Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries

BACKGROUND

Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians' treatment choices for post-traumatic stress disorder (PTSD).

METHODS

The case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148).

RESULTS

About 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct "profiles" of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines.

CONCLUSIONS

Clinicians' decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.

Ethical dilemmas in contemporary psychiatry: Findings from a survey of National Psychiatric Associations in Europe

BACKGROUND

The European Psychiatric Association (EPA) is an organization that speaks on behalf of its individual members and members of National Psychiatric Associations (NPAs). The aim of this study to identify and investigate current contents of ethical codes and practices in the countries belonging to EPA.

METHODS

The study is an expert survey sent out to 44 representatives of 30 NPAs covering the following topics: the existence of national bodies dealing with ethical issues in psychiatry, the availability of documents relevant to ethical issues, the types of ethical issues addressed at the national level, and the current and envisaged ethical debates.

RESULTS

Out of 44 experts invited to participate in the study, 31 NPAs from 30 countries responded (response rate 70.45%). In the majority of countries, the general mission statement serves as the main document covering ethical issues in psychiatry. Most frequently, internal documents were reported to address medical malpractice, workplace bullying, plagiarism, academic fraud, sexual abuse, and discrimination/racism. Furthermore, internal documents cover the ethical assessment of potentially controversial procedures, including psychosurgery, euthanasia, and pregnancy termination. The most important topics for debate at the level of NPAs/EPA were associated with violations of clinical practice standards and human rights.

CONCLUSIONS

NPAs are active in the field of professional ethics, defining ethical standards related to interactions among professionals and services provided by mental health care professionals. Future collaboration of NPAs, under the umbrella of the EPA, could allow to develop a database of local ethical documents that would be translated into English and accessible to all EPA members.

An expert review of clozapine in Eastern European countries: Use, regulations and pharmacovigilance

OBJECTIVES

To compare the prevalence, regulations, and pharmacovigilance practices of clozapine use in Eastern European countries (except Russia).

METHODS

Questionnaires and data from administrative databases (2016 and 2021), package inserts and national guidelines were collected from 21 co-authors from 21 countries. Reports of clozapine adverse drug reactions (ADRs) sent to the global pharmacovigilance database (VigiBase™) were analyzed from introduction to December 31, 2022.

RESULTS

Clozapine prescription among antipsychotics in 2021 varied six-fold across countries, from 2.8 % in the Czech Republic to 15.8 % in Montenegro. The utilization of antipsychotics in both 2016 and 2021 was highest in Croatia, and lowest in Serbia in 2016, and Montenegro in 2021, which had half the defined daily dose (DDD)/1000/day compared to the Croatian data. From 2016 to 2021, the prevalence of antipsychotic use increased in almost all countries; the proportion of clozapine use mainly remained unchanged. Differences were detected in hematological monitoring requirements and clozapine approved indications. Only a few national schizophrenia guidelines mention clozapine-induced myocarditis or individual titration schemes. The VigiBase search indicated major underreporting regarding clozapine and its fatal outcomes. By comparison, the United Kingdom had less than half the population of these Eastern European countries but reported to VigiBase more clozapine ADRs by 89-fold and clozapine fatal outcomes by almost 300-fold.

CONCLUSION

Clozapine is under-utilized in Eastern European countries. Introducing individualized clozapine treatment schedules may help to maximize clozapine benefits and safety. Major improvement is needed in reporting clozapine ADRs and fatal outcomes in Eastern European countries.

Intact and deficient contextual processing in schizophrenia patients

Schizophrenia patients are known to have deficits in contextual vision. However, results are often very mixed. In some paradigms, patients do not take the context into account and, hence, perform more veridically than healthy controls. In other paradigms, context deteriorates performance much more strongly in patients compared to healthy controls. These mixed results may be explained by differences in the paradigms as well as by small or biased samples, given the large heterogeneity of patients' deficits. Here, we show that mixed results may also come from idiosyncrasies of the stimuli used because in variants of the same visual paradigm, tested with the same participants, we found intact and deficient processing.

The EEG multiverse of schizophrenia

Research on schizophrenia typically focuses on one paradigm for which clear-cut differences between patients and controls are established. Great efforts are made to understand the underlying genetical, neurophysiological, and cognitive mechanisms, which eventually may explain the clinical outcome. One tacit assumption of these "deep rooting" approaches is that paradigms tap into common and representative aspects of the disorder. Here, we analyzed the resting-state electroencephalogram (EEG) of 121 schizophrenia patients and 75 controls. Using multiple signal processing methods, we extracted 194 EEG features. Sixty-nine out of the 194 EEG features showed a significant difference between patients and controls, indicating that these features detect an important aspect of schizophrenia. Surprisingly, the correlations between these features were very low. We discuss several explanations to our results and propose that complementing "deep" with "shallow" rooting approaches might help in understanding the underlying mechanisms of the disorder.

Past, Present, and Future of Involuntary Admission in Georgia

Since gaining independence in 1991, Georgia has struggled to transform the old-Soviet mental health care structure into a humane system to meet basic human rights standards.

The current version of the mental health law was introduced in 2007, which instituted the new practice that required court decisions for involuntary hospitalization and several practical procedures.

The Public Defender’s Office (Special reports, 2019-2021) revealed gaps and contradictions within the law that lead to human rights violations and malpractices in involuntary hospitalization.

Currently, the group of Georgian experts with international support from Expertise France- French Development Agency, at the request of the Ministry, are working on the new version of the mental health law, which will be in line with international requirements and standards.

Disclosure

No significant relationships.

Embedded figures in schizophrenia: A main deficit but no specificity

Visual deficits are core deficits of schizophrenia. Classically, deficits are determined with demanding psychophysical tasks requiring fine-grained spatial or temporal resolution. Less is known about holistic processing. Here, we employed the Leuven Embedded Figures Test (L-EFT) measuring classic aspects of Gestalt processing. A target shape is embedded in a context and observers have to detect as quickly as possible in which display the target is embedded. Targets vary in closure, symmetry, complexity, and good continuation. In all conditions, schizophrenia patients had longer RTs compared to controls and depressive patients and to a lesser extent compared to their siblings. There was no interaction suggesting that, once the main deficit of schizophrenia patients is discarded, there are no further deficits in Gestalt perception between the groups. This result is in line with a growing line of research showing that when schizophrenia patients are given sufficient time to accomplish the task, they perform as well as controls.

Mental health services in Scandinavia and Eurasia: comparison of financing and provision

The aim of this study was to compare financial and human resources for mental health services in selected Scandinavian and Eurasian countries. A cross-sectional descriptive and analytical approach was adopted to analyse questionnaire data provided by members of the Ukraine-Norway-Armenia Partnership Project. We compared Scandinavia (Sweden and Norway) and Eurasia (Armenia, Georgia, Kyrgyzstan and Ukraine). Health expenditure in Eurasia was generally below 4% of gross domestic product, with the exception of Georgia (10.2%), compared with 11% in Scandinavia. Inpatient hospital care commonly exceeded 50% of the mental health budget. The central governments in Eurasia paid for over 50% of the health expenditure, compared to 2% in Scandinavia. The number of mental health personnel per head of population was much smaller in Eurasia than Scandinavia. Financial and human resources were limited in Eurasia and mainly concentrated on institutional services. Health activities were largely managed by central governments. Community-based mental healthcare was poorly implemented, compared to Scandinavia, especially for children and adolescents.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries

Background

While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.

Methods

We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.

Results

SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.

Conclusions

The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

Transitioning to community-based mental healthcare: reform experiences of five countries

Following the growing global focus on deinstitutionalisation in the past 50 years, accessible community mental health services was a highlighted commitment in the European Mental Health Action Plan 2013–2020 to improve well-being of patients and families. The progress of transition has been uneven in some Eastern European countries. This paper aims to update and reflect on the examples of five countries across the region.

Mental health services during the first wave of the COVID-19 pandemic in Europe: Results from the EPA Ambassadors Survey and implications for clinical practice

Background

The COVID-19 pandemic caused an unprecedented worldwide crisis affecting several sectors, including health, social care, economy and society at large. The World Health Organisation has emphasized that mental health care should be considered as one of the core sectors within the overall COVID-19 health response. By March 2020, recommendations for the organization of mental health services across Europe have been developed by several national and international mental health professional associations.

Methods

The European Psychiatric Association (EPA) surveyed a large European sample of psychiatrists, namely the “EPA Ambassadors”, on their clinical experience of the impact of COVID-19 pandemic on the treatment of psychiatric patients during the month of April 2020 in order to: a) identify and report the views and experiences of European psychiatrists; and b) represent and share these results with mental health policy makers at European level. Based on the recommendations issued by national psychiatric associations and on the results of our survey, we identified important organisational aspects of mental health care during the peak of the first wave of the COVID-19.

Results

While most of the recommendations followed the same principles, significant differences between countries emerged in service delivery, mainly relating to referrals to outpatients and for inpatient admission, assessments and treatment for people with mental disorders. Compared to previous months, the mean number of patients treated by psychiatrists in outpatient settings halved in April 2020. In the same period, the number of mentally ill patients tested for, or developing, COVID-19 was low. In most of countries, traditional face-to-face visits were replaced by online remote consultations.

Conclusions

Based on our findings we recommend: 1) to implement professional guidelines into practice and harmonize psychiatric clinical practice across Europe; 2) to monitor the treatment outcomes of patients with COVID-19 and pre-existing mental disorders; 3) to keep psychiatric services active by using all available options (for example telepsychiatry); 4) to increase communication and cooperation between different health care providers.

The Implementation of the WHO Mental Health Gap Intervention Guide (mhGAP-IG) in Ukraine, Armenia, Georgia and Kyrgyz Republic

Despite the increasing burden of mental disorders, a lot of people worldwide suffer a gap in receiving necessary care in these countries. To close this gap, the WHO has developed mhGAP training modules aimed at scaling up mental health and substance use disorders services, especially in low- and middle-income countries. This article presents the experience of implementing the Mental Health Gap Action Programme (mhGAP) in Ukraine, Armenia, Georgia, and Kyrgyz Republic. Data were gathered from an electronic questionnaire administered to representatives from higher educational institutions where the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) was implemented in existing curricula for medical students, interns, and residents in family medicine and neurology, practicing physicians, and master's program in mental health students. More than 700 students went through the programs that provided the feedback. Evaluations of program effectiveness mainly involved standard discipline tests or pre- and post-tests proposed in the mhGAP trainer manual. This finding suggested that mhGAP-IG can be successfully adapted and implemented both on undergraduate and on postgraduate education levels and among medical and nonmedical specialists. Future evaluations need to more definitively assess the clinical effectiveness of mhGAP-IG implementation.

Electrophysiological correlates of visual backward masking in patients with bipolar disorder

In visual backward masking (VBM), a target is followed by a mask that decreases target discriminability. Schizophrenia patients (SZ) show strong and reproducible masking impairments, which are associated with reduced EEG amplitudes. Patients with bipolar disorder (BP) show masking deficits, too. Here, we investigated the neural EEG correlates of VBM in BP. 122 SZ, 94 unaffected controls, and 38 BP joined a standard VBM experiment. 123 SZ, 94 unaffected controls and 16 BP joined a corresponding EEG experiment, analyzed in terms of global field power. As in previous studies, SZ and BP show strong masking deficits. Importantly and similarly to SZ, BP show decreased global field power amplitudes at approximately 200 ms after the target onset, compared to controls. These results suggest that VBM deficits are not specific for schizophrenia but for a broader range of functional psychoses. Potentially, both SZ and BP show deficient target enhancement.

Universal Patterns in Color-Emotion Associations Are Further Shaped by Linguistic and Geographic Proximity

Many of us “see red,” “feel blue,” or “turn green with envy.” Are such color-emotion associations fundamental to our shared cognitive architecture, or are they cultural creations learned through our languages and traditions? To answer these questions, we tested emotional associations of colors in 4,598 participants from 30 nations speaking 22 native languages. Participants associated 20 emotion concepts with 12 color terms. Pattern-similarity analyses revealed universal color-emotion associations (average similarity coefficient r = .88). However, local differences were also apparent. A machine-learning algorithm revealed that nation predicted color-emotion associations above and beyond those observed universally. Similarity was greater when nations were linguistically or geographically close. This study highlights robust universal color-emotion associations, further modulated by linguistic and geographic factors. These results pose further theoretical and empirical questions about the affective properties of color and may inform practice in applied domains, such as well-being and design.

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.

Neural Compensation Mechanisms of Siblings of Schizophrenia Patients as Revealed by High-Density EEG

Visual backward masking (VBM) deficits are candidate endophenotypes of schizophrenia indexing genetic liability of the disorder. In VBM, a target is followed by a mask that deteriorates target perception. Schizophrenia patients and, to a lesser extent, their unaffected relatives show strong and reproducible VBM deficits. In patients, VBM deficits are associated with strongly decreased amplitudes in the evoked-related potentials (ERPs). Here, to unveil the neural mechanisms of VBM in schizophrenia, circumventing illness-specific confounds, we investigated the electroencephalogram correlates of VBM in unaffected siblings of schizophrenia patients. We tested 110 schizophrenia patients, 60 siblings, and 83 healthy controls. As in previous studies, patients showed strong behavioral deficits and decreased ERP amplitudes compared to controls. Surprisingly, the ERP amplitudes of siblings were even higher than the ones of controls, while their performances were similar. ERP amplitudes in siblings were found to correlate with performance. These results suggest that VBM is deteriorated in patients and siblings. However, siblings, unlike patients, can partially compensate for the deficits by over-activating a network of brain regions.

WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG): the first pre-service training study

Background

Despite the increasing burden of mental, neurological, and substance use (MNS) disorders, a significant treatment gap for these disorders continues to exist across the world, and especially in low- and middle-income countries. To bridge the treatment gap, the World Health Organization developed and launched the Mental Health Gap Action Programme (mhGAP) and the mhGAP Intervention Guide (mhGAP-IG) to help train non-specialists to deliver care. Although the mhGAP-IG has been used in more than 100 countries for in-service training, its implementation in pre-service training, that is, training prior to entering caregiver roles, is very limited.

Aim of the study

The aim of this study was to collect and present information about the global experience of academic institutions that have integrated WHO’s mhGAP-IG into pre-service training.

Methods

A descriptive cross-sectional study was conducted using an electronic questionnaire, from December 2018 to June 2019.

Results

Altogether, eleven academic institutions across nine countries (Mexico, Nigeria, Liberia, Sierra Leone, Somaliland, Armenia, Georgia, Ukraine and Kyrgyzstan) participated in this study. Five of the institutions have introduced the mhGAP-IG by revising existing curricula, three by developing new training programmes, and three have used both approaches. A lack of financial resources, a lack of support from institutional leadership, and resistance from some faculty members were the main obstacles to introducing this programme. Most of the institutions have used the mhGAP-IG to train medical students, while some have used it to train medical interns and residents (in neurology or family medicine) and nursing students. Use of the mhGAP-IG in pre-service training has led to improved knowledge and skills to manage mental health conditions. A majority of students and teaching instructors were highly satisfied with the mhGAP-IG.

Conclusions

This study, for the first time, has collected evidence about the use of WHO’s mhGAP-IG in pre-service training in several countries. It demonstrates that the mhGAP-IG can be successfully implemented to train a future cadre of medical doctors and health nurses.

EEG microstates are a candidate endophenotype for schizophrenia

Electroencephalogram microstates are recurrent scalp potential configurations that remain stable for around 90 ms. The dynamics of two of the four canonical classes of microstates, commonly labeled as C and D, have been suggested as a potential endophenotype for schizophrenia. For endophenotypes, unaffected relatives of patients must show abnormalities compared to controls. Here, we examined microstate dynamics in resting-state recordings of unaffected siblings of patients with schizophrenia, patients with schizophrenia, healthy controls, and patients with first episodes of psychosis (FEP). Patients with schizophrenia and their siblings showed increased presence of microstate class C and decreased presence of microstate class D compared to controls. No difference was found between FEP and chronic patients. Our findings suggest that the dynamics of microstate classes C and D are a candidate endophenotype for schizophrenia.

Electrophysiological correlates of visual backward masking in patients with major depressive disorder

Depression and schizophrenia are two psychiatric diseases with high co-morbidity. For this reason, it is important to find sensitive endophenotypes, which may disentangle the two disorders. The Shine-Through paradigm, a visual backward masking task, is a potential endophenotype for schizophrenia. Masking is strongly deteriorated in schizophrenia patients, which is reflected in reduced EEG amplitudes. Here, we tested whether masking deficits and associated EEG changes are also found in patients with major depressive disorder. First, we replicated previous findings showing that depressive patients exhibit, at most, only weak masking deficits. Second, we found that the EEG amplitudes of depressive patients were reduced compared to controls and slightly increased compared to schizophrenia patients. As a secondary analysis, we compared the performance in the masking paradigm with three cognitive tasks, namely: the Wisconsin card sorting test, a verbal fluency test and a degraded continuous performance test. Performance in all but the verbal fluency test could discriminate schizophrenia from depression.

Schizophrenia patients using atypical medication perform better in visual tasks than patients using typical medication

Schizophrenia (SCZ) patients show deficits in many domains, including cognition and perception. However, results are often mixed. One reason for mixed results may be differences in medication. Very little is known about the role of medication in visual processing. Here, we investigated the effects of typical vs. atypical medication on contrast sensitivity (spatial frequencies ranging from 0.2 to 20 cycles per degree), vernier acuity, and visual backward masking. From a large pool of patients, we selected 50 patients (Study 1, conducted in Brazil) and 97 patients (Study 2, conducted in Georgia) taking either only typical or atypical medication. Patients with atypical medication performed significantly better than patients with typical medication for contrast sensitivity, vernier duration, and backward masking. As a secondary result, we found similar, but not significant, trends for the cognitive tasks (Stroop, Flanker, Trail-Making Test-B, Wisconsin Card Sorting Test and Continuous Performance Test) in the same patients. No correlations were found between demographics, psychopathology, chlorpromazine equivalents and visual processing. A conclusion of our study is that one needs to be careful comparing studies when medication is not comparable.

Electrophysiological correlates of visual backward masking in patients with first episode psychosis

Visual backward masking is strongly impaired in patients with schizophrenia. Masking deficits have been proposed as potential endophenotypes of schizophrenia. Masking performance deficits manifest as strongly reduced amplitudes in the electroencephalogram (EEG). In order to fulfill the criteria of an endophenotype, masking deficits should not vary substantially across time and should be present at the first psychotic event. To verify whether these conditions are met for visual backward masking, we tested patients with first episode psychosis (n = 21) in a longitudinal study. Patients were tested with visual backward masking and EEG three times every six months over a period of one year. We found that the EEG amplitudes of patients with first episode psychosis were higher as compared to those of patients with schizophrenia but lower as compared to those of unaffected controls. More interestingly, we found that the EEG amplitudes of patients with first episode psychosis remained stable over the course of one year. Since chronic schizophrenia patients have strongly reduced amplitudes, we speculate that the neural correlates of masking deficits (EEG amplitudes) continue to decrease as the disease progresses.

Is the perception of illusions abnormal in schizophrenia?

There seems to be no common factor for visual perception, i.e., performance in visual tasks correlates only weakly with each other. Similar results were found with visual illusions. One may expect common visual factors for individuals suffering from pathologies that alter brain functioning, such as schizophrenia. For example, patients who are more severely affected by the disease, e.g., stronger positive symptoms, may show increased illusion magnitudes. Here, in the first experiment, we used a battery of seven visual illusions and a mental imagery questionnaire. Illusion magnitudes for the seven illusions did not differ significantly between the patients and controls. In addition, correlations between the different illusions and mental imagery were low. In the second experiment, we tested 59 patients (mostly outpatients) with ten visual illusions. As for the first experiment, patients and controls showed similar susceptibility to all but one visual illusion. Moreover, there were no significant correlations between different illusions, symptoms, or medication type. Thus, it seems that perception of visual illusions is mostly intact in schizophrenia.

Sex-related differences in vision are heterogeneous

Despite well-established sex differences for cognition, audition, and somatosensation, few studies have investigated whether there are also sex differences in visual perception. We report the results of fifteen perceptual measures (such as visual acuity, visual backward masking, contrast detection threshold or motion detection) for a cohort of over 800 participants. On six of the fifteen tests, males significantly outperformed females. On no test did females significantly outperform males. Given this heterogeneity of the sex effects, it is unlikely that the sex differences are due to any single mechanism. A practical consequence of the results is that it is important to control for sex in vision research, and that findings of sex differences for cognitive measures using visually based tasks should confirm that their results cannot be explained by baseline sex differences in visual perception.

Rethinking Body Ownership in Schizophrenia: Experimental and Meta-analytical Approaches Show no Evidence for Deficits

Schizophrenia is a severe psychiatric disorder, in which patients experience an abnormal sense of self. While deficits in sensorimotor self-representation (agency) are well documented in schizophrenia, less is known about other aspects of bodily self-representation (body ownership). Here, we tested a large cohort (N = 59) of chronic schizophrenia patients and matched controls (N = 30) on a well-established body illusion paradigm, the Full Body Illusion (FBI). In this paradigm, changes in body ownership are induced through prolonged multisensory stimulation, in which participants are stroked on their back while seeing the stroking on the back of a virtual body. When the felt and seen stroking are synchronous, participants typically feel higher identification with the seen body as well as a drift in self-location towards it. However, when the stroking is asynchronous, no such changes occur. Our results show no evidence for abnormal body ownership in schizophrenia patients. A meta-analysis of previous work corroborates this result. Thus, while schizophrenia patients may be impaired in the sense of agency, their multisensory bodily self-representation, as tested here, seems to be unaffected by the illness.

Local versus global and retinotopic versus non-retinotopic motion processing in schizophrenia patients

Schizophrenia impairs cognitive functions as much as perception. For example, patients perceive global motion in random dot kinematograms less strongly, because, as it is argued, the integration of the dots into a single Gestalt is complex and therefore deteriorated. Similarly, the perception of apparent motion is impaired, because filling-in of the illusory trajectory requires complex processing. Here, we investigated very complex motion processing using the Ternus-Pikler display. First, we tested whether the perception of global apparent motion is impaired in schizophrenia patients compared to healthy controls. The task requires both the grouping of multiple elements into a coherent Gestalt and the filling-in of its illusory motion trajectory. Second, we tested the perception of rotation in the same stimulus, which in addition requires the computation of non-retinotopic motion. Contrary to earlier studies, patients were not impaired in either task and even tended to perform better than controls. The results suggest that complex visual processing itself is not impaired in schizophrenia patients.

Attitude Toward Mental Health in the Republic of Georgia

The stigma, discrimination and human rights violations that individuals and families affected by mental disorders suffer are intense and pervasive.

In order to study attitude toward mental health problems, more than 1000 population from the different region of Georgia have been interviewed within 3 months (May-July 2015) in their household.

The scope of questions used in the survey were based on the questionnaire proposed by the NHS Information Centre, Mental Health and Community.

The population of Georgia showed high levels of understanding and tolerance of mental disorders. Despite of this, the fear and exclusion toward people with mental illness were almost twice as more, compare to the countries, where community mental health services are developed. More than half of the interviewed reported that institutional care is quite sufficient for providing treatment and suggested that person with mental disorder should not have rights to a job. Social status, income and occupation did not play any role in terms of attitude.

Majority of the respondents thought that mentally ill patient is a person who is violent or who need isolation due to the disturbed or inadequate behavior.

The survey revealed that the attitude toward persons with mental disorders in the republic of Georgia less likely is based on evidence and objective information. The lack of knowledge and awareness of mental health issues increase stigma and discrimination regarding the people with mental health problems and prevent them from the integration into the society.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Does chronic nicotine consumption influence visual backward masking in schizophrenia and schizotypy?

Nicotine consumption is higher for people within the schizophrenia spectrum compared to controls. This observation supports the self-medication hypothesis, that nicotine relieves symptoms in, for example, schizophrenia patients. We tested whether performance in an endophenotype of schizophrenia (visual backward masking, VBM) is modulated by nicotine consumption in i) smoking and non-smoking schizophrenia patients, their first-degree relatives, and age-matched controls, ii) non-smoking and smoking university students, and iii) non-smoking, early and late onset nicotine smokers. Overall, our results confirmed that VBM deficits are an endophenotype of schizophrenia, i.e., deficits were highest in patients, followed by their relatives, students scoring high in Cognitive Disorganisation, and controls. Moreover, we found i) beneficial effects of chronic nicotine consumption on VBM performance, in particular with increasing age, and ii) little impact of clinical status alone or in interaction with nicotine consumption on VBM performance. Given the younger age of undergraduate students (up to 30 years) versus controls and patients (up to 66 years), we propose that age-dependent VBM deficits emerge when schizotypy effects are targeted in populations of a larger age range, but that nicotine consumption might counteract these deficits (supporting the self-medication hypothesis).

Schizophrenia patients and 22q11.2 deletion syndrome adolescents at risk express the same deviant patterns of resting state EEG microstates: A candidate endophenotype of schizophrenia

Schizophrenia is a complex psychiatric disorder and many of the factors contributing to its pathogenesis are poorly understood. In addition, identifying reliable neurophysiological markers would improve diagnosis and early identification of this disease. The 22q11.2 deletion syndrome (22q11DS) is one major risk factor for schizophrenia. Here, we show further evidence that deviant temporal dynamics of EEG microstates are a potential neurophysiological marker by showing that the resting state patterns of 22q11DS are similar to those found in schizophrenia patients. The EEG microstates are recurrent topographic distributions of the ongoing scalp potential fields with temporal stability of around 80 ms that are mapping the fast reconfiguration of resting state networks. Five minutes of high-density EEG recordings was analysed from 27 adult chronic schizophrenia patients, 27 adult controls, 30 adolescents with 22q11DS, and 28 adolescent controls. In both patient groups we found increased class C, but decreased class D presence and high transition probabilities towards the class C microstates. Moreover, these aberrant temporal dynamics in the two patient groups were also expressed by perturbations of the long-range dependency of the EEG microstates. These findings point to a deficient function of the salience and attention resting state networks in schizophrenia and 22q11DS as class C and class D microstates were previously associated with these networks, respectively. These findings elucidate similarities between individuals at risk and schizophrenia patients and support the notion that abnormal temporal patterns of EEG microstates might constitute a marker for developing schizophrenia.

Crowding, grouping, and gain control in schizophrenia

Visual paradigms are versatile tools to investigate the pathophysiology of schizophrenia. Contextual modulation refers to a class of paradigms where a target is flanked by neighbouring elements, which either deteriorate or facilitate target perception. It is often proposed that contextual modulation is weakened in schizophrenia compared to controls, with facilitating contexts being less facilitating and deteriorating contexts being less deteriorating. However, results are mixed. In addition, facilitating and deteriorating effects are usually determined in different paradigms, making comparisons difficult. Here, we used a crowding paradigm in which both facilitation and deterioration effects can be determined all together. We found a main effect of group, i.e., patients performed worse in all conditions compared to controls. However, when we discounted for this main effect, facilitation and deterioration were well comparable to controls. Our results indicate that contextual modulation can be intact in schizophrenia patients.

Assessing the need for a protected living environment among severely mentally ill adults in the republic of Georgia

The purpose of this study is to assess the need for a new mental health service called a Protected Living Environment (PLE) in the republic of Georgia. PLE intends to provide residential care for the severely mentally ill (SMI) in the community. Patients and staff members from all six long-term psychiatric hospitals (Tbilisi, Batumi, Rustavi, Khoni, Surami, Bediani) in Georgia have participated in the study. The study includes a quantitative (a structured survey) and a qualitative component (in-depth interviews), which together provide a more comprehensive data. The questionnaire and the questioning route for focus group interviews were self-designed according the recommendations of World Health organization and based on a health facility assessment tool SARA - The Service Availability and Readiness Assessment. The study revealed that consumers and mental health professionals have positive attitudes towards the development of protected residential institutions, which could be an important alternative for residential care and would promote deinstitutionalization and reintegration into society.

Association of the Nicotinic Receptor α7 Subunit Gene (CHRNA7) with Schizophrenia and Visual Backward Masking

The nicotinic system is involved in the pathophysiology of schizophrenia. However, very little is known about its genetic basis and how it relates to clinical symptoms and potentially pharmacological intervention. Here, we investigated five single nucleotide polymorphisms (SNPs) [rs3826029] [rs2337506] [rs982574] [rs904952] [rs2337980] of the cholinergic nicotinic receptor gene, alpha 7 subunit (CHRNA7) and their association to schizophrenia. We found an association with rs904952 (p = 0.009) in a German sample of 224 schizophrenic patients and 224 healthy control subjects. The same trend was shown in an independent Georgian sample of 50 schizophrenic patients, 57 first order unaffected relatives, and 51 healthy controls. In addition, visual backward masking (VBM), a sensitive test for early visual information processing, was assessed in the Georgian sample. In line with prior studies, VBM performance deficits were much more pronounced in schizophrenic patients and their unaffected relatives compared to healthy controls (schizophrenic patients: 156 ms; unaffected relatives: 60 ms; healthy controls: 33 ms). VBM was strongly correlated with SNP rs904952 (H[2] = 7.3, p = 0.026). Our results further support the notion that changes in the nicotinic system are involved in schizophrenia and open the avenue for pharmacological intervention.

Schizophrenia and visual backward masking: a general deficit of target enhancement

The obvious symptoms of schizophrenia are of cognitive and psychopathological nature. However, schizophrenia affects also visual processing which becomes particularly evident when stimuli are presented for short durations and are followed by a masking stimulus. Visual deficits are of great interest because they might be related to the genetic variations underlying the disease (endophenotype concept). Visual masking deficits are usually attributed to specific dysfunctions of the visual system such as a hypo- or hyper-active magnocellular system. Here, we propose that visual deficits are a manifestation of a general deficit related to the enhancement of weak neural signals as occurring in all other sorts of information processing. We summarize previous findings with the shine-through masking paradigm where a shortly presented vernier target is followed by a masking grating. The mask deteriorates visual processing of schizophrenic patients by almost an order of magnitude compared to healthy controls. We propose that these deficits are caused by dysfunctions of attention and the cholinergic system leading to weak neural activity corresponding to the vernier. High density electrophysiological recordings (EEG) show that indeed neural activity is strongly reduced in schizophrenic patients which we attribute to the lack of vernier enhancement. When only the masking grating is presented, EEG responses are roughly comparable between patients and control. Our hypothesis is supported by findings relating visual masking to genetic deviants of the nicotinic α7 receptor (CHRNA7).

Electrophysiological evidence for ventral stream deficits in schizophrenia patients

Schizophrenic patients suffer from many deficits including visual, attentional, and cognitive ones. Visual deficits are of particular interest because they are at the fore-end of information processing and can provide clear examples of interactions between sensory, perceptual, and higher cognitive functions. Visual deficits in schizophrenic patients are often attributed to impairments in the dorsal (where) rather than the ventral (what) stream of visual processing. We used a visual-masking paradigm in which patients and matched controls discriminated small vernier offsets. We analyzed the evoked electroencephalography (EEG) responses and applied distributed electrical source imaging techniques to estimate activity differences between conditions and groups throughout the brain. Compared with controls, patients showed strongly reduced discrimination accuracy, confirming previous work. The behavioral deficits corresponded to pronounced decreases in the evoked EEG response at around 200 ms after stimulus onset. At this latency, patients showed decreased activity for targets in left parietal cortex (dorsal stream), but the decrease was most pronounced in lateral occipital cortex (in the ventral stream). These deficiencies occurred at latencies that reflect object processing and fine shape discriminations. We relate the reduced ventral stream activity to deficient top-down processing of target stimuli and provide a framework for relating the commonly observed dorsal stream deficiencies with the currently observed ventral stream deficiencies.

Trends in the use of outpatient psychiatric services in the republic of Georgia

For a long time, in Georgia, as in most eastern European and post-soviet countries, mental health services have been mainly ran in large institutions with restricted financial and professional resources. In 2010, Ministry of Health and Social Affairs of Georgia declared the reforms in mental health care system. The ongoing reforms are actively supported by many international organizations, but there still some local and cultural barriers that should be carefully analyzed. The study aimed to identify factors affecting referral to the outpatient mental health services and to describe the trends of common therapeutic interventions. The cases of patients who referred to the outpatient mental health services during one year in 2011-12 have been studied. Investigation the trends of referral to outpatient psychiatric services in Georgia showed that patients with severe and chronic psychosis less likely apply to outpatient psychiatric services. In most of the cases they come for single consultation and revealed significant problems in treatment adherence. Patients from remote areas prefer to visit central outpatient clinic, rather than go to their local, free of charge facilities. The main reasons of referral appeared behavioural (hyperactivity, retardation) and emotional problems (depression, anxiety). Due to insufficient legislative and financial support patients could not receive psychological treatments. The treatment outcome significantly depends on treatment compliance and level of education. Educated patients were much more disciplined in keeping their prescription and appointments. The additional effort need to be focused on improving patients' attitude toward local psychiatric services and enhancing coordination between in and outpatient mental health services.

Patients with functional psychoses show similar visual backward masking deficits

Recent genetic, behavioral, and clinical studies suggest that functional psychoses (schizophrenia, bipolar disorder, schizoaffective disorder), previously thought to be distinct from each other, may belong to one continuum. The shine-through masking paradigm is a potential endophenotype of schizophrenia with high sensitivity and specificity for discriminating between patients, their clinically unaffected relatives, and healthy controls. Hence, if schizophrenia, bipolar disorder and schizoaffective disorder belong to one common disease, strong masking deficits are expected to occur in all three diseases whereas no masking deficits are expected for abstinent alcoholic or depressive patients. Indeed, we found masking to be much stronger in psychotic patients compared to controls and to depressive patients and abstinent alcoholics, who performed on similar levels.

Combining vernier acuity and visual backward masking as a sensitive test for visual temporal deficits in aging research

Performance in many everyday situations slows down when age increases. The causes of slowing down may be found on any stage of information processing. Here, we show that the combination of a vernier acuity task and the shine-through backward masking paradigm is a good paradigm to determine temporal processing deficits. The paradigm is relatively robust to optical blur and unlikely affected by motor dysfunctions. Strong masking deficits are found from an age of about 50 years on.

The shine-through masking paradigm is a potential endophenotype of schizophrenia

BACKGROUND

To understand the genetics of schizophrenia, a hunt for so-called intermediate phenotypes or endophenotypes is ongoing. Visual masking has been proposed to be such an endophenotype. However, no systematic study has been conducted yet to prove this claim. Here, we present the first study showing that masking meets the most important criteria for an endophenotype.

METHODOLOGY/PRINCIPAL FINDINGS

We tested 62 schizophrenic patients, 39 non-affected first-degree relatives, and 38 healthy controls in the shine-through masking paradigm and, in addition, in the Continuous Performance Test (CPT) and the Wisconsin Card Sorting Test (WCST). Most importantly, masking performance of relatives was significantly in between the one of patients and controls in the shine-through paradigm. Moreover, deficits were stable throughout one year. Using receiver operating characteristics (ROC) methods, we show that the shine-through paradigm distinguishes with high sensitivity and specificity between schizophrenic patients, first-order relatives and healthy controls.

CONCLUSIONS/SIGNIFICANCE

The shine-through paradigm is a potential endophenotype.

Overview of referrals to mental health services in Georgia

The prevalence of mental illnesses in society is difficult to measure accurately as current techniques are relatively poor. Mental health professionals argue that data provided by Ministry of Health of Georgia concerning the prevalence of mental illnesses should be treated with great caution as the official rates of mental disorders are likely to be largely underestimated. The most significant reason of this could be focusing on referral to state mental health institution and ignoring the private sector. In order to understand the gap between official data and real needs in mental health care we compare statistical data of state institutions and private practice. The structured questionnaire was used for obtaining referral information from the Asatiani Psychiatric Hospital, Gotsiridze Psycho-Neurological Dispensary and a private psychiatrist.

RESULTS

The state institutions with great proportion serve patients with schizophrenia, schizotypal, delusional and organic mental disorders, while patient with mood disorder and neurotic, stress-related and somatoform disorders preferred private psychiatrist. People with different psychiatric problems (e.g. sleep and eating disorders), especially young and elderly patients seldom are seen by psychiatrist.

CONCLUSIONS

Hence, the official data concerning the prevalence of mental illnesses in Georgia are highly underestimated and could not reflect real demands.

The relation between the general intellect of schizophrenic patients and psychopathological deterioration

The aim of the study was to examine whether the postpsychotic decline in IQ during schizophrenia are due to a dementing process and psychopathological deterioration or this is a state independent premorbid impairment. The IQ score of 32 schizophrenic patients and 25 normal comparison subjects were evaluated three times during an average of 4,5 years, after short (mean 2,3 years) and long (mean 4,6) follow-up periods. The regression analysis was used to evaluate the association of clinical symptoms and IQ scores at the different period of time. The results were examined and related to changes of negative and positive symptoms of the illness. The schizophrenic group had low IQ score at baseline than the normal comparison subjects but showed comparable stability over time. The raw IQ score slightly increased in both groups in follow-up period. The regression analyses revealed that low IQ score especially in the block design (MT) and non-verbal reasoning (LPS3) subtests could be additional predictors for deterioration of negative symptoms. The IQ score of patients with schizophrenia appears to remain stable regardless of psychopathological decline, and even could be improved by learning and rehearsal.

Backward Masking Performance in Schizophrenic Patients and their Healthy Relatives

Over the past years, studies of unaffected first-degree relatives of schizophrenic patients have reported cognitive deficits in the domains of executive functions, memory, and attention. However, these deficits may rely on lower level information processing deficits. Here, we investigated visual information processing with a visual backward masking task. A vernier target was followed by a grating mask. Observers had to indicate the offset direction of the vernier. We determined the SOA between the vernier and the grating onset for schizophrenic patients, their healthy first order relatives, and a healthy control group. Schizophrenic patients needed SOAs about three times longer than healthy controls to reach a predefined criterion level. Backward masking performance of unaffected relatives was significantly better than the one of patients but significantly worse than performance of controls. This result adds further evidence that low level deficits as determined by visual backward masking are endophenotypes of schizophrenia.

Contextual suppression and protection in schizophrenic patients

INTRODUCTION

Contextual processing is often strongly deteriorated in schizophrenic patients as found, for example, in higher cognitive as well as lower visual paradigms. In visual detection tasks, impoverished contextual facilitation was attributed to aberrant excitatory neural circuits. On the other hand, we found contextual suppression, possibly related to neural inhibition, to be fast and intact in a visual backward masking task. Here, we combine a suppressive with a "protective" paradigm to further our understanding of the contextual deficiencies of schizophrenic patients in visual information processing.

METHODS

Twenty three schizophrenic patients and 18 healthy controls were asked to discriminate the offset direction of a vernier target, which was followed by one of a variety of masks for several stimulus onset asynchronies (SOAs).

RESULTS

As in previous studies, patients needed clearly longer SOAs than controls. However, when longer SOAs were taken into account, increases as well as decreases in backward mask strength had comparable effects in patients and controls.

CONCLUSIONS

From these results, we suggest that complex spatial processing is fast and intact in schizophrenic patients.