Is mindfulness practice "at risk" of increasing spirituality? Systematic review and critical analysis of a claimed effect

INTRODUCTION

Mindfulness meditation has gained prominence in somatic and psychiatric care in several countries including France. Studies have shown its effectiveness in various conditions, in particular the prevention of depressive relapses. However, there are criticisms and concerns about its potential links to Buddhism and spirituality, raising issues of secularism and sectarianism. This issue is particularly conflicting in France with regard its historical and political relationship with secularism.

OBJECTIVES

This study aims to assess quantitative data regarding the impact of mindfulness meditation on spirituality and religiosity using quantitative validated scales.

METHODS

A systematic review was conducted. PubMed was searched for relevant studies using keywords related to mindfulness and spirituality/religiosity scales. Four scales assessing spirituality were identified: FACIT-sp, INSPIRIT, DSES, and DUREL. Qualitative analysis determined if scale items pertained to spirituality or other topics considered by opponents to mindfulness as "at risk" for deviances or sectarian aberrations. Quantitative analysis assessed the effect size of changes in scale scores before and after mindfulness meditation interventions.

RESULTS

Eighteen studies were analyzed, with varying scales and program durations including 1272 participants. Qualitative analysis showed that most scales contained items related to spirituality as well as "at risk" elements like religion and mysticism. Quantitative analysis revealed that a few studies reported significant increases in spirituality scores following mindfulness meditation, but the clinical relevance of these changes was questioned. In general, control groups had smaller score changes.

INTERPRETATION

While some studies suggest a potential increase in spirituality due to mindfulness meditation, the clinical significance of these findings remains uncertain. Moreover, mindfulness meditation's ties to Buddhism are disputed, and its roots are intertwined with various psychotherapy traditions that incorporate spirituality. The role of secularism in psychotherapy is also debated in France, emphasizing the need for proper use and regulation policy rather than prohibition of mindfulness-based approaches. This study highlights the complexity of assessing the impact of mindfulness meditation on spirituality and religiosity. It suggests that a pragmatic approach focusing on risk and harm reduction may be more suitable than labeling the practice as "at risk". Further research is needed to clarify these issues in the specific cultural context of France.

Care for Adolescents With Polycystic Ovary Syndrome: Development and Prescribing Patterns of a Multidisciplinary Clinic

STUDY OBJECTIVE

Based on updated guidelines and expressed patient needs, we created a multidisciplinary clinic including endocrinology, gynecology/adolescent medicine, dermatology, psychology, and nutrition to provide comprehensive care to adolescent girls with polycystic ovary syndrome (PCOS). We describe the patient population presenting to this clinic, and prescribing patterns when a multidisciplinary approach is used.

DESIGN

Retrospective chart review.

SETTING

Tertiary care hospital.

PARTICIPANTS

Female patients, aged 11-24 years, presenting for initial assessment in a multidisciplinary PCOS clinic.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Medical history, physical examination findings, laboratory measurements and prescribed therapies.

RESULTS

A total of 92 patients seen from 2014 to 2018 are described (age 15.9 years, range 11-24 years, body mass index 35.6 kg/m2, range 19.9-53.5). Metabolic syndrome features were common: 26% had a prediabetes hemoglobin A1c (>5.6%), 83% had a high-density lipoprotein (HDL) <50 mg/dL, 40% had a systolic blood pressure >120 mm Hg, and 43% had an alanine aminotransferase level of >30 U/L. Dermatologic findings included acne 93%, hirsutism 38%, acanthosis nigricans 85%, hidradenitis suppurativa 16%, and androgenic alopecia 2%. Of the patients, 33% had a diagnosis of depression or anxiety, 16% of patients had a diagnosis of obstructive sleep apnea, and an additional 59% had symptoms warranting a sleep study The most commonly prescribed medications were topical acne preparations (62%), followed by estrogen-containing hormonal therapy (56%) and metformin (40%).

CONCLUSION

In adolescents with PCOS and obesity, metabolic, dermatologic, and psychologic co-morbidities are common. The use of a multidisciplinary clinic model including dermatology in addition to endocrinology, gynecology, psychology, and lifestyle experts provides care for most aspects of PCOS.

[Difficult-to-engage patients: What evolution after discharge from Assertive Community Programs?]

OBJECTIVES

Beneficial effects of Assertive Community Treatment (ACT) programs on patients with severe mental disorders are well established over short or medium term. However, studies that investigate long term clinical and psychosocial outcomes are remarkably scarce, and it is not known whether the support and intensive care delivered by these programs maintain their benefits over time, especially after discharge. Thus, the present study sought further understanding on this issue by evaluating long term clinical and psychosocial evolution of patients who had been treated by an ACT team in 2007. We investigated the nature of treatment interventions and the level of care since discharge from ACT, especially in terms of adherence to care and number of psychiatric hospitalizations. We also examined factors, at inclusion in the ACT program and after six months of treatment, that could predict better long-term outcomes.

METHODS

Twenty-nine patients with severe mental disorders, characterized by the heavy use of inpatient facilities and refusal of care, were treated by an ACT team which was implmented between 2007 and 2009. They participated at that time in an initial study on the effect of the program and were therefore assessed at inclusion and again after six months of treatment. Between 2016 and 2017, the present follow up took place and patients were assessed again on their current psychosocial functioning, quality of life and intensity of symptoms, using the same scales as those administered in the initial study. This design allowed us to compare baseline with "early" (after six months) and "late" (after a mean of 8.7 years) effects of ACT program on patients. In order to assess adherence to care since discharge from ACT, data on nature and level of psychiatric treatment was systematically reviewed, including all public and private inpatient and outpatient treatments since the end of the ACT program.

RESULTS

Detailed tables on hospitalizations before, during and after ACT treatment are reported, as well as tables summarizing the level of care and nature of treatment since discharge from ACT. During the mean of 8.7 years of evolution and 6.3 years after discharge from ACT, these patients, characterized by severe mental disorders, heavy use of inpatient facilities and refusal of care, sustained a reduced rate of hospitalizations and a minor rate of disengagement from outpatient care (6.9 %). Both severity of symptoms, poorer quality of life and worst functioning in the community at inclusion (baseline) as well as early improvements (after six month of ACT treatment) of the same outcomes were significantly associated with long term improvements. Results also show other baseline predictors of long term improvement: fewer years since disorder onset was associated with improvement of functioning in the community; further advancement in the recovery process predicted better enhancement in quality of life, and a better initial functioning in the community was associated with a better improvement of symptomatology.

CONCLUSIONS

This study provides insight on the sustainability of the benefits of ACT programs, suggesting that these interventions can help patients who are refractory to care to gain clinical and psychosocial improvement in the long term. Our results also suggest that baseline severity as well as early improvements after six months of treatment were associated with larger improvement at follow up. These clinical predictors provide some help to distinguish which patients are more likely to benefit from an ACT approach.

Toxicity of psychotropic drugs in patients with COVID-19: A systematic review

OBJECTIVE

Due to the global spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), guidance for the use of psychotropic drugs in this context is necessary. We aimed to review clinical evidence regarding the potential toxicity of psychiatric medications in the context of SARS-CoV-2 infection.

METHODS

A systematic search for all types of empirical studies and reviews in a broad set of electronic databases and trial registries was conducted up to the 15th of August 2020.

RESULTS

We identified 3 case series and 4 single-case reports on the occurrence of toxicity induced by various psychotropic drugs (lithium, n = 2; clozapine, n = 5; risperidone n = 2; haloperidol n = 1; duloxetine, n = 1). In addition, we provide a new case report on the possible precipitation of valproic acid-induced hyperammonemic encephalopathy. In most cases, SARS-CoV-2 infection may have precipitated drug toxicity/side effects. The management of toxicity did not diverge from the usually applied principles in the absence of infection.

CONCLUSIONS

Due to the limited available evidence and the recent genomic diversity and evolution of the SARS-CoV-2, it is currently not possible to derive evidence-based recommendations for the use of psychotropic drugs in the context of SARS-CoV-2 infection. Nevertheless, we provide some guidance based on the reviewed literature. At the current state of knowledge, there is no contraindication for any psychotropic drug. Caution is warranted regarding the dosing and, in particular, the monitoring of clozapine, lithium and valproate.

[Pandemic COVID-19: what about patients with mental health disorders?]

The COVID-19 pandemic represents a major challenge for the general population. What about people already suffering from mental health problems? We describe the results of a regular survey conducted on patients undergoing treatment in an outpatient psychiatric clinic. The goal was to determine their experience of the first wave of the pandemic, its impact on the meaning of their lives and their spirituality and the types of support (medical and other) they receive. The results highlight that the role of outpatient treatment (sometimes the only assistance provided when containment measures are put in place) is important for a large number of patients. Overall, these data justify and inform the continuation of psychiatric and psychotherapeutic treatment during the pandemic period.

Does the Beck Cognitive Insight Scale predict change in delusional beliefs?

OBJECTIVES

The Beck Cognitive Insight Scale (BCIS) is composed of two subscales, self-reflectiveness and self-certainty, assessing reflectiveness and openness to feedback, and mental flexibility. Delusions have previously been associated with low cognitive insight. The aim of this study was to determine whether changes in BCIS scores predict changes in delusional beliefs.

METHODS

The study is a secondary analysis of a previously published randomized controlled trial. All participants had a psychotic disorder diagnosis and received treatment as usual, with half of them also receiving the cognitive restructuring intervention 'Michael's game'. Participants were assessed at three different times: at baseline (T1), at 3 months (T2), and at 9 months (T3). Cognitive insight was measured with the BCIS, belief flexibility with the Maudsley assessment of delusions schedule (MADS), and psychotic symptoms with the Brief Psychiatric Rating Scale (BPRS).

RESULTS

A total of 172 participants took part in the trial. After using generalized estimating equation (GEE) modelling, we observed (1) significant main effects of BCIS self-certainty and Time and (2) significant Time × BCIS self-certainty and Time × treatment group interaction effects on belief flexibility. Improvements in self-certainty (i.e., decrease in scores) were associated with more changes in conviction over time, more accommodation, improved ability in ignoring or rejecting a hypothetical contradiction and increased use of verification of facts. Medication and BPRS total scores were controlled for in the GEE analyses at their baseline values.

CONCLUSIONS

Overall improvement in BCIS self-certainty scores over time predicted better treatment outcomes as assessed with MADS items.

PRACTITIONER POINTS

Treatments for patients with psychosis should focus on improving cognitive insight as this seems to improve overall treatment outcomes and recovery. The Beck Cognitive Insight Scale can be used to measure changes during treatment and can predict treatment outcomes.

[Meaning of life and mental health: the role of religion]

Patients suffering from severemental illness often turn to spirituality to help cope with their difficulties, in particular to (re)discover meaning in life.Some thereby try to explain their symptoms through religious causes.Generally, turning to spirituality in this way can be adaptive or on the contrary, detrimental. This question and its therapeutic consequences arediscussed and illustrated through clinical examples.

Follow-up study of 67 first episode schizophrenic patients and their involvement in religious activities

We studied the characteristics of religious practice in a cohort of 67 first admission schizophrenic patients over 5 years. Thirty percent of these patients were involved in religious activities, either with an established religion or in a marginal group. They were mostly women, who had a good premorbid psychosocial adaptation and tended not to be substance abusers. Their social adaptation was improved at year 5. They were as compliant with their ambulatory treatment as the other patients. However, when controlling for the inclusion characteristics, a similar outcome was shown between the group of practicing patients and the nonpracticing group. Religious activity may not be by itself the cause of this favorable outcome, as it is probable that only the patients who are less symptomatic and relatively well adapted could actually join a religious movement. The fact that many schizophrenic patients find an occupation and relationships in religious activities that they would not find elsewhere should encourage the psychiatric community target its occupational goals.

Effect of religion on suicide attempts in outpatients with schizophrenia or schizo-affective disorders compared with inpatients with non-psychotic disorders

Little is known of the relations between psychosis, religion and suicide. One hundred and fifteen outpatients with schizophrenia or schizo-affective disorder and 30 inpatients without psychotic symptoms were studied using a semi-structured interview assessing religiousness/spirituality. Their past suicide attempts were examined. Additionally, they were asked about the role (protective or incentive) of religion in their decision to commit suicide. Forty-three percent of the patients with psychosis had previously attempted suicide. Religiousness was not associated with the rate of patients who attempted suicide. Twenty-five percent of all subjects acknowledged a protective role of religion, mostly through ethical condemnation of suicide and religious coping. One out of ten patients reported an incentive role of religion, not only due to negatively connotated issues but also to the hope for something better after death. There were no differences between groups (i.e. psychotic vs. non-psychotic patients). Religion may play a specific role in the decisions patients make about suicide, both in psychotic and non-psychotic patients. This role may be protective, a finding particularly important for patients with psychosis who are known to be at high risk of severe suicide attempts. Interventions aiming to lower the number of suicide attempts in patients with schizophrenia should take these data into account.

Does Change over Time in Delusional Beliefs as Measured with PDI Predict Change over Time in Belief Flexibility Measured with MADS?

Delusional beliefs and their behavioral consequences are predominant symptoms in patients with psychosis and play an important role in the treatment. Delusional beliefs are a multidimensional concept which can be divided into three components: distress, preoccupation and conviction of delusions. These can be measured using Peters delusions inventory (PDI-21). We question, whether changes in delusional beliefs over time during treatment measured with the PDI-21 can predict changes in belief flexibility measured with the Maudsley assessment of delusions schedule (MADS). We used a group of patients from a randomized controlled trial for a cognitive intervention for psychosis or psychotic symptoms. Aside standard treatment for psychosis, half of the patients took part in a group treatment "Michael's game". Patients were assessed at baseline (T1), at 3 months (T2), and at 9 months (T3). We measured delusional beliefs using PDI-21 and belief flexibility with the MADS. One hundred seventy-two patients were included in the analysis. We measured a main effect of PDI-21scores on belief flexibility measured with MADS. PDI-21 Conviction scores predicted outcomes for all measured MADS items. Increasing PDI Distress and Preoccupation scores were predictors for being more likely to dismiss beliefs and change conviction. Time itself was a predictor for changing conviction and being able to plan a behavioral experiment. Overall the changes in PDI scores predicted outcomes for belief flexibility measured with MADS items. The PDI-21 could be a simple and effective way to measure progress in treatment on delusional beliefs.

[The assessment of spirituality and religiousness in patients with psychosis]

OBJECTIVES

There is evidence that psychiatrists are rarely aware of how religion may intervene in their patient's life. That is particularly obvious concerning patients with psychosis. Yet, even for patients featuring delusions with religious content, religious activities and spiritual coping may have a favourable influence. Indeed, patients with psychosis can use religion to cope with life difficulties related to their psychotic condition, in a social perspective but also in order to gain meaning in their lives. Also, religion may be part of explanatory models about their disorder with, in some cases, a significant influence on treatment adhesion.

PATIENTS AND METHODS

This paper describes a prospective randomized study about a spiritual assessment performed by the psychiatrists of patients with schizophrenia. The outpatient clinics in which the sample was collected are affiliated with the department of psychiatry at the university hospitals of Geneva. Eighty-four outpatients with psychosis were randomized into two groups: an experimental group receiving both traditional treatment and spiritual assessment with their psychiatrist and a control group of patients receiving only their usual treatment. Psychiatrists were supervised by a clinician (PH) and a psychologist of religions (PYB) for each patient in the spiritual assessment group. Data were collected from both groups before and after 3 months of clinical follow-up.

RESULTS

Spiritual assessment was well-tolerated by all patients. Moreover, their wish to discuss religious matters with their psychiatrist persisted following the spiritual assessment. Even though clinicians acknowledged the usefulness of the supervision for some patients, especially when religion was of importance for clinical care, they reported being moderately interested in applying spiritual assessments in clinical settings. Compared to the control group, there were no differences observed in the 3 months' outcome in terms of primary outcome measures for satisfaction with care, yet the attendance at the appointments was significantly increased in the group with spiritual assessment. The same result was found when restricting analyses to patients for whom an intervention was suggested or patients who invested more in religion. Areas of potential intervention were frequent both in a psychiatric and psychotherapeutical perspective.

CONCLUSIONS

Spiritual assessment appears to be useful for patients with psychosis. This is in accordance with the recommendations of the World Psychiatric Association which promotes considering the whole person in clinical care. Spiritual assessment is quite simple to perform, providing that clinicians do not prescribe or promote religion, and that no critical comments are made concerning religious issues. Clinicians do not need to know in depth the religious domains of each of their patients, as it appears that each patient accommodates his/her religious background his/her own way.

Sens de la vie et troubles psychotiques

Le rétablissement est un processus visant à promouvoir l’acceptation de ce qui ne peut pas être changé, puis de construire un nouveau projet de vie positif. Se rétablir implique donc de trouver l’espoir, de redéfinir l’identité et de trouver un sens à la vie. Les philosophes puis les thérapeutes existentialistes se sont penchés sur la question du sens. Le sens revêt deux significations :

– que signifient nos vies ?

– à quoi servent nos vies ?

Le sens de la vie est en lien avec une bonne estime de soi. Il découlerait cependant principalement d’une bonne congruence entre nos valeurs (définies comme « des croyances stables selon lesquelles certains buts dans la vie sont préférables à d’autres ») et les moyens donnés par le contexte social pour les appliquer. Nous décrirons dans cet exposé l’application d’un modèle postulant que chez les sujets souffrant de troubles mentaux, des éléments biologiques, psychologiques (p. ex. déficits motivationnels, idées délirantes) et sociaux (isolement) vont empêcher la reconnaissance de valeurs par le sujet, puis leur mise en application. Cela aura un impact sur le sens de la vie. Ce manque de sens va influencer négativement en feed-back la motivation, l’estime de soi et impacter sur des symptômes dépressifs. Notre étude a porté sur 176 sujets dont 75 souffraient de troubles psychotiques, 38 de trouble de la personnalité borderline, 35 de trouble bipolaire et 28 d’anorexie. Globalement, nos hypothèses ont été validées par une analyse de médiation : certains symptômes (manque d’espoir, dépression) influencent les valeurs ; celles-ci sont associées au sens de la vie ; en retour, celui-ci impacte sur des symptômes. Ces résultats, observables dans les quatre groupes diagnostiques, suggèrent de considérer les valeurs et le sens dans la prise en charge orientée sur le rétablissement des patients souffrant de troubles mentaux persistants.

Les éléments psychologiques du rétablissement dans les troubles mentaux sévères : identité, spiritualité et sens

Le concept de rétablissement a été introduit comme principe organisateur des soins aux patients souffrant de troubles mentaux sévères. L’enjeu du rétablissement est de promouvoir l’acceptation de ce qui ne peut pas être changé, puis de construire un nouveau projet de vie positif. Se rétablir implique la plupart du temps pour le patient de redéfinir son identité et de trouver un nouveau sens à sa vie. D’innombrables publications ont porté sur l’organisation des soins selon ce concept. Cependant les aspects portant sur le vécu des patients n’ont pas encore été étudiés à leur juste mesure. Lors de cette session, nous aborderons trois thèmes relatifs à cette expérience du sujet : les perturbations de son identité, le rôle de la spiritualité et le sens de la vie. Notre réflexion s’appuiera sur les travaux scientifiques récents des trois intervenants. L’identité est lourdement mise à l’épreuve lors de l’irruption d’un trouble psychiatrique sévère en raison du traumatisme occasionné par l’émergence des symptômes, des conséquences sociales qui enferment le sujet dans un rôle de malade ou de personne handicapée, mais aussi parfois des troubles cognitifs qui grèvent la capacité des patients de donner un sens à cette expérience déstructurant l’identité. Face aux souffrances subies dans l’expérience d’un trouble psychiatrique, la spiritualité peut représenter une aide souvent négligée par les cliniciens. Ce thème sera abordé notamment par rapport aux troubles psychotiques chroniques mais aussi par rapport aux conduites suicidaires. Enfin, s’il apparaît nécessaire pour chacun de trouver un sens à sa vie, les conséquences sociales et interpersonnelles d’un trouble mental vont de manière inéluctable nécessiter une redéfinition de ce sens. Cela notamment par rapport aux valeurs de l’individu qui impactent sur ce paramètre. Les applications cliniques pratiques de ces recherches seront développées en insistant sur les liens réciproques entre ces domaines essentiels du rétablissement.

Attachment and coping in psychosis in relation to spiritual figures

Background

Studies have found higher levels of insecure attachment in individuals with schizophrenia. Attachment theory provides a framework necessary for conceptualizing the development of interpersonal functioning. Some aspects of the attachment of the believer to his/her spiritual figure are similar to those between the child and his/her parents. The correspondence hypothesis suggests that early child-parent interactions correspond to a person’s relation to a spiritual figure. The compensation hypothesis suggests that an insecure attachment history would lead to a strong religiousness/spirituality as a compensation for the lack of felt security. The aim of this study is to explore attachment models in psychosis vs. healthy controls, the relationships between attachment and psychopathology and the attachment processes related to spiritual figures.

Methods

Attachment models were measured in 30 patients with psychosis and 18 controls with the AAI (Adult Attachment interview) in relationship with psychopathology. Beliefs and practices related to a spiritual figure were investigated by qualitative and quantitative analyses.

Results

Patients with psychosis showed a high prevalence of insecure avoidant attachment. Spiritual entities functioned like attachment figures in two thirds of cases. Interviews revealed the transformation of internal working models within relation to a spiritual figure: a compensation process was found in 7 of the 32 subjects who showed a significant attachment to a spiritual figure.

Conclusions

Attachment theory allows us to highlight one of the underlying dimensions of spiritual coping in patients with psychosis.

[An exploration of sexual desire and sexual activities of women with psychosis]

Most clinicians avoid discussing sexuality with patients with severe mental disorders. Sexual disturbances can be related to medication, to psychological issues such as self-stigma and anhedonia, and to the social context. We studied desire and sexual practices in women suffering from schizophrenia, in comparison with healthy women. Contrary to previous research, women with schizophrenia featured dyadic and individual desire similar to women of comparable age. Yet, only half of women with psychosis had sexual practice, either alone or with a partner. They were less satisfied with their activity, both in terms of function and psychological issues such as sexual self-esteem. This finding underscores the stigmatization these women suffer from, which prevents the opportunity of a possible improvement in this important interpersonal domain.

An exploration of sexual desire and sexual activities of women with psychosis

Sexual disturbances in patients with severe mental disorders can be related to medication, to psychological issues such as self-stigma and anhedonia, but also to the social context. This research aims to gain knowledge of desire and sexual practices in women suffering from schizophrenia. Women outpatients suffering from schizophrenia were compared with healthy women. Contrary to previous research, women with schizophrenia featured dyadic and individual desire similar to women of comparable age. Yet, only half of women with psychosis had sexual practice, either alone or with a partner. They were less satisfied with their activity, both in terms of function and psychological issues such as sexual self-esteem. Keeping into account the fact that most clinicians avoid this topic, this finding underscores the stigmatization these women suffer from, which prevents the opportunity of a possible improvement in this important interpersonal domain.

Reducing Delusional Conviction through a Cognitive-Based Group Training Game: A Multicentre Randomized Controlled Trial

OBJECTIVE

"Michael's game" (MG) is a card game targeting the ability to generate alternative hypotheses to explain a given experience. The main objective was to evaluate the effect of MG on delusional conviction as measured by the primary study outcome: the change in scores on the conviction subscale of the Peters delusions inventory (PDI-21). Other variables of interest were the change in scores on the distress and preoccupation subscales of the PDI-21, the brief psychiatric rating scale, the Beck cognitive insight scale, and belief flexibility assessed with the Maudsley assessment of delusions schedule (MADS).

METHODS

We performed a parallel, assessor-blinded, randomized controlled superiority trial comparing treatment as usual plus participation in MG with treatment as usual plus being on a waiting list (TAU) in a sample of adult outpatients with psychotic disorders and persistent positive psychotic symptoms at inclusion.

RESULTS

The 172 participants were randomized, with 86 included in each study arm. Assessments were performed at inclusion (T1: baseline), at 3 months (T2: post-treatment), and at 6 months after the second assessment (T3: follow-up). At T2, a positive treatment effect was observed on the primary outcome, the PDI-21 conviction subscale (p = 0.005). At T3, a sustained effect was observed for the conviction subscale (p = 0.002). Further effects were also observed at T3 on the PDI-21 distress (p = 0.002) and preoccupation subscales (p = 0.001), as well as on one of the MADS measures of belief flexibility ("anything against the belief") (p = 0.001).

CONCLUSION

The study demonstrated some significant beneficial effect of MG.

The wishes of outpatients with severe mental disorders to discuss spiritual and religious issues in their psychiatric care

OBJECTIVE

In a previous multisite comparative study of spiritual and religious coping (S/R) among outpatients with schizophrenia; S/R were adaptive for 80% of patients; harmful for 13%; and marginal for 7%. This importance was underestimated by clinicians. We created an interfaith therapeutic group to address such topics. The aim of the study is to assess patients' wish to address S/R issues in their psychiatric care.

METHOD

Psychiatrists asked consecutive outpatients about their wish; with who they shared S/R concerns; and their interest to enroll in the "Spiritual and Recovery Group".

RESULTS

Among the 147 patients included less than half shared their spiritual concerns with other people. A quarter wished to address S/R issues in their care; 24/147 already shared those issues with a religious professional; half of them wished also to share them with their psychiatrist. Among the 21 patients who participated in an in-depth spiritual assessment 16 patients were directed to the S/R group and 5 patients were directed to groups addressing other therapeutic objectives.

CONCLUSION

For one patient out of ten, S/R issues were of a clinical significance warranting integration into psychiatric treatment. This study shows that patients' views are in accordance with former research, putting forward psychiatrists' stance on this issue.

Spirituality and religion among French prisoners: an effective coping resource?

The aim of this study was to describe the role of spirituality and religiousness (SR) among detainees. Thirty detainees from a French short-stay prison were assessed with the World Health Organization Quality of Life-Spirituality Religion and Personal Beliefs questionnaire (WHOQOL-SRPB) and with open questions about SR. Forty percent of detainees described SR as an important way of coping with incarceration and stressful events, as a means of finding inner peace, showing altruism, and gaining the respect of others. SR involvement was associated with reports of decreased suicide risk and of the prevention of future offences. SR appears to be an important coping mechanism and may help the transition to the community following incarceration. This study endorses the view that SR should be considered when treating this population.

[Can we prescribe lithium during pregnancy? Summary of a controversy]

Lithium is the standard treatment for bipolar disorder. It has long been contra-indicated during pregnancy because of its teratogenicity, especially regarding cardiac anomalies. More recent epidemiological studies show that the teratogenic risk of lithium has been overestimated in the past. When caring for a pregnant bipolar woman, physicians should consider the risk of fetal exposure to a mood stabilizer but also the risk of relapse if the treatment is interrupted. We have conducted a literature review on this subject. In the second part of the article, we have looked at the authors' recommendations about possible administration of lithium during pregnancy, timing of prophylaxis and precautions to minimize risks.

Spirituality and religion in outpatients with schizophrenia: a multi-site comparative study of Switzerland, Canada, and the United States

OBJECTIVE

To assess the importance of spirituality and religious coping among outpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder living in three countries.

METHOD

A total of 276 outpatients (92 from Geneva, Switzerland, 121 from Trois-Rivières, Canada, and 63 from Durham, North Carolina), aged 18-65, were administered a semi-structured interview on the role of spirituality and religiousness in their lives and to cope with their illness.

RESULTS

Religion is important for outpatients in each of the three country sites, and religious involvement is higher than in the general population. Religion was helpful (i.e., provided a positive sense of self and positive coping with the illness) among 87% of the participants and harmful (a source of despair and suffering) among 13%. Helpful religion was associated with better social, clinical and psychological status. The opposite was observed for the harmful aspects of religion. In addition, religion sometimes conflicted with psychiatric treatment.

CONCLUSIONS

These results indicate that outpatients with schizophrenia or schizoaffective disorder often use spirituality and religion to cope with their illness, basically positively, yet sometimes negatively. These results underscore the importance of clinicians taking into account the spiritual and religious lives of patients with schizophrenia.

Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy: preliminary results

OBJECTIVE

One of the components of dialectical behavior therapy (DBT) is the use of mindfulness skills as a core component of treatment for subjects with borderline personality disorder (BPD). In this study, we investigated changes in and correlates of mindfulness skills over a 1-year follow-up including a 4-week session of intensive DBT followed by 10 months of standard DBT.

METHODS

Fifty-two BPD subjects were assessed several times using the Kentucky Inventory of Mindfulness Skills (KIMS) which describes mindfulness in four discrete dimensions: observing (Obs), describing (Des), acting with awareness (AwA) and accepting without judgment (AwJ).

RESULTS

AwJ was the only dimension that increased significantly over time after adjustment for potential confounding factors (β = 0.24; P = 0.0002). Increases in AwJ correlated with improvement in BPD symptoms.

CONCLUSIONS

This study highlights the usefulness of investigating changes in mindfulness dimensions during DBT. AwJ is a possible mechanism for positive change. Encouraging this skill should lead to a more adaptive response to problematic situations and counteract impulsive and problematic behaviors. The lack of specific control groups means that these findings are preliminary and replication is required.

Effects of an assertive community program in patients with severe mental disorders and impact on their families

AIMS

Assertive community treatment (ACT) is known to have a positive impact on the number and length of inpatient stays. However, recent studies have shown little or no effect of such programs in European settings. This paper aims to describe the impact of a newly implemented ACT program on patients and their families' burden. Predictive factors have also been examined.

METHOD

Fifty-five patients characterized by heavy use of psychiatric care, numerous hospitalizations, or failure to link with outpatient psychiatric care and their relatives were followed. Data were gathered on patients before and after follow up as well as on relatives' burden and costs. The number and domains of clinician interventions have been detailed.

RESULTS

The ACT program had a positive effect on symptoms, psychosocial adaptation and quality of life. Age was the most significant predictor of changes. Older patients, most of them suffering from delusional disorders, showed no improvement or even some impairment. Finally, the program appeared to have a marked effect on easing families' burden in domains such as assistance in daily life activities and costs.

CONCLUSIONS

ACT appears to be recommended for patients with poor outcome when treated in other settings. Early intervention seems to be justified as highlighted by younger age being the best predictor of positive changes. Families can be helped considerably, particularly those confronted with patients with persistent disturbing symptoms which do not, however, warrant hospitalization. Finally, the fact that patients with delusional disorder do not seem to improve warrants further research.

Functions and timescale of self-cutting in participants suffering from borderline personality disorder

The purpose of this study was to examine the meanings and timescale of self-cuttings in a cohort of 22 outpatients suffering from borderline personality disorder. Sixty-one events were recorded using the newly developed self-cutting-checklist (SCUC) designed to investigate the severity of self-cuttings, and intent to die, suicidal ideation, inner tension, sense of relief and anesthesia, and consequences associated with this behavior. We found that typical self-cuttings were associated with a decrease in inner tension and suicidal ideation. Moreover self-cuttings associated with a desire to die differentiated from those associated with no desire to die by significantly less reduction in inner tension. Finally, self-cuttings occurred significantly more often during evenings and nights than during daytime. In conclusion, self-cuttings can be reasonably addressed by self-report. Attention to specific issues such as intent to die and the time of the self-cuttings may improve the outcome of these particularly high-risk subjects.

A randomized trial of spiritual assessment of outpatients with schizophrenia: patients' and clinicians' experience

OBJECTIVE

Recovery-oriented care for patients with schizophrenia involves consideration of cultural issues, such as religion and spirituality. However, there is evidence that psychiatrists rarely address such topics. This study examined acceptance of a spiritual assessment by patients and clinicians, suggestions for treatment that arose from the assessment, and patient outcomes--in terms of treatment compliance and satisfaction with care (as measured by treatment alliance).

METHODS

Outpatients with psychosis were randomly assigned to two groups: an intervention group that received traditional treatment and a religious and spiritual assessment (N=40) and a control group that received only traditional treatment (N=38). Eight psychiatrists were trained to administer the assessment to their established and stable patients. After each administration, the psychiatrist attended a supervision session with a psychiatrist and a psychologist of religion. Baseline and three-month data were collected.

RESULTS

The spiritual assessment was well accepted by patients. During supervision, psychiatrists reported potential clinical uses for the assessment information for 67% of patients. No between-group differences in medication adherence and satisfaction with care were found at three months, although patients in the intervention group had significantly better appointment attendance during the follow-up period. Their interest in discussing religion and spirituality with their psychiatrists remained high. The process was not as well accepted by psychiatrists.

CONCLUSIONS

Spiritual assessment can raise important clinical issues in the treatment of patients with chronic schizophrenia. Cultural factors, such as religion and spirituality, should be considered early in clinical training, because many clinicians are not at ease addressing such topics with patients.

Rare genotype combination of the serotonin transporter gene associated with treatment response in severe personality disorder

The insertion deletion (ins/del) polymorphism of the serotonin transporter gene (5-HTTLPR) has been associated with several psychiatric phenotypes and antidepressant's response. We investigated, in a large cohort of 5,608 controls and subjects suffering from various psychiatric disorders, the frequency of haplotypes and corresponding genotypes combining the 5-HTTLPR and the other serotonin transporter promoter functional variant (rs25531). We showed that rs25531 lies 18 bp 5' to the site where the 43 bp (and not 44 bp as previously described) ins/del defines the 14- and 16-repeat alleles. These polymorphisms should therefore be considered as four alleles instead of a triallelic unique locus. The very rare G-14/G-16 genotype was carried on by only three subjects. These are women with a history of suicide attempt with a psychiatric history strongly suggesting a borderline personality disorder. Two of them have shown a non-response to serotoninergic antidepressant. Interestingly, in one of them was observed a spectacular response after the introduction of bupropion. The genotyping droved our therapeutic approach, by preferring a dopaminergic over a serotoninergic agent. This study highlights the usefulness of studying very rare clinical cases as well as rare variants, in order to deal with the biological heterogeneity of spectral disorders. © 2010 Wiley-Liss, Inc.

The relationship between addiction and religion and its possible implication for care

Spirituality is a topic of increasing interest to clinicians and researchers interested in addiction because its perceived role in the promotion of meaningfulness in the recovery from addiction. Our review of the literature evaluates different domains relative to the relation between addiction, religion, and psychiatric treatment. Spirituality as a protective or precipitating factor for substance use and as a key component of recovery will be debated. Illustrations of its potential and limitations as a component of treatment will be presented. Types of investigation and integration of this dimension in an eventual therapeutic process strictly respecting the needs and specificities of each one will be discussed.

Predictors of response and drop-out during intensive dialectical behavior therapy

The purpose of this study was to examine the effectiveness, and predictors of response and drop-out during a four-week course of intensive dialectical behavior therapy (I-DBT) in 447 outpatients suffering from borderline personality disorder (BPD), over a 10-year period. Assessments included a diagnostic interview, the International Personality Disorder Examination Screening Questionnaire, the Beck Depression Inventory, and the Beck Hopelessness Scale. Among these participants, 103 started a second course of treatment. In agreement with previous reports, I-DBT was effective in reducing levels of depression and hopelessness with a trend of increasing effectiveness over the study period. High schizoid scores and low narcissistic score predicted poor response. Treatment completion rate was high, and low education predicted dropout. A discussion on the usefulness of a second course of treatment should be held with patients and staff as it was not effective in reducing depression and hopelessness.

A measure of dysfunctional eating-related cognitions in people with psychotic disorders

Obesity and binge eating disorder are common in individuals with psychotic disorders. Eating and weight-related cognitions are known to influence eating behaviors. The study was designed to assess the psychometric properties of the Mizes Anorectic Cognitions Questionnaire (MAC-R) in patients with psychotic disorders. Binge eating disorder (BED), body mass index (BMI), the MAC-R and the three factor eating questionnaire (TFEQ) were assessed in 125 patients with a diagnosis of schizophrenia or schizoaffective disorder. Whereas the MAC-R has not acceptable psychometric properties, a brief version of the MAC-R (BMAC) has good psychometrical properties and is correlated with TFEQ and BMI. Binge eating disorder is also correlated to the Rigid Weight Regulation and Fear of Weight Gain subscale. The BMAC is a useful brief measure to assess eating and weight related cognitions in people with psychotic disorders.

Religion and spirituality: how clinicians in quebec and geneva cope with the issue when faced with patients suffering from chronic psychosis

Spirituality and religion have been found to be important in the lives of many people suffering from severe mental disorders, but it has been claimed that clinicians "neglect" their patients' religious issues. In Geneva, Switzerland and Trois-Rivières, Quebec, 221 outpatients and their 57 clinicians were selected for an assessment of religion and spirituality. A majority of the patients reported that religion was an important aspect of their lives. Many clinicians were unaware of their patients' religious involvement, even if they reported feeling comfortable with the issue. Both areas displayed strikingly similar results, which supports their generalization.

Religious explanatory models in patients with psychosis: a three-year follow-up study

BACKGROUND/AIMS

Spirituality and religiousness have been shown to be highly prevalent in patients with psychosis. Yet the influence of religious denomination as it affects coping methods and/or as an explanatory model for illness and treatment remains to be determined. This study aims (1) to investigate if religious denomination is associated with explanatory models, (2) to assess the evolution over time of these explanatory models, and (3) to examine the relationship between these explanatory models and the spiritual vision of treatment and adhesion to such treatment.

SAMPLING AND METHODS

Of an initial cohort of 115 outpatients, 80% (n = 92) participated in a 3-year follow-up study. The evolution of their religious explanatory models was assessed in order to evaluate if religious denomination, as a meaning-making coping tool, is associated with the patients' explanatory models. Finally, we examined the relationship between these representations and the patients' spiritual visions of treatment and treatment adhesion.

RESULTS

A spiritual vision of the illness (as part of an explanatory model) was more frequent in patients with psychosis for whom the subjective dimension of religion was important. However, there was no association between the patients' religious denomination and their spiritual vision of the illness. The analyses showed that the various contents of spiritual visions of illness were not positive or negative per se; instead, they depended on how this religious vision was integrated into the person's experience. Examining longitudinal aspects of coping showed that the spiritual vision sometimes changed, but was not associated with clinical or social outcome.

CONCLUSIONS

For patients with psychosis, explanatory models frequently involve a religious component which is independent of denomination and likely to change over time. Clinicians should address this issue on a regular basis, by asking patients about their explanatory model before trying to build a bridge with the medical model.

Delusions with religious content in patients with psychosis: how they interact with spiritual coping

Delusions with religious content have been associated with a poorer prognosis in schizophrenia. Nevertheless, positive religious coping is frequent among this population and is associated with a better outcome. The aim of this study was to compared patients with delusions with religious content (n = 38), patients with other sorts of delusions (n = 85) and patients without persistent positive symptoms (n = 113) clinically and spiritually. Outpatients (n = 236) were randomly selected for a quantitative and qualitative evaluation of religious coping. Patients presenting delusions with religious content were not associated with a more severe clinical status compared to other deluded patients, but they were less likely to adhere to psychiatric treatment. For almost half of the group (45%), spirituality and religiousness helped patients cope with their illness. Delusional themes consisted of: persecution (by malevolent spiritual entities), influence (being controlled by spiritual entities), and self-significance (delusions of sin/guilt or grandiose delusions). Both groups of deluded patients valued religion more than other patients, but patients presenting delusions with religious content received less support from religious communities. In treating patients with such symptoms, clinicians should go beyond the label of "religious delusion," likely to involve stigmatization, by considering how delusions interact with patients' clinical and psychosocial context.

Influence of spirituality and religiousness on substance misuse in patients with schizophrenia or schizo-affective disorder

Substance misuse represents a major issue in the treatment of schizophrenia patients. Spirituality and religiousness have been shown to reduce substance misuse and to foster recovery among substance misusers in the general population. One hundred and fifteen stabilized outpatients with schizophrenia (mean age 39; 70% male) were selected in 2004 for an interview about religious coping. Religious involvement was significantly inversely correlated to substance use and abuse. A content analysis showed that religion may play a protective role toward substance misuse in 14% of the total sample, especially for patients who had stopped substance misuse (42%). It played a negative role in 3% of cases. Religion may play a role in the recovery of schizophrenia patients with substance misuse comorbidity.

Influence of spirituality and religiousness on smoking among patients with schizophrenia or schizo-affective disorder in Switzerland

BACKGROUND

The rates of cigarette smoking among patients with schizophrenia are two to four times the rates observed in the community. Spirituality and religiousness have been shown to be associated with lower smoking rates in the general population.

AIMS

This study assessed the role of religion in cigarette smoking among patients with schizophrenia or schizo-affective disorder.

METHODS

Some 115 stabilized outpatients from Geneva's public psychiatric facilities were included. Interviews were conducted to investigate spiritual and religious beliefs, religious practices and religious coping. Cigarette smoking was assessed through interviews and medical records.

RESULTS

Some 58% of patients were smokers. Two-thirds of the total sample considered spirituality as very important or essential in their every day life. Religiosity was negatively associated with tobacco use: there were more current smokers without religious affiliation than non-smokers (p < 0.05). For non-smokers, the support of their faith community was significantly more important and they reported more frequent group religious practices than smokers ( p < 0.05). This relation persisted after controlling for demographic confounders (gender, age, ethnicity, education, civil status).

CONCLUSION

In patients with schizophrenia, religion and spirituality seem to be related to smoking behaviour. Similar results were previously found in the general population. These results underscore the need for a systematic exploration of religious issues in the care of smokers with schizophrenia.

Schizophrenia and beta-thalassemia: a genetic link?

This report of two cases in which schizophrenia and beta-thalassemia occurred simultaneously in several family members may suggest that a genetic link exists between these two disorders. A known genetic disease (beta-thalassemia) could help confirm the presence, on the short arm of chromosome 11, of a genetic susceptibility factor for schizophrenia.

Pulmonary thromboembolism associated with olanzapine and risperidone

Several studies and reports suggest an increased risk of venous thromboembolism (VTE) in patients treated with conventional antipsychotic drugs, as well as with clozapine. We report the case of a 25-year-old man with early-onset schizo-affective disorder, with no identified risk factor for thromboembolism, who developed pulmonary embolism on three occasions, once shortly after initiating treatment with olanzapine and twice with risperidone. This case indicates that VTE can be associated with the use of olanzapine and risperidone, two atypical agents having similar properties and the same 5HT2 receptors antagonism, possibly implicated in this adverse event. As suggested by this observation, patients who have had one episode of VTE with antipsychotics with an affinity for 5HT2 receptors should receive neuroleptics from other classes, such as amisulpride, which does not interact with 5HT2 receptors. They should also be closely monitored to ensure early detection and prompt treatment of VTE.

Patients with schizophrenia and their finances: how they spend their money

INTRODUCTION

Although most patients with schizophrenia rely on state financial support, little is known about their expenses and how they use the money at their discretion. However, the ability to budget is a predictive factor in rehabilitation. An assessment of financial management skills could make it possible to develop more appropriate psycho-social assistance.

METHOD

Fifty-seven outpatients with schizophrenia treated in the public sector in Geneva, Switzerland took part in the study. Psychosocial, diagnostic, neurocognitive and symptomatological measures were collected. Data were gathered on patients' incomes and quality of life. A prospective analysis of their expenses during a 1-month period was also performed.

RESULTS

Median income was 4,125 Swiss francs per month (i.e., 3,372 US dollars). After paying fixed expenses (which were handled with or without the assistance of a representative payee), a mean of 400 Swiss francs remained at their disposal to use as they wished. Seventy-two percent of this money was devoted to the use of psychoactive substances (e.g., cigarettes, alcohol, cannabis) or various drinks in coffee houses, and 28% on leisure activities (trips, sports and other recreational activities). Eighty-four percent of patients would have liked to have more money for leisure activities. The study was well-accepted and led to modification of the treatment plan in 84% of cases.

CONCLUSION

Most of the discretionary money patients received was used for buying substances with addictive properties; this may hinder the practice of activities favouring recovery. Thus, it appears essential to guide patients in the management of their budgets.

[Income and expenses of patients with chronic psychosis]

Knowledge about the income of patients with chronic psychotic disorder and how they use the money may help to provide appropriate clinical and social assistance. Fifty-seven outpatients with schizophrenia treated in Geneva, Switzerland, were studied. Mean income was 3866 Swiss francs (4209 for those with the Swiss disability fund). Only a minority of patients live on meager resources with insufficient comfort. A 4 weeks follow-up showed that patients disposed of a mean of 400 Swiss francs discretionary money. Twenty eight percent of this money was used for leisure activities. This psychiatric and social system allows stabilized patients with psychosis to get what they need in terms of financial support and housing. However, patients should be helped to use their discretionary money in ways more prone to help recovery.

Religious beliefs in schizophrenia: their relevance for adherence to treatment

The study examined how religious beliefs and practices impact upon medication and illness representations in chronic schizophrenia. One hundred three stabilized patients were included in Geneva's outpatient public psychiatric facility in Switzerland. Interviews were conducted to investigate spiritual and religious beliefs and religious practices and religious coping. Medication adherence was assessed through questions to patients and to their psychiatrists and by a systematic blood drug monitoring. Thirty-two percent of patients were partially or totally nonadherent to oral medication. Fifty-eight percent of patients were Christians, 2% Jewish, 3% Muslim, 4% Buddhist, 14% belonged to various minority or syncretic religious movements, and 19% had no religious affiliation. Two thirds of the total sample considered spirituality as very important or even essential in everyday life. Fifty-seven percent of patients had a representation of their illness directly influenced by their spiritual beliefs (positively in 31% and negatively in 26%). Religious representations of illness were prominent in nonadherent patients. Thirty-one percent of nonadherent patients and 27% of partially adherent patients underlined an incompatibility or contradiction between their religion and taking medication, versus 8% of adherent patients. Religion and spirituality contribute to shaping representations of disease and attitudes toward medical treatment in patients with schizophrenia. This dimension should be on the agenda of psychiatrists working with patients with schizophrenia.

The assessment of spirituality and religiousness in schizophrenia

To assess religious coping in schizophrenia, we developed and tested a clinical grid, as no validated questionnaire exists for this population. One hundred fifteen outpatients were interviewed. Results obtained by 2 clinicians were compared. Religion was central in the lives of 45% of patients, 60% used religion extensively to cope with their illness. Religion is a multifaceted construct. Principal component analysis elicited 4 factors: subjective dimension, collective dimension, synergy with psychiatric treatment, and ease of talking about religion with psychiatrist. Different associations were found between these factors and psychopathology, substance abuse, and psychosocial adaptation. The high prevalence of spirituality and religious coping clearly indicates the necessity of addressing spirituality in patient care. Our clinical grid is suitable for this purpose. It proved its applicability to a broad diversity of religious beliefs, even pathological ones. Interjudge reliability and construct validity were high and specific training is not required.