study of prescribing trends at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade, during the period from September 2009 to September 2010. Analyzed demographic data (age, gender) and the number of hospitalizations were obtained from medical histories, while diagnoses were obtained from discharge notes. Prescribed therapy was copied from medication charts. Drug dosages were analyzed as average daily doses prescribed during the hospitalization. Psychiatric diagnoses were classified according to The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). During the examined time period, 264 patients were hospitalized (61.4% males), with an average age of 11.4±5.1 years. We have found that 66.3% of admitted patients were treated with pharmacotherapy in addition to other treatment modalities. There was a highly significant correlation between the age of patients and the prescribed dosage (Spearman's rho=0.360, p<0.001) as well as the number of prescribed drugs (Spearman's rho=0.405, p<0.001). The most commonly diagnosed psychiatric disorders were: autism spectrum disorders (20.8%), conduct disorders(19.7%), mixed developmental disorder (14.8%), adjustment disorder (7.2%), mental retardation (7.2%),acute psychosis (4.5%), and ADHD (2.3%). The most commonly prescribed medications were antipsychotics(45.9%), followed by antidepressants (17.2%), mood stabilizers (16.1%), benzodiazepines (14.4%), and other psychotropic drugs (6.4%). The most commonly prescribed antipsychotic was risperidone, used for more than 50% of the patients treated with antipsychotics. Taken together risperidone and chlorpromazine were more than 75% of all prescribed antipsychotics. 98.4% of prescribed antidepressants belonged to the SSRIs,with sertraline and fluoxetine accounting for almost 90% of them. All prescribed dosages were in accordance with the official guidelines. This is the first survey in Serbia to document the practice of prescribing psychotropic medication in the field of child and adolescent psychiatry. Current drug-prescribing practices at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade are in accordance with current practices in the United States and Europe. Not every child with symptoms of mental health problems needs pharmacological treatment; when they do, the general rule of thumb should be "start low, go slow, and taper slowly". Follow-up studies are necessary to assess the change of trends, as well as studies in different patient populations and health centers, in order to globally evaluate psychotropic medication use in children and adolescents in Serbia.

Quality of Life of Patients Suffering from Schizophrenia Treated with Clozapine and Risperidone

Background:

Quality of life (QoL) is considered an important outcome in the treatment of schizophrenia and is linked with clinical and social recovery. Until recently treatments of schizophrenia have focused mainly on reducing positive symptoms, often leaving patients with numerous residual difficulties. It's been expected that atypical antipsychotics improve QoL equally as they improve clinical outcome of the patients with schizophrenia.

Objectives:

To compare clinical improvement and QoL of patients treated with risperidone and clozapine two months after the beginning of treatment.

Methods:

The sample included 40 patients (17 males and 23 females, mean age 33.1) with diagnosis of schizophrenia according to ICD-X. the patients were treated with either risperidone (n=20) or clozapine (n=20). the PANSS and CGI scales for clinical status were applied at the beginning of the treatment and two months later. the QoL was assessed by the WHOQOL-BREF.

Results:

Analysis of data has shown a significant difference for all four domains (physical, psychological, social relationships and environment) at WHOQOL-BREF scale for both medications after two months, but no difference between the two antipsychotics. the patients treated with clozapine had significantly higher scores on PANSS at the beginning of treatment. PANSS and CGI applied after two months have not shown differences between the medications.

Conclusion:

Both clozapine and risperidone had equal and statistically significant effect in reducing the symptoms of schizophrenia measured by PANSS and CGI in two months period, as well as in improving the quality of life. However no difference was found between the two medications.

Personality dimensions of sexually transmitted disease repeaters assessed with the Millon Clinical Multiaxial Inventory

OBJECTIVE

To assess the personality characteristics of patients with repeated sexually transmitted diseases (STD).

METHOD

A case-control study comparing 101 STD repeaters (subjects with a lifetime history of three or more STDs) with 182 controls who had no history of STD. All subjects attended the City Department for Skin and Venereal Diseases in Belgrade (Yugoslavia) from June 1997 to April 1998. Personality characteristics was assessed by the Millon Clinical Multiaxial Inventory (MCMI).

RESULTS

The analysis of MCMI test showed that STD repeaters had higher scores on narcissistic, antisocial and paranoid scales. The difference between STD repeaters and the controls was significant on antisocial, psychotic thinking and psychotic delusion scales, although scores on clinical syndromes were low for both cases and controls. Discriminant analysis showed that antisocial personality was predictive for STD repeaters.

CONCLUSIONS

This study support the hypothesis that STD repeaters are different from controls in terms of their psychological characteristics. The behaviour of STD repeaters is ego-syntonic, which makes the treatment of their personality difficult and emphasizes the importance of work on primary and secondary prevention of STD.

Personality disorders: model for conceptual approach and classification. Part I: General model

In this article we present data suggesting that one core deficit in personality represents a common dimension extending across most categories of personality disorders (PDs), whereas clinically discrete syndromes classified as PDs in DSM IIIR are categorical maladaptive types related orthogonally to the common borderline dimension. In a sample of 121 subjects with PDs and 67 controls, persons with PDs and without PDs manifested similar profiles on the Millon Clinical Multiaxial Inventory (MCMI) scales for various behavior styles. Conversely, the two groups consistently differed with respect to the MCMI borderline scale: in contrast to non-PD persons, those with PDs were strikingly more borderline and typically scored above 75 points (the latter has been established as the cut off for the diagnosis of Borderline PD). Likewise, persons with PDs scored significantly higher on the Diagnostic Interview for Borderlines than the control group. These results suggest that: i) most symptoms usually considered typical of the borderline personality characterize other PDs as well; ii) borderline features seem to be characteristic of persons with PDs and can be used to distinguish PDs vs. non-PDs. Therefore, symptoms widely regarded as typical of the borderline personality characterize other PDs as well. This shared dimension may explain the overlap in categorical diagnoses of individual PDs. Moreover, this shared dimension may be efficiently used as the classificatory principle for PDs. In Part II of this article, we present a model that classifies deviant behaviors in a systematic way, i.e., combines three levels of functioning (normal, neurotic, and borderline) with a limited number of categories of (mal) adaptive behavior types.