Outcome of Involuntary Mental Health Assessment in a Psychiatric Department in Greece

Despite their controversiality, involuntary admissions in psychiatric departments remain a central issue in mental health care. The present study aims to identify demographic and clinical factors possibly associated with emergency involuntary psychiatric assessment and its outcome in Greece. This study was carried out in the psychiatric department of the University General Hospital of Alexandroupolis (UGHA) from 1 March 2018 to 28 February 2019. The sample included 191 individuals who had been psychiatrically assessed without their consent following a prosecutorial order. The majority of the involuntary assessments resulted in hospitalization (71%), with 51% of them resulting in involuntary hospitalization. Almost all patients diagnosed with "F20-29 schizophrenia, schizotypal and delusional disorders" were subsequently admitted to the psychiatric department of the UGHA (77 of 81, 66 of them involuntarily). Higher admission rates were recorded among those who had been referred from the Prosecutor's Office of regions that are located far from the psychiatric department of UGHA (Fisher's exact test, p-value = 0.045). In multivariate logistic regression, prior contact with psychiatric services and having an "F20-29 schizophrenia, schizotypal and delusional disorders" diagnosis was statistically significant with admission to the hospital as an outcome variable. Our study suggests an increased risk of involuntary admission among patients with psychosis, patients who had visited a psychiatric service prior to their assessment as well as those living further away from the main psychiatric services of the hospital. Better organization of community psychiatric services in remote places from hospital central services may lead to fewer prosecutorial referrals and coercive measures.

Involuntary psychiatric hospitalizations in Greece: Contemporary research and policy implications

Involuntary psychiatric hospitalization is a contested issue in mental health care provision. Despite indications of very high rates of involuntary hospitalizations in Greece, no valid national statistical data has been collected. After reviewing current research on involuntary hospitalizations in Greece, the paper introduces the Study of Involuntary Hospitalizations in Greece (MANE), a multi-centre national study of the rates, process, determinants and outcome of involuntary hospitalizations, conducted in the regions of Attica, Thessaloniki and Alexandroupolis, from 2017 to 2020, and presents some preliminary comparative findings regarding the rates and process of involuntary hospitalizations. There is a major difference in the rates of involuntary hospitalizations between Alexandroupolis (around 25%) and Athens and Thessaloniki (over 50%), that is possibly related to the sectorized organization of mental health services in Alexandroupolis and to the benefits of not covering a metropolitan urban area. There is a significantly larger percentage of involuntary admissions that end in involuntary hospitalization in Attica and Thessaloniki compared to Alexandroupolis. Reversely, of those accessing the emergency departments voluntarily, almost everyone is admitted in Athens, while large percentages are not admitted in Thessaloniki and in Alexandroupolis. A significantly higher percentage of patients were formally referred upon discharge in Alexandroupolis compared to Athens and Thessaloniki. This may be due to increased continuity of care in Alexandroupolis and that might explain the low rates of involuntary hospitalization there. Finally, re-hospitalization rates were very high in all the study centers, demonstrating the revolving-door phenomenon, especially for voluntary hospitalizations. The MANE project came to address the gap in national recording of involuntary hospitalizations, by implementing, for the first time, a coordinated monitoring of involuntary hospitalizations in three regions of the country with different characteristics, so that a picture of involuntary hospitalizations can be drawn at national level. The project contributes to raising awareness of this issue at the level of national health policy and to formulating strategic goals to address the problem of violation of human rights and to promote mental health democracy in Greece.

The introduction and implementation of open dialogue in a day center in Athens, Greece: experiences and reflections of mental health professionals

Introduction

The present study is part of a large-scale original action-research project aiming to assess the introduction and implementation of the Open Dialogue approach within the clinical practice of an established multidisciplinary team in a Day Centre in Athens, Greece. More specifically, it aimed to explore the experiences of professionals within the process of implementation both in relation to their clinical practice and their professional identity.

Methods

Data collection employed a focus group, which was set up to explore professional reflections of the implementation and research processes since the introduction of the model. Thematic Analysis of transcripts revealed two main themes that correspond to the impact of Open Dialogue on professionals' clinical practice and on team dynamics, respectively.

Results

Professionals identify several challenges in implementing OD, such as difficulties in linking theory to practice, containing uncertainty, and addressing cultural barriers to dialogical ways of working. Professionals further reflect on their own internal journey stemming from the implementation of Open Dialogue that has led them to greater openness and growth, personally and as a team.

Discussion

The role of mental health professionals is being acknowledged as being at the frontline of any meaningful psychiatric reform through the assimilation and promotion of humanistic paradigms aiming towards a change of culture in psychiatric care across different contexts. Despite variations in implementation across different contexts, the importance of consolidating and embracing Open Dialogue as a philosophical framework underpinning mental health care is being discussed.

Clinical determinants of involuntary psychiatric hospitalization: A clinical profile approach

OBJECTIVES

The study examines the clinical determinants of involuntary psychiatric hospitalization. Specifically, it investigates whether distinct clinical profiles of hospitalized patients can be discerned, what other characteristics they are linked with, and which profiles predict involuntary admission.

METHODS

In this cross-sectional multicentre population study, data were collected for 1067 consecutive admissions in all public psychiatric clinics of Thessaloniki, Greece, during 12 months. Through Latent Class Analysis distinct patient clinical profiles were established based on Health of the Nation Outcome Scales ratings. The profiles were then correlated with sociodemographic, other clinical, and treatment-related factors as covariates and admission status as a distal outcome.

RESULTS

Three profiles emerged. The "Disorganized Psychotic Symptoms" profile, combining positive psychotic symptomatology and disorganization, included mainly men, with previous involuntary hospitalizations and poor contact with mental health services and adherence to medication, indicating a deteriorating condition and chronic course. Τhe "Active Psychotic Symptoms" profile included younger persons with positive psychotic symptomatology in the context of normal functioning. The "Depressive Symptoms" profile, characterized by depressed mood coupled with nonaccidental self-injury, included mainly older women in regular contact with mental health professionals and treatment. The first two profiles were associated with involuntary admission and the third with voluntary admission.

CONCLUSIONS

Identifying patient profiles allows the examination of the combined effect of clinical, sociodemographic, and treatment-related characteristics as risk factors for involuntary hospitalization, moving beyond the variable-centered approach mainly adopted to date. The identification of two profiles associated with involuntary admission necessitates the development of interventions tailored to chronic patients and younger persons suffering from psychosis respectively.

Patient-reported needs predict perceived psychosocial disability and quality of life beyond symptom severity in schizophrenia

PURPOSE

We examined whether patient-rated or clinician-rated needs are more strongly associated with perceived psychosocial disability (PPD) and subjective quality of life (SQOL) of schizophrenia patients, beyond symptom severity.

METHODS

Hierarchical regression analyses were computed to test patient and clinician-rated unmet and met needs (estimated by eighty-two patient-clinician pairs) as predictors of PPD and SQOL above and beyond demographics and psychopathology. Needs, symptomatology, PPD and SQOL were estimated using Camberwell Assessment of Need (CAN), PANSS, WHODAS 2.0 and WHOQOL-BREF respectively.

RESULTS

Needs were significantly associated with all WHODAS 2.0 and WHOQOL-BREF domains above and beyond demographics and PANSS variables. Clinician-rated needs were better predictors of only one WHODAS 2.0 domain, while patient-rated needs were better predictors of all other WHODAS 2.0 and WHOQOL-BREF domains. Patient-rated unmet needs were more strongly than met needs associated with the most WHODAS 2.0 and WHOQOL-BREF subscores.

CONCLUSION

This study offers the first evidence that patient-rated needs, especially unmet needs, are strongly associated, above and beyond symptomatology, with global and domain-specific PPD of schizophrenia patients. Accordingly, strong relations of patient-rated needs with SQOL emerged. Identifying and addressing patient-reported needs could facilitate PPD and SQOL improvement more effectively than interventions confined solely to symptom remission.IMPLICATIONS FOR REHABILITATIONSchizophrenia is associated with poor rehabilitation and recovery outcomes, i.e., perceived psychosocial disability (PPD) and subjective quality of life (SQOL).Assessment of patients' needs constitutes the basis of determining treatment goals and planning tailor-made interventions to achieve crucial rehabilitative outcomes.Higher levels of patient-reported unmet needs are associated with poorer SQOL and higher global and domain-specific PPD of schizophrenia patients, above and beyond symptom severity.Addressing patient-reported needs through personalized interventions can facilitate more effectively PPD and SQOL improvement, than treatment confined to symptomatic alleviation.

COVID-19 pandemic and the mental health care system

The psychological impact of pandemics, which historically appear in the human species, is described in detail in Steven Taylor's excellent book "The Psychology of Pandemics",1 which was published in 2019, a few months before the outbreak of the Covid-19 pandemic. This pandemic shows similar characteristics in terms of mental health problems to the previous ones described in the book, according to the findings of epidemiological research, both internationally and in Greece.2-5 The results of these studies show a significant increase of the prevalence of common mental disorders, especially in vulnerable groups, particularly in persons with preexisting mental disorders. The necessary restrictive measures applied, especially in the first stages of the pandemic, had an impact in the accessibility of psychiatric patients to the mental health services, both in- and outpatient ones.6 This led to decreased outpatient appointments and admissions in inpatient wards, depriving a large number of these patients from necessary treatments and interventions, often resulting in worsening their mental state or relapse of acute episodes. The lack of accessibility to mental health services, had a greater impact on persons with social and financial problems, which deteriorated during the pandemic, leading to mental health problems.3 An additional problem is that persons suffering from severe mental disorders, such as chronic psychoses, face a greater risk of infection and death by Covid-19.7 These problems, arising during the pandemic (increased prevalence of mental disorders, increase of relapses of serious mental disorders, increased risk of infection and death by Covid-19, increased prevalence in those infected, especially those in the ICUs, problems of accessibility) underline the chronic insufficiencies of the mental health care system, which in many countries, especially in Greece, is fragmented and is not covering adequately the mental health needs of the population. A series of articles in prestigious mental health journals point out the problem and propose solutions, in order to correct insufficiencies and create a new strong mental health system through a series of activities.8-10 These articles underline the problems known for decades and propose the following solutions for enhancing the existing mental health system, not only to cover additional needs created by the pandemic, but leading to a new mental health system covering adequately the needs of the population: (1) Strengthening leadership and governance, with interventions to politicians and administrators, in order to understand mental health issues, and provide services in terms of inclusivity, equity and accountability. (2) Supporting financially evidence-based services, adopting policies to counteract the social determinants of mental health, as well as the additional needs created by the pandemic. (3) Promoting programmes targeting vulnerable groups, especially those related to social determinants, with the active participation of stakeholders, with emphasis in combating stigma and enhancing mental health literacy. (4) Strengthen mental health services in all three levels, with emphasis in community mental health services, treatment at home, special services for vulnerable groups, services for the Covid-infected and the relatives of the deceased from the infection, the staff of health services dealing with Covid-19, using "telehealth" services, adopting information systems to assist services and close collaboration with the services dealing with Covid-19. (5) Training the staff of primary health care in mental health by using the mhGAP programme of the World Health Organization (WHO) and linking them to the special mental health services. (6) Implementing programmes for mental health promotion and prevention of mental disorders, with the participation of stakeholders, NGOs and the civil society. (7) Improving mental health information systems and connecting them with parallel systems dealing with Covid-19. (8) Strengthen and finance research in mental health, from epidemiology and services research, to neurobiology, as well as research aiming to provide innovative solutions for improving the system of mental health services and the provision of services and interventions through the social media. (9) Protecting rights of mental patients aiming to provide high quality services by use of evaluation instruments such as WHOQualityRights of WHO.

“Let’s face it… it’s futile”: Experiences of futility among nurses who provide care to patients with borderline personality disorder

Introduction

Research studies suggest that mental health nurses hold negative attitudes towards patients diagnosed with borderline personality disorder (BPD).

Objectives

The aim of this study was to explore mental health nurses’ experiences and attitudes towards BPD patients in Greece, using a qualitative approach.

Methods

Data were collected through two audio-recorded focus group discussions. The participants were twelve nurses who work in two General Hospital Psychiatric Units –one in Athens and one regional– and have direct clinical experience with BPD patients. The audio recordings were transcribed verbatim and analysed using thematic analysis in the context of grounded theory.

Results

One overarching theme and three main themes were identified. The overarching theme that emerged was: “Futility”, which refers to feelings that the provision of nursing care to BPD patients is devoid of purpose and meaning. The main themes were: “Uncertainty”, which refers to the absence of valid causal explanations for mental disorders and on the perplexity of the BPD psychopathology; “Frustration”, which refers to challenges and barriers to providing care to BPD patients; “Unsupportiveness”, which refers to a complex mental health system, where there is a lack of guidance and goal orientation. Of significance are the nurses’ feelings of frustration and futility creating a sense of being burdened and leading to negative attitudes and behaviours towards BPD patients.

Conclusions

Understanding treatment goals from the recovery model perspective and developing guidelines to help nurses revisit the concept of medical futility, may improve care to BPD patients.

Disclosure

No significant relationships.

Mental health professionals’ attitudes towards patients with borderline personality disorder: The role of disgust

Introduction

Mental health professionals’ derogatory attitudes towards patients diagnosed with borderline personality disorder (BPD) may negatively affect treatment outcomes.

Objectives

We aimed to identify a) negative attitudes exhibited by mental health professionals towards BPD patients and b) the effects of disgust propensity and disgust sensitivity on theses negative attitudes.

Methods

Mental health professionals (N = 136) completed questionnaires on attitudes towards BPD patients, disgust propensity/sensitivity, and sociodemographic variables.

Results

Significant differences in negative attitudes toward BPD patients based on gender, marital status, occupational subgroup, educational level, psychotherapy training, level of exposure to BPD patients, and political ideology were found. Results suggested BPD patients are viewed by mental health professionals as ineffective, incomprehensible, dangerous, unworthy, immoral, undesirable to be with, and dissimilar to the mental health professionals. Moreover, disgust propensity and the pathogen component of disgust sensitivity were associated with stronger negative attitudes towards BPD patients.

Conclusions

The findings emphasize the importance of mental health professionals’ awareness of the emotion of disgust as a relevant factor to their negative attitudes towards BPD patients.

Disclosure

No significant relationships.

Outcome of Voluntary vs Involuntary Admissions in Greece over 2 years after Discharge: A Cohort Study in the Psychiatric Hospital of Attica "Dafni"

The increasing rates of involuntary hospitalization constitute a major ethical issue in psychiatric practice. The present cohort study endeavours to investigate the relationship between patients' legal status (involuntary vs voluntary) and the outcome of their hospitalization, over 2 years after discharge. All individuals admitted in the 3rd Psychiatric Department of the Psychiatric Hospital of Attica during February 2015-February 2017 took part in the study. 64.7% of patients were compulsory admitted. Findings indicate a statistically significant improvement in global functioning and symptomatology levels from admission to discharge for all treated patients, independently of their legal status. However, readmission rates over 2 years after discharge were high (34.8% vs. 21.9% in voluntary and involuntary patients, respectively). In conclusion, psychiatric admission, irrespectively of legal status leads to clinical improvement.

Experiences of Futility Among Nurses Providing Care to Patients With Borderline Personality Disorder in the Greek Mental Health System

The aim of the current study was to explore mental health nurses' experiences and attitudes toward patients with borderline personality disorder (BPD) in Greece using a qualitative approach. Data were collected through two audio-recorded focus group discussions. Participants were 12 nurses who work in two general hospital psychiatric units and have direct clinical experience with patients with BPD. Audio recordings were transcribed verbatim and analyzed using thematic analysis in the context of grounded theory. One overarching theme and three main themes were identified. The overarching theme, Futility, refers to feelings that the provision of nursing care to patients with BPD is devoid of purpose and meaning. The main themes were: Uncertainty, Frustration, and Unsupportiveness. Of significance are nurses' feelings of frustration and futility creating a sense of being burdened and leading to negative attitudes and behaviors toward patients with BPD. Understanding treatment goals from the recovery model perspective and developing guidelines to help nurses revisit the concept of medical futility may improve care to patients with BPD. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Insights into involuntary hospital admission procedures for psychiatric patients: A 3-year retrospective analysis of police records

The procedure of involuntary hospitalization has been an ongoing subject of study. Its implementation requires the systematic co-ordination between the Justice and Health Care systems around the globe. In the case of Greece, the procedure under discussion is regulated by Law 2071/1992, which designates the Police as the agent that links the aforementioned systems together. The present study aims to shed light upon the procedure of involuntary hospitalizations, regarding the preparatory stage and the Police involvement up to the individuals' admission to the on-call hospital for a mental health assessment (MHA). The entry data of two police stations in Athens was recorded by the respective Duty Officer responsible for each case. The police records were retrospectively inspected and information on socio-demographic, clinical and parametric characteristics was extracted. The data collection took place between March and July 2020 and included 324 cases, 80.3% of which referred to involuntary hospitalizations; 17.6% of sample cases did not meet the criteria of the procedure, as opposed to 1.9% of the cases in which the patients eventually ended up being voluntarily admitted and afterwards hospitalized for treatment. There was a statistically comparison of socio-demographic, clinical and parametric variables in relation to the status of hospitalization groups (involuntary, voluntary and no hospitalization). Additionally, statistical comparisons were made between parametric and clinical variables in relation to the type of prosecution order (written: standard route, oral: emergency route). Acute mental health deterioration accounted for around 45% of the total data and it has been identified as the main factor for informing the Hearings Prosecutor office mainly by the patient's family and subsequently proceeding to the issuance of an order (in either written or oral form) to the Police. This enables the Police to escort the individuals and lead them to a psychiatric unit for mental health assessment (MHA) and based on this, for involuntary hospitalization if deemed necessary. In 87.9% of the cases, the individual was transported by police vehicles over a time span ranging from the very same day to 22 days. In total, the written prosecution orders (63.6%) outnumbered the oral ones (36.7%). The findings of the present study demonstrate that the Prosecution order type varies significantly depending on the causes that instigated the involuntary hospitalization procedure. The psychiatric decision whether there should be hospitalization or outpatient therapy also significantly varies depending on the diagnosis. Lastly, the results point out that the need for improvement and further clarification of the aforementioned Greek Law is absolutely essential.

Assessment of the Mobile Mental Health Units' effectiveness in Cyclades islands

In Greece, the provision of mental health shows inefficiencies in remote and inaccessible areas due to the lack of appropriate structures and access to healthcare. The purpose of this study was to assess the effectiveness of the Mobile Mental Health Units (MMHUs) in Cyclades with and without MMHUs' operation based on Real-World Evidence (RWE). The study population consisted of 724 people who visited the MMHUs of the western and northeastern Cyclades in 2015. The data derived from the patients' medical records of EPAPSY classified by International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) and the Global Assessment of Functioning (GAF) scale. The analysis revealed that 60.9% of the participants were women and the average age was 50.1. 50.4% of the people who visited MMHUs without referral from primary health care professionals and 18.8% with referral. The calculation of effectiveness was based on DALYs (Disability-Adjusted Life Years) and was performed according to the World Health Organization methodology. In the specific population, there are no recorded deaths caused by mental disorders and thus DALYs are equal to Years Lost due to Disability (YLDs) with MMHUs' operation. 18% of the population was diagnosed with mood disorders (F30-F39) and morbidity burden 9.49 (YLDs), while 17.5% of the patients were diagnosed with neurotic, stress-related and somatoform disorders (F40-F48) and corresponding morbidity burden 4.53 (YLDs). Our results revealed that the effectiveness of MMHUs corresponds to 17.98 Disability-Adjusted Life Years (DALYs) averted in 2015. The mood disorders and the neurotic, stress-related disorders have shown a high morbidity burden. Advanced age, non-permanent employment, existence of psychopathology in the family and referral on patients' own will were found to significantly affect the mental health status of the participants. The implementation and expansion of flexible and alternative community-based interventions, such as MMHUs, constitute a best practice both for obtaining higher clinical outcomes and for facing regional inefficiencies related to population's access to healthcare.

Prevalence and risk factors of compulsory admissions in athens region: Are there any differences between psychiatric and general hospitals?

Introduction

Concerns have been raised about Europe facing a reinstitutionalization process. Thus, research and policy interest in prevalence and determinants of involuntary hospitalizations has recently rekindled. In Greece, heightened rates of compulsory admissions have been partly ascribed to the incomplete psychiatric reform. Psychiatric hospitals remain the mainstay of inpatient care, as opposed to the more community-oriented psychiatric departments of general hospitals.

Objectives

To investigate differences between a psychiatric and a general hospital with respect to rates and determinants of involuntary hospitalizations in Athens.

Methods

All admissions in one psychiatric and one general hospital between May – September 2020 were considered. Information about patients’ socio-demographic characteristics and mental health status was garnered through clinical records and patient and physician interviews. Symptom severity was assessed with the Health of Nations Outcome Scale and diagnosis was assigned in accordance with the ICD-10 criteria.

Results

A total of 600 admissions were analysed. In the general hospital, 52.5% of admissions were involuntary, as opposed to 63.1% in the psychiatric hospital (OR = 0.65, 95%CI = 0.43 – 0.97). In the general hospital, the sole risk factor for compulsory admission was aggression (OR= 3.23, 95%CI = 1.24-8.4). Interestingly, in the psychiatric hospital, sex, age, nationality, education, diagnosis and the severity of symptoms tapped by HoNOS were not found to predict involuntary status.

Conclusions

In psychiatric hospitals, no patient subgroups appear to be at elevated risk of civil detention. Therefore, further research is warranted as to what drives the decision there.

Experiences of Recovery in EPAPSY's Community Residential Facilities and the Five CHIME Concepts: A Qualitative Inquiry

In the context of the reform of psychiatric services in Greece, the debate about the concept of recovery is still growing. Recovery is defined as a path through which individuals facing mental health challenges are enabled to regain and further develop significant relationships with family, friends, the community, and themselves and at the same time to cope with the detrimental effects of stigma through empowerment. The present qualitative study aims to explore the experiences of people living in EPAPSY's (Association for Regional Development and Mental Health) community residential facilities focusing mainly upon the key concepts of the CHIME (connectivity, hope, identity, meaning, and empowerment) conceptual framework of recovery. To this end, semi-structured interviews were conducted with seven participants living and receiving mental health care in a residential facility of EPAPSY. The participants' accounts were analyzed using thematic analysis in a deductive and inductive manner. The research findings highlighted, among others, the challenges the participants faced during their early years in family and school, the experience of the revolving door effect, and the perceived turn their life took when they were transferred to a community residential facility, thus opening a new chapter in their lives. Of the five CHIME concepts, all are present in the participants' accounts, with emphasis given to a meaningful present, a need to feel "normal" again, and a positive outlook for the future, both for themselves and their relationships, despite the persistence of certain difficulties.

The impact of the long-lasting socioeconomic crisis in Greece

Since 2009, Greece has experienced a long-lasting socioeconomic crisis that has had substantial consequences on the health and mental health of the population. Unemployment, financial hardship and income loss constitute the hallmarks of the socioeconomic landscape. Consequently, a substantial decline in health and mental health has been documented. Converging evidence corroborates a deterioration of self-rated health, an alarming rise in suicide rates and a gradual increase in the prevalence of major depression. Concomitantly, the healthcare system is on the verge of collapse and the mental healthcare system is incapable of addressing the emerging needs. Therefore, a multifaceted and concerted effort is urgently needed to mitigate the mental health effects of the recession.

Mental health care in Athens: Are compulsory admissions in Greece a one-way road?

Involuntary hospitalization has long been a contentious issue worldwide. In Greece, the frequency of compulsory admissions is assumed to be alarmingly high; however, no study has systematically investigated this issue. In line with this, the present study aims to estimate the frequency of compulsory admissions in a psychiatric hospital and to explore its underpinnings. All individuals who were admitted to the Psychiatric Hospital of Attica during June-October 2011 were included into the study. Information about their socio-demographic and clinical characteristics as well as their previous contact with mental health services was obtained from interviewing the patient and his/her physician. Furthermore, information about the initiation of the process of compulsory admission as well as patient's referral upon discharge was retrieved from patients' administrative record. Out of the 946 admissions 57.4% were involuntary. A diagnosis of unipolar depression, high social support and previous contact with community mental health services were found to yield a protective effect against involuntary hospitalization. Moreover, 69.8% of civil detentions were instigated by close relatives and 30.2% ex officio. These two groups differed in patients' social support levels and in medication discontinuation being the reason for initiation of the process. Lastly, only 13.8% of patients were referred to community mental health services at discharge. Our findings suggest that civil detentions are deeply entrenched in clinical routine in Greece. Moreover, poor coordination among services and relatives' burden seem to contribute substantially to the elevated rates.

Depression in late adolescence: a cross-sectional study in senior high schools in Greece

BACKGROUND

Depression is a common mental health problem in adolescents worldwide. The aim of the present study was to investigate the prevalence, comorbidity and sociodemographic and socioeconomic associations of depression and depressive symptoms, as well as the relevant health services use in a sample of adolescents in Greece.

METHODS

Five thousand six hundred fourteen adolescents aged 16-18 years old and attending 25 senior high schools were screened and a stratified random sample of 2,427 were selected for a detailed interview. Psychiatric morbidity was assessed with a fully structured psychiatric interview, the revised Clinical Interview Schedule (CIS-R). The use of substances, such as alcohol, nicotine and cannabis, and several sociodemographic and socioeconomic variables have been also assessed.

RESULTS

In our sample the prevalence rates were 5.67 % for the depressive episode according to ICD-10 and 17.43 % for a broader definition of depressive symptoms. 49.38 % of the adolescents with depressive episode had at least one comorbid anxiety disorder [OR: 7.76 (5.52-10.92)]. Only 17.08 % of the adolescents with depression have visited a doctor due to a psychological problem during the previous year. Anxiety disorders, substance use, female gender, older age, having one sibling, and divorce or separation of the parents were all associated with depression. In addition, the presence of financial difficulties in the family was significantly associated with an increased prevalence of both depression and depressive symptoms.

CONCLUSIONS

Prevalence and comorbidity rates of depression among Greek adolescents are substantial. Only a small minority of depressed adolescents seek professional help. Significant associations with financial difficulties are reported.

Prevalence of mental disorders in a Greek island

In Greece, the need for epidemiological data became evident at the beginning of the mental health reform during 1983 with the emergence of the necessity to develop community-based mental health services. This survey was conducted in 2005 by the Association for Regional Development and Mental Health (EPAPSY), supported by the local authorities. It followed the methodology of the survey "Mental Health in the General Population: Images and Realities" (MHGP), a large scale multisite epidemiological research conducted by the World Health Organization Collaborative Centre of Lille in France and other countries. The aim of this study was to assess prevalence, sociodemographic and comorbidity patterns of mental disorders in the general adult population of Evia Island, Greece. This was a cross-sectional survey investigating point, period and lifetime prevalence of mental disorders. The target population was the non-institutionalized adult population of island of Evia (population 230,000 people). The Mini International Neuropsychiatric Interview and a sociodemographic data questionnaire were administered by trained interviewers to 900 residents of Evia. The quota sampling method was used to obtain a sample representative of the target population. Lifetime prevalence of any disorder, as identified by the MINI, was 29%. The prevalence of depression was high, with 17.5% of women and 14.6% of men currently meeting the criteria for diagnosis. Affective and anxiety disorders were found to be more frequent in women than men, except for dysthymia, social phobia and post-traumatic stress disorder which were slightly more frequent in men. The prevalence of psychiatric disorders in Evia was much higher than the prevalence found by other epidemiological studies in Greece and among the highest in Southern Europe. The high prevalence of mental disorders found in Evia means that almost one third of the population will suffer from a clinically significant disorder in their lifetime. Therefore, the resulting social burden is very relevant and requires the inclusion of mental health care among the main goals of a public health strategy. Methodological issues concerning the comparison of results between different countries, the limitations of the study and the rates of alcohol use disorders discussed. High rates of mental disorders are related to demographic changes, such as the increasing are size of elderly population, and probably to economic hardship and rise in unemployment. Results should be taken into consideration for the planning and development of interventions for vulnerable groups.

[Between European harmonisation and the consequences of the Greek economic crisis]

Since 1984, psychiatry in Greece has undergone a gradual and complex evolution. One of the aims of the Psychargos programme which began in 2002 is to deinstitutionalise chronic patients and to implement a system of regionalisation across the whole country. Inserting the momentum of users' and families' associations remains a major objective.

[Frame of internal functioning and innovative practices in a Day Center for psychotics]

The Day Center (DC) of EPAPSI (Scientific Association for Regional Development and Mental Health) offers complete psycho-social interventions for the psyhotic patients of the 5th Psychiatric Sector, in order to prevent them from relapsing, helps reduce hospitalisation and also works towards psychological and vocational rehabilitation; always aiming at improving the quality of patients' life. Working towards the continuum of care of its patients, the DC applies innovative practises such as: the creation of a community-based supportive network, the running of social clubs, participation in European Programmes concerning the social and vocational rehabilitation of patients, creation of KoiSPE (Limited Liability Social Co-operatives) in co-operation with the Local Authorities, application of new methods of caring and curing, involving the patients in co-running the "therapeutic contract". The successful application of "community psychiatry" and the continuation of psychiatric reform will be accommodated with the contribution and co-operation of "communal" services and the wider public sector as well as the application of new and pioneering programmes.

[An individualized behavioral approach in psychosocial rehabilitation]

The deinstitutionalization of chronic mental health patients and the simultaneous growth of community mental health structures were elected as central objectives of interventions, based on the concept of psychosocial rehabilitation. The main axes of this ef fort were maximization of the individual's potential and minimization of the long-term hospitalizations' negative consequences. The individualized approach via the application of an individual therapeutic program and the simultaneous evaluation of patients' needs and course during their stay in community residential home structures of psychiatric care constitute the basic condition for the achievement of therapeutic goals of rehabilitation, guarantee of the quality of services provided and continuity of care. The article is completed with the quotation of thoughts and proposals in connection with current approaches concerning the sector of social psychiatry, which everybody has to take into careful consideration in order to do the individual therapeutic program more effective being a powerful tool that helps therapists to draw satisfaction and pleasure from their work and helps patients to become active members of a democratic society.

[Study of mortality under 30 years of age in families of psychotic patients]

After O. Bourguignon's studies (1984), the authors made the following assumption: there is an higher mortality rate before 30 years in families including at least one psychotic. This assumption is confirmed, as far as brothers, sisters and children are concerned, for 101 psychotics compared to 101 control-subjects. This higher death-rate in young subjects is associated in these psychotics' families with greater psychiatric morbidity, with higher rates of celibacy and break-ups of couples. It is the opinion of the authors that these phenomena should be interpreted as portent of a possible extinction of the lineage.