THU0026 CLONAL HAEMATOPOIESIS ASSOCIATED SOMATIC MUTATIONS IN RHEUMATOID ARTHRITIS

Background:

Clonal haematopoiesis of indeterminate potential (CHIP) occurs when somatic mutations arise in myeloid neoplasia driver genes of haematopoietic progenitor cells, in the absence of overt cytopenia or dysplasia. The prevalence of CHIP increases with age. The most common genes affected by CHIP mutations in unselected populations are DNMT3A, ASXL1, and TET2. The presence of CHIP is linked to increased basal level of inflammation and a high risk of cardiovascular disease and all-cause mortality. Rheumatoid arthritis (RA) is one of the most common and debilitating multi-system autoimmune disorders, affecting up to 1% of adults in developed countries. The role of somatic mutations in the pathogenesis of autoimmune diseases is an unexplored area; therefore, we aimed to test the hypothesis that clonal haematopoiesis (CH) is associated with the incidence and severity of RA.

Objectives:

To evaluate the association of CH somatic mutation with severity of RA.

Methods:

163 RA patients were recruited from the following cohorts: (i)Early RA/treatment naive (n=31), (ii)Refractory RA - non-responders to Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and biologics (n=48), (ii)Flare (n=41) vsRemission patients (n=43) –patients treated with DMARDs and withdrawn from treatment on achieving remission. Six months later, 50% relapse and 50% sustain remission. Single molecule molecular inversion probes (smMIPs) were used to screen for somatic mutations in 40 loci known to carry clonal haematopoiesis driver mutations (CHDMs). Whole exome sequencing was also performed on Flare/Remission patients (n = 84) to screen for CHDMs and other somatic mutations. In-house bioinformatics pipelines were used to call mutations from both the datasets.

Results:

We identified CH in RA with an overall prevalence of 14%. Twenty-four unique variants with a variant allele frequency (VAF) of 2-35% were found in ten genes including ASXL1, CBL, DNMT3A, GNAS, GNB1, PTPN11, PTPN12, SF3B1, TET2, and TP53. The number of unique patients carrying mutations in these genes are follows:refractory: n=12/48, flare: n=6/41,remission: n=4/43 andearly RA: n=2/31. The majority of the mutations occurred in DNMT3A (n=6) followed by TP53 (N=4) and TET2 (n=3). Two variants with VAF of 15% were identified in two patients under the age of 30, both with clinically severe disease. In patients between the ages of 50-59 yrs., 60-69 yrs., and 70-79 yrs., CH was observed at 11% (4/35), 23% (11/46) and 17%(7/41), respectively.

Conclusion:

We here report the prevalence of CH in RA, affecting more patients with clinically advanced/refractory disease compared to those with early/less severe disease.

Further study will be conducted to confirm the results.

References:

[1]Acuna-Hidalgo, R., Sengul, H., Steehouwer, M., van de Vorst, M., Vermeulen, S., & Kiemeney, L. et al. (2017). Ultra-sensitive Sequencing Identifies High Prevalence of Clonal Hematopoiesis-Associated Mutations throughout Adult Life.The American Journal Of Human Genetics,101(1), 50-64. doi: 10.1016/j.ajhg.2017.05.013

[2]NRAS - National Rheumatoid Arthritis Society. (2020). Retrieved 30 January 2020, fromhttps://www.nras.org.uk/what-is-ra-article

[3]Steensma, D., Bejar, R., Jaiswal, S., Lindsley, R., Sekeres, M., Hasserjian, R., & Ebert, B. (2015). Clonal hematopoiesis of indeterminate potential and its distinction from myelodysplastic syndromes.Blood,126(1), 9-16. doi: 10.1182/blood-2015-03-631747

Acknowledgments:

National Institute for Health Research, United Kingdom

Disclosure of Interests:

Fareeha Tariq: None declared, Bilal Alobaidi: None declared, Miguel Xavier: None declared, Michael McCorkindale: None declared, Joris Veltman: None declared, John Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, Arthur Pratt Grant/research support from: Pfizer, GSK, Amy Anderson: None declared, Matthew Collin: None declared

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

The association between childhood adversities and subsequent first onset of psychotic experiences: a cross-national analysis of 23 998 respondents from 17 countries

BACKGROUND

Although there is robust evidence linking childhood adversities (CAs) and an increased risk for psychotic experiences (PEs), little is known about whether these associations vary across the life-course and whether mental disorders that emerge prior to PEs explain these associations.

METHOD

We assessed CAs, PEs and DSM-IV mental disorders in 23 998 adults in the WHO World Mental Health Surveys. Discrete-time survival analysis was used to investigate the associations between CAs and PEs, and the influence of mental disorders on these associations using multivariate logistic models.

RESULTS

Exposure to CAs was common, and those who experienced any CAs had increased odds of later PEs [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.9-2.6]. CAs reflecting maladaptive family functioning (MFF), including abuse, neglect, and parent maladjustment, exhibited the strongest associations with PE onset in all life-course stages. Sexual abuse exhibited a strong association with PE onset during childhood (OR 8.5, 95% CI 3.6-20.2), whereas Other CA types were associated with PE onset in adolescence. Associations of other CAs with PEs disappeared in adolescence after adjustment for prior-onset mental disorders. The population attributable risk proportion (PARP) for PEs associated with all CAs was 31% (24% for MFF).

CONCLUSIONS

Exposure to CAs is associated with PE onset throughout the life-course, although sexual abuse is most strongly associated with childhood-onset PEs. The presence of mental disorders prior to the onset of PEs does not fully explain these associations. The large PARPs suggest that preventing CAs could lead to a meaningful reduction in PEs in the population.

The cross-national epidemiology of DSM-IV intermittent explosive disorder

BACKGROUND

This is the first cross-national study of intermittent explosive disorder (IED).

METHOD

A total of 17 face-to-face cross-sectional household surveys of adults were conducted in 16 countries (n = 88 063) as part of the World Mental Health Surveys initiative. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) assessed DSM-IV IED, using a conservative definition.

RESULTS

Lifetime prevalence of IED ranged across countries from 0.1 to 2.7% with a weighted average of 0.8%; 0.4 and 0.3% met criteria for 12-month and 30-day prevalence, respectively. Sociodemographic correlates of lifetime risk of IED were being male, young, unemployed, divorced or separated, and having less education. The median age of onset of IED was 17 years with an interquartile range across countries of 13-23 years. The vast majority (81.7%) of those with lifetime IED met criteria for at least one other lifetime disorder; co-morbidity was highest with alcohol abuse and depression. Of those with 12-month IED, 39% reported severe impairment in at least one domain, most commonly social or relationship functioning. Prior traumatic experiences involving physical (non-combat) or sexual violence were associated with increased risk of IED onset.

CONCLUSIONS

Conservatively defined, IED is a low prevalence disorder but this belies the true societal costs of IED in terms of the effects of explosive anger attacks on families and relationships. IED is more common among males, the young, the socially disadvantaged and among those with prior exposure to violence, especially in childhood.

Assessing Medication Beliefs of Mental Health Professionals: The Portuguese Version of the Medication Alliance Beliefs Questionnaire

Introduction

Clinician's attitudes are an important consideration in implementing adherence strategies and that these attitudes can be successfully improved as a result of training. The 22-item Medication Alliance Beliefs Questionnaire (MABQ; Byrne et al.2008) was used to assess clinician attitudes towards non-adherence. The MABQ contains five subscales reflecting the clinician's self-efficacy (adequacy), the satisfaction (work satisfaction); their appraisal of their self-worth (self-esteem), their outcome expectancies (pessimism) in relation to non-adherent patients, and the extent to which they understand the difficulties patients might experience in trying to adhere to treatment (empathy).

Aims/objectives

To develop the Portuguese version of the MABQ.

Methods

The MABQ was translated and adapted for Portuguese language. The translation was done by the first author (AC). The accuracy of this translation was discussed in a two focus group of experts, providing opinion on face and content validity. After pre-testing, the final version of the Portuguese translation was produced.

Results

A convenience sample of 65 mental health professionals working in a variety of settings is being collected. The average score in MABQ was 80.06 (SD 9.5). The value of internal reliability coefficient α was 0.80. The intraclass correlation coefficient of total MABQ score was 0.35. The t-test showed that there were no statistically significant differences between the mean values of the measurement scale at two different times (80.4 vs.76.2; P = 0.02).

Conclusion

The attitudes of mental health professionals may have a predictive relationship with treatment outcomes of patients with mental health disorders. The validation of the Portuguese version of MABQ will provide professionals with a new tool to evaluate crucial issues related to medication beliefs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

How we can enhance treatment adherence? Perspective of patients and clinicians

Introduction

Non-adherence to antipsychotic medication is commonly found in mental health disorders (MHD), thus forming a major obstacle to long-term maintenance treatment and contributing to high relapse rates and also can influence the attitudes and beliefs of mental health professionals (MHP).

Objectives

–assess the beliefs of MHP;

–assess perception of illness in patients with MHD.

Aims

Contribute to treatment adherence of patients with MHD, through developing adequate strategies to their needs.

Methods

In this cross-sectional study, we use a convenience sample of patients with MHD attending in the mental health departments of three general hospitals in Lisbon great area. Data is being collected through individual interviews. We have applied clinical and socio-demographic questionnaire and additional measures to assess symptom severity, treatment adherence and attitudes towards medication. For MHP, we used a optimism scale (ETOS), Difficulty Implementing Adherence Strategies (DIAS); Medication Alliance Beliefs Questionnaire (MABQ).

Results

Two convenience samples were composed by 150 patients with MHD (mean age: 39.7; SD ± 9.8) and 65 MHP (mean age: 37.0; sd 8.3) working in a variety of settings is being collected. From the perspective of patients, the most important reason for adherence is to accept the illness (54,7%, n = 82). 50.8% (n = 33) of MHP believes that if patients are unmotivated for treatment, adherence strategies are unlikely to be effective. 43.1 (n = 28) of MHP agrees that if patients do not accept their illness, any adherence strategies that result.

Conclusion

With this study, we expect to gain further knowledge on the factors related patients and MHP that might influence compliance and, therefore, contribute to the development of effective strategies to promote treatment adherence in MHD.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Assessing Strategies to Improve Antipsychotic Adherence: The Portuguese Version of the Difficulty Implementing Adherence Strategies

Introduction

Non-adherence is a problem throughout medicine and there are many strategies that are used to improve antipsychotic adherence. A review of the literature identified 33 commonly cited strategies for enhancing consumer adherence. Three core themes were identified: Information/Education; Behavioural strategies; and Cognitive/Motivational strategies.

Aims/objectives

To develop the Portuguese version of the DIAS.

Methods

The DIAS was translated and adapted for Portuguese language. The translation was done by the first author (AC). The accuracy of this translation was discussed in a two focus group of experts, providing opinion on face and content validity. The participants were asked to rate how often they had difficulties using each of the 33 strategies with consumers who were non-adherent. A four point Likert scale was used (1 = never; 4 = always) such that higher scores indicated more frequent difficulty using the strategy.

Results

A convenience sample of 65 mental health professionals working in a variety of settings is being collected. The average score in DIAS was 85.0 (SD14.6). The value of internal reliability coefficient α was 0.93. The intraclass correlation coefficient of total MABQ score was 0.45. The t-test showed that there were no statistically significant differences between the mean values of the measurement scale at two different times (84.5 vs.90.5; P = 0.04).

Conclusion

Interventions to improve antipsychotic adherence would benefit from further research. However, it is important always to bear in mind that none of these strategies can be a substitute a positive therapeutic alliance. The Portuguese version of DIAS will provide professionals with a new tool to evaluate the frequency how strategies are implemented and the impact of each strategy in treatment adherence.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Association between suicide attempts and insight among patients with bipolar disorders

Introduction

Insight is an important factor associated with non-compliance and poor outcome. Poor level of insight has been described as a characteristic in patients with acute bipolar disorder with more unawareness in social consequences. In contrast, awareness of having a mental disorder, of its symptoms, of its consequences, and/or of the need for treatment is associated with a number of positive prognostic indicators. Insight is also linked, however, to depression and suicidal ideation in bipolar disorder.

Objectives

(1) Assess the illness perception. (2) Assess the impact of insight in suicidal tendencies.

Aims

Contribute to development measures to improve the insight in bipolar disorders.

Methods

In this cross sectional study we use a convenience sample of patients with bipolar disorder attending in the mental health departments of three general hospitals in Lisbon great area. We have applied clinical and socio-demographic questionnaire and additional measures to assess symptom severity, treatment adherence and illness perception.

Results

A samples was composed by 64 patients with bipolar disorder (mean age = 38.7; SD ± 10.1). A total of 48.4% patients (n = 31) had made a suicide attempted and 23.4% (n = 15) of this patient done 5 or more attempted suicide. We found a significant correlation with symptoms and insight (rs = 0.56; P < 0.01).

Conclusion

Mental health professionals often utilize insight as an indicator of prognosis, because of its association with treatment adherence. The findings of the current study suggest that having intact or good insight may be an indicator for suicidal ideation among patients with bipolar disorders. A brief psychoeducational approach could potentially be effective. We recommend a combined approach to Improve clinical insight in bipolar disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The effects of co-morbidity in defining major depression subtypes associated with long-term course and severity

BACKGROUND

Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question.

METHOD

Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes.

RESULTS

Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6-72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors.

CONCLUSIONS

Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.

Barriers to mental health treatment: results from the WHO World Mental Health surveys

BACKGROUND

To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders.

METHOD

Data were from the World Health Organization (WHO) World Mental Health (WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 63,678) and analyzed at different levels of clinical severity.

RESULTS

Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders).

CONCLUSIONS

Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.

Barriers to mental health treatment: results from the WHO World Mental Health surveys

BACKGROUND

To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders.

METHOD

Data were from the World Health Organization (WHO) World Mental Health (WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 63,678) and analyzed at different levels of clinical severity.

RESULTS

Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders).

CONCLUSIONS

Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.

A comparative analysis of role attainment and impairment in binge-eating disorder and bulimia nervosa: results from the WHO World Mental Health Surveys

Background. Cross-national population data from the WHO World Mental Health surveys are used to compare role attainments and role impairments associated with binge-eating disorder (BED) and bulimia nervosa (BN). Methods. Community surveys assessed 23 000 adults across 12 countries for BED, BN and ten other DSM-IV mental disorders using the WHO Composite International Diagnostic Interview. Age-of-onset was assessed retrospectively. Ten physical disorders were assessed using standard conditions checklists. Analyses examined reciprocal time-lagged associations of eating disorders (EDs) with education, associations of early-onset (i.e., prior to completing education) EDs with subsequent adult role attainments and cross-sectional associations of current EDs with days of role impairment. Results. BED and BN predicted significantly increased education (females). Student status predicted increased risk of subsequent BED and BN (females). Early-onset BED predicted reduced odds of current (at time of interview) marriage (females) and reduced odds of current employment (males). Early-onset BN predicted increased odds of current work disability (females and males). Current BED and BN were both associated with significantly increased days of role impairment (females and males). Significant BED and BN effects on adult role attainments and impairments were explained by controls for comorbid disorders. Conclusions. Effects of BED on role attainments and impairments are comparable with those of BN. The most plausible interpretation of the fact that these associations are explained by comorbid disorders is that causal effects of EDs are mediated through secondary disorders. Controlled treatment effectiveness studies are needed to trace out long-term effects of BED-BN on secondary disorders.

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

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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.