Effect of managed transition on mental health outcomes for young people at the child-adult mental health service boundary: a randomised clinical trial

BACKGROUND

Poor transition planning contributes to discontinuity of care at the child-adult mental health service boundary (SB), adversely affecting mental health outcomes in young people (YP). The aim of the study was to determine whether managed transition (MT) improves mental health outcomes of YP reaching the child/adolescent mental health service (CAMHS) boundary compared with usual care (UC).

METHODS

A two-arm cluster-randomised trial (ISRCTN83240263 and NCT03013595) with clusters allocated 1:2 between MT and UC. Recruitment took place in 40 CAMHS (eight European countries) between October 2015 and December 2016. Eligible participants were CAMHS service users who were receiving treatment or had a diagnosed mental disorder, had an IQ ⩾ 70 and were within 1 year of reaching the SB. MT was a multi-component intervention that included CAMHS training, systematic identification of YP approaching SB, a structured assessment (Transition Readiness and Appropriateness Measure) and sharing of information between CAMHS and adult mental health services. The primary outcome was HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents) score 15-months post-entry to the trial.

RESULTS

The mean difference in HoNOSCA scores between the MT and UC arms at 15 months was -1.11 points (95% confidence interval -2.07 to -0.14, p = 0.03). The cost of delivering the intervention was relatively modest (€17-€65 per service user).

CONCLUSIONS

MT led to improved mental health of YP after the SB but the magnitude of the effect was small. The intervention can be implemented at low cost and form part of planned and purposeful transitional care.

Remote Assessment of Disease and Relapse in Major Depressive Disorder (RADAR-MDD): Recruitment, retention, and data availability in a longitudinal remote measurement study

Introduction

Major Depressive Disorder (MDD) is prevalent, often chronic, and requires ongoing monitoring of symptoms to track response to treatment and identify early indicators of relapse. Remote Measurement Technologies (RMT) provide an exciting opportunity to transform the measurement and management of MDD, via data collected from inbuilt smartphone sensors and wearable devices alongside app-based questionnaires and tasks.

Objectives

To describe the amount of data collected during a multimodal longitudinal RMT study, in an MDD population.

Methods

RADAR-MDD is a multi-centre, prospective observational cohort study. People with a history of MDD were provided with a wrist-worn wearable, and several apps designed to: a) collect data from smartphone sensors; and b) deliver questionnaires, speech tasks and cognitive assessments and followed-up for a maximum of 2 years.

Results

A total of 623 individuals with a history of MDD were enrolled in the study with 80% completion rates for primary outcome assessments across all timepoints. 79.8% of people participated for the maximum amount of time available and 20.2% withdrew prematurely. Data availability across all RMT data types varied depending on the source of data and the participant-burden for each data type. We found no evidence of an association between the severity of depression symptoms at baseline and the availability of data. 110 participants had > 50% data available across all data types, and thus able to contribute to multiparametric analyses.

Conclusions

RADAR-MDD is the largest multimodal RMT study in the field of mental health. Here, we have shown that collecting RMT data from a clinical population is feasible.

Disclosure

No significant relationships.

Influence of childhood trauma on diagnosis and substance use in first-episode psychosis

BackgroundChildhood trauma has been significantly associated with first-episode psychosis, affective dysfunction and substance use.AimsTo test whether people with first-episode psychosis who had experienced childhood trauma, when compared with those who had not, showed a higher rate of affective psychosis and an increased lifetime rate of substance use.MethodThe sample comprised 345 participants with first-episode psychosis (58% male, mean age 29.8 years, s.d. = 9.7).ResultsSevere sexual abuse was significantly associated with a diagnosis of affective psychosis (χ² = 4.9, P = 0.04) and with higher rates of lifetime use of cannabis (68% v 41%; P = 0.02) and heroin (20% v 5%; P = 0.02). Severe physical abuse was associated with increased lifetime use of heroin (15% v 5%; P = 0.03) and cocaine (32% v 17%; P = 0.05).ConclusionsPatients with first-episode psychosis exposed to childhood trauma appear to constitute a distinctive subgroup in terms of diagnosis and lifetime substance use.

The needs of children who have parents suffering from severe mental disorders

Objective

Mental illness in parents is a biological and environmental risk factor to which young people are exposed. Living with a parent suffering from a mental disorder may have a variety of detrimental consequences, including: (a) the reversal of caregiving (“parentification”); (b) the exposure to an adverse environment, where developmental needs of the child (emotional and practical) might be repeatedly neglected (lack of communication, high expressed emotion, etc.); (c) stigma and discrimination. We will provide a review of needs of these children and of possible interventions.

Methods

Systematic searches located studies reporting and assessing met and unmet needs of these children.

Results

Young people living in such families often have problems of internalizing and externalizing symptoms, cognitions of shame, guilt, and loneliness, perceptions of lacking social support and social acceptance. Children who have mentally ill parents are up to two and a half times more likely to experience poorer mental health outcomes than their peers. Compared to peers, children of parents with mental disorders are also at risk of poorer intellectual and social outcomes, of affect dysregulation, of behavioral problems, of impaired attention and reduced overall adaptive functioning, of higher rates of substance abuse and multiple diagnosis and finally of low occupational status, health risk behaviour and antisocial behavior.

Conclusions

Given the high toll paid by children having parents suffering from severe mental disorders, it is urgent to develop, test and implement structured programmes to help these children cope with stressful circumstances and improve their resilience.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Forensic Care in Italy: Changes, Illusions and Realities

Violence and the risk of violence posed by patients with severe mental illness is a major public health problem for many reasons. Firstly there is the obvious harm to victims, secondly the counter-therapeutic effect on patients of the violence itself, thirdly the restrictive measures typically deployed by services to manage the violence, and finally the significant additional financial cost of these specialist services. Within mental health services the sometimes inaccurate estimate of risk of violence posed by patients can lead to the frequent use of a variety of coercive measures including involuntary hospitalization, enforced medication, restraint and seclusion. These restrictive and costly interventions are almost unanimously perceived as traumatic by the patients and can, in turn, trigger frustration, therapeutic resistance and even aggression instead of treatment adherence and cooperation.

Services for the treatment of psychiatric patients who pose a risk of violence are developing and maturing across Europe. New models of care for this extremely complicated multiple needs clinical population exist. However across Europe intervention strategies and service organization and delivery for these patients are very different, and have never been comparatively evaluated. The lack of reliable comparative data has prevented many European countries benefiting from innovative strategies already tested in those countries which have made the greatest efforts in research and service innovation. In this workshop we will compare the organization and functioning of forensic mental health services in different countries; in particular this presentation will inform about the recent changes in forensic mental health services occurred in Italy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

How long is the interval between the onset and the initial management of bipolar disorder? A meta-analysis

Objective

To evaluate the length of the interval between the onset and the initial management of bipolar disorder (BD).

Method

We conducted a meta-analysis using the preferred reporting items for systematic reviews and meta-analyses guidelines. Systematic searches located studies reporting estimates of the age of onset (AOO) and indicators of the age at initial management of BD. We calculated a pooled estimate of the interval between AOO and age at management. Factors influencing between-study heterogeneity were investigated using sensitivity analyses, meta-regression, and multiple meta–regression.

Results

Twenty-seven studies, reporting 51 samples and a total of 9415 patients, met the inclusion criteria. The pooled estimate for the interval between the onset of BD and its management was 5–8 years (standardized difference, .53; 95% confidence interval, .45 to .62). There was very high between-sample heterogeneity (I2 ¼ 92.6; Q ¼ 672). A longer interval was found in studies that defined the onset according to the first episode (compared to onset of symptoms or illness) and defined management as age at diagnosis (rather than first treatment or first hospitalization). A longer interval was reported among more recently published studies, among studies that used a systematic method to establish the chronology of illness, among studies with a smaller proportion of bipolar I patients, and among studies with an earlier mean AOO.

Conclusions

There is currently little consistency in the way researchers report the AOO and initial management of BD. However, the large interval between onset and management of BD presents an opportunity for earlier intervention.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Neuronal cell adhesion genes and antidepressant response in three independent samples

Drug-effect phenotypes in human lymphoblastoid cell lines recently allowed to identify CHL1 (cell adhesion molecule with homology to L1CAM), GAP43 (growth-associated protein 43) and ITGB3 (integrin beta 3) as new candidates for involvement in the antidepressant effect. CHL1 and ITGB3 code for adhesion molecules, while GAP43 codes for a neuron-specific cytosolic protein expressed in neuronal growth cones; all the three gene products are involved in synaptic plasticity. Sixteen polymorphisms in these genes were genotyped in two samples (n=369 and 90) with diagnosis of major depressive episode who were treated with antidepressants in a naturalistic setting. Phenotypes were response, remission and treatment-resistant depression. Logistic regression including appropriate covariates was performed. Genes associated with outcomes were investigated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) genome-wide study (n=1861) as both individual genes and through a pathway analysis (Reactome and String databases). Gene-based analysis suggested CHL1 rs4003413, GAP43 rs283393 and rs9860828, ITGB3 rs3809865 as the top candidates due to their replication across the largest original sample and the STAR*D cohort. GAP43 molecular pathway was associated with both response and remission in the STAR*D, with ELAVL4 representing the gene with the highest percentage of single nucleotide polymorphisms (SNPs) associated with outcomes. Other promising genes emerging from the pathway analysis were ITGB1 and NRP1. The present study was the first to analyze cell adhesion genes and their molecular pathways in antidepressant response. Genes and biomarkers involved in neuronal adhesion should be considered by further studies aimed to identify predictors of antidepressant response.

Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder

BACKGROUND

Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD).

AIMS

To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative.

METHOD

An ADHD screen was administered to respondents aged 18-44 years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability.

RESULTS

Estimates of ADHD prevalence averaged 3.4% (range 1.2-7.3%), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders.

CONCLUSIONS

Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case.

Survival among elderly Italian patients with dementia treated with atypical antipsychotics: observational study

The objective was to compare survival in a population-based cohort of elderly demented patients with behavioural and psychological symptoms (BPSD) dispensed an atypical antipsychotic (AA) with that of a sample of demented patients not treated with AAs. An observational cohort study was carried out in the province of Modena, Italy (644,000 inhabitants) on a cohort of 294 patients with BPSD diagnosed by a dementia specialist and treated with an AA, and a cohort of 2020 demented adults not dispensed AAs. All patients were 65 years of age or older. Measured outcomes were death by any cause and death by cerebrovascular accident at the end of the study. After a median follow-up of one year, survival was not significantly different between patients treated and not treated with AAs (overall mortality rates: 0.52 vs. 0.55/1000 years/person, respectively; relative risk reduction 0.047, 95% confidence interval -0.251 to 0.286). Multivariate survival analysis showed that older age at entry, male gender, severe dementia and functional impairment were associated with a higher risk of death. Although our sample size does not allow the exclusion of small differences in the short term, age, gender and dementia severity but not treatment with AAs seem to influence survival among elderly demented patients.

[The impact on the international literature of the scientific production of Italian researchers in the disciplines "psychiatry" and "psychology". A bibliometric evaluation]

OBJECTIVE

The aim of the study was to present the results of a citation analysis concerned with the impact of Italian researchers and institutions in psychiatry and psychology upon the international scientific community.

METHOD

The analysis has been performed using a database of the Institute for Scientific Information (ISI): All scientific papers which were published between 1981 and 1998 in psychiatric and psychological journals included in the Science Citation Index (SCI) and the Social Sciences Citation Index (SSCI) were considered. The most cited Italian papers, authors and institutions are reported, as well the most frequently utilised journals.

RESULTS

Publications concerned with neuropsychology, psychopharmacology and biological psychiatry were the most cited. This prevalence also affected the ranking of the most cited authors, even though, in this case, research groups in disciplines such as clinical psychology and epidemiological psychiatry appeared to be strong. The four most productive Italian Universities were characterized by the presence of both a School of Medicine and a School of Psychology. The Journal of Neurology, Neurosurgery and Psychiatry and Psychopharmacology were the most frequent vehicles of scientific communication.

CONCLUSIONS

The results entail important implications for Italian research in psychology and psychiatry. On a general level, these analyses appear to be helpful for monitoring scientific production by granting agencies and for comparing different individual researchers. On a more specific level the analysis has identified the leading trends in research of Italian psychiatry and psychology.

[Quality of life assessment: validation of the Italian version of the WHOQOL-Brief]

OBJECTIVE

To test the psychometric properties of the Italian version of the WHOQOL-BRIEF (e.g., construct and internal validity, concurrent validity with the MOS SF-36 and test-retest reliability). The WHOQOL-BRIEF is a 26-items self-report instrument which assesses four domains assumed to represent the Quality Of Life (QOL) construct: physical domain, psychological domain, social relationships domain and environment domain, plus two facets for assessing overall QOL and general health.

METHODS

Data have been collected in three sites (Bologna, Modena and Padua), located in the North of Italy, in the framework of the international WHOQOL project. According to the study design, the sample had to include about 50% males and 50% females, 50% of subjects below and 50% above the age of 45, all in contact with various health services. A subsample has been re-interviewed after 2-3 weeks in order to study test-retest reliability. After the WHOQOL-BRIEF, most subjects have also been administered the MOS-SF36 in order to test the concurrent validity between these two instruments.

RESULTS

The instrument was administered to 379 subjects (1/6 healthy and 1/6 sick), chosen to be representative of a variety of different medical conditions. Seventy patients, who displayed stable health conditions, have been reassessed after 2-3 weeks to study test-retest reliability. The WHOQOL-BRIEF domains has shown good internal consistency, ranging from 0.65 for the social relationships domain to 0.80 for the physical domain; it has been able to discriminate between in- and out-patients and between the two age groups considered in the present study (< 45, > or = 45 years). Only physical and psychological domains were found to discriminate between healthy and ill subjects. No gender differences in the mean scores for the four domains were found. Concurrent validity between the WHOQOL-Brief and the MOS-SF-36 was satisfactory, and specific for the physical and psychological health domains. Test-retest reliability values were also good, ranging from 0.76 for the environment domain to 0.93 for the psychological domain.

CONCLUSIONS

This study shows that the WHOQOL-BRIEF is psychometrically valid and reliable, and that it is also potentially useful in discriminating between subjects with different health conditions in clinical settings.

The changing histopathology of primitive lung cancer

This study was performed on 1710 lung epithelial malignant tumours, diagnosed in the biennia 1963/1964 (42 cases), 1973/ 1974 (293), 1983/1984 (637) and 1993/1994 (738). It was aimed at evaluating whether, over a time span that long, the distribution of the histopathological patterns could have changed. The neoplasms were classified according to the WHO criteria (1981). From our data, a striking increase becomes apparent for all histotypes. Squamous cell carcinoma holds the leading position both among males and females, even though its rate of increase tends to slow down among males. Analogous trend is observed for all the other histotypes but adenocarcinoma. Among females, the rate of increase continues to accelerate for all histotypes but large cell carcinoma. The male to female ratio is ranging from 2:6 for adenocarcinomas to 12:1 for squamous cell carcinomas. In conclusion, impressive changes seem to have occurred in the frequency of the different lung oncotypes over this time span, especially for adenocarcinoma (increasing trend) and large cell carcinoma (decreasing trend). It also seems worth underlying that the marked increase among females could make lung carcinoma the number one cause of cancer-related deaths in this sex.

Italian psychiatry and reform law: a review of the international literature

Through the reform law, and the experiences of change realized prior to the reform, Italian psychiatry expanded its size and influences significantly. The aim of this review is to describe some issues relevant to Italian psychiatry and to try and evaluate the experience of reform as shown in international literature. In this literature, three large groups of contributions can be identified: the so called 'impressionistic' group; the group dealing with the analysis of local and regional situations; and finally the group represented by epidemiological researches and by analysis of national data. The main contributions of each of the three groups are reviewed, and finally the main problems which Italian psychiatry has to face, are outlined.

Intraventricular antipyretics and bacterial pyrogen fever

In adult fowls with cannulae chronically implanted into the IIIrd cerebral ventricle or into the hypothalamus, the effects of various hydrosoluble antipyretics, given intraventricularly, on bacterial pyrogen fever were studied. It has been shown that fever evoked by intrahypothalamic or intraventricular infusion of O somatic antigen of Shigella Dysenteriae was reduced by intraventricular administration of acetylsalicylate-lysine, indomethacin-methylglucamine or ibuprofen-lysine given during the febrile plateau. However, a 3-day intraventricular pretreatment with acetylsalicylate or indomethacin, or a single administration 30 min before, did not prevent fever by subsequent intraventricular or intrahypothalamic injection of pyrogen. On the contrary, intraventricular infusion of indomethacin or acetylsalicylate substantially reduced pyrogen fever when given after pyrogen latency period, e.g. just at the beginning of the febrile response. A possible involvement of E prostaglandins as mediator to pyrogen fever is discussed.