BMC Psychiatry - Latest articles

Stress load during childhood affects psychopathology in psychiatric patients

2008-07-23

Background: Childhood stress and trauma have been related to adult psychopathology in different psychiatric disorders. The present study aimed at verifying this relationship for stressful experiences during developmental periods by screening stress load across life in adult psychiatric inpatients with different diagnoses compared to healthy subjects. In addition, a relationship between the amount of adverse experiences and the severity of pathology, which has been described as a building block effect in posttraumatic stress disorder (PTSD), was explored for non-traumatic events in psychiatric disorders other than PTSD. Methods: 96 patients with diagnoses of Major Depressive Disorder (MDD), schizophrenia, drug addiction, or personality disorders (PD) and 31 subjects without psychiatric diagnosis were screened for adverse experiences in childhood (before the age of six years), before onset of puberty, and in adulthood using the Early Trauma Inventory and the Posttraumatic Stress Diagnostic Scale. Effects of stress load on psychopathology were examined for affective symptoms, PTSD, and severity of illness by regression analyses and comparison of subgroups with high and low stress load. Results: High stress load in childhood and before puberty, but not in adulthood, was related to negative affect in all participants. In patients, high stress load was related to depressive and posttraumatic symptoms, severity of disorder, and the diagnoses of MDD and PD. Conclusions: Results support the hypothesis of stress-sensitive periods during development, which may interact with genetic and other vulnerability factors in their impact on the progress of psychiatric disorders. A 'dose' effect of stress load on the severity of psychopathology is not restricted to the relationship between traumata and PTSD.

Development of mental health first aid guidelines for non-suicidal self-injury: A Delphi study

Claire M Kelly, Anthony F Jorm, Betty A Kitchener and Robyn L Langlands — 2008-07-23

Background: It is estimated that around 4% of the population engages, or has engaged, in non-suicidal self-injury (NSSI). In clinical samples, the figures rise as high as 21%. There is also evidence to suggest that these figures may be increasing. A family member or friend may suspect that a person is injuring themselves, but very few people know how to respond if this is the case. Simple first aid guidelines may help members of the public assist people to seek and receive the professional help they require to overcome self-injury. Methods: This research was conducted using the Delphi methodology, a method of reaching consensus in a panel of experts. Experts recruited to the panels included 26 professionals, 16 people who had engaged in self-injurious behaviour in the past and 3 carers of people who had engaged in self-injurious behaviour in the past. Statements about providing first aid to a person engaged in self-injurious behaviour were sought from the medical and lay literature, but little was found. Panel members were asked to respond to general questions about first aid for NSSI in a variety of domains and statements were extracted from their responses. The guidelines were written using the items most consistently endorsed by the consumer and professional panels. Results: Of 79 statements rated by the panels, 18 were accepted. These statements were used to develop the guidelines appended to this paper. Conclusions: There are a number of actions which are considered to be useful for members of the public when they encounter someone who is engaging in deliberate, non-suicidal self-injury. These guidelines will be useful in revising curricula for mental health first aid and NSSI first aid training programs. They can also be used by members of the public who want immediate information about how to assist a person who is engaging in such behaviour.

Use of antipsychotics and benzodiazepines in patients with psychiatric emergencies: results of an observational trial

Stefan Wilhelm, Alexander Schacht and Thomas Wagner — 2008-07-22

Background: Conventional antipsychotics augmented with benzodiazepines have been the standard acute treatment for psychiatric emergencies for more than 50 years. The inability of patients to give informed consent limits randomised, controlled studies. This observational study on immediate therapy for aggression and impulse control in acutely agitated patients (IMPULSE) evaluated the short-term effectiveness and tolerability of atypical and typical antipsychotic medications (AP) in a non-interventional setting. Methods: This was a comparative, non-randomised, prospective, open-label, observational study. Treatment over the first 5 days was classified according to whether any olanzapine, risperidone, or haloperidol was included or not. Documentations (PANSS-excited component, CGI-aggression, CGI-suicidality, tranquilisation score) were at baseline (day 1) and days 2-6 after start of AP. Results: During the short treatment-period, PANSS-EC and CGI-aggression scores improved in all cohorts. 68.7% of patients treated with olanzapine, 72.2% of patients treated with risperidone, and 83.3% of patients treated with haloperidol received concomitant benzodiazepines (haloperidol vs. non-haloperidol: p< 0.001). More patients treated with olanzapine (73.8%) were fully alert according to a tranquilisation score and active at day 2 than patients treated with risperidone (57.1%) or haloperidol (58.0%). Conclusions: Current medication practices for immediate aggression control are effective with positive results present within a few days. In this study, concomitant benzodiazepine use was significantly more frequent in patients receiving haloperidol.

Psychotherapy mediated by remote communication technologies: a meta-analytic review

2008-07-22

Background: Access to psychotherapy is limited by psychopathology (e.g. agoraphobia), physical disability, occupational or social constraints and/or residency in under-served areas. For these populations, interventions delivered via remote communication technologies (e.g. telephone, internet) may be more appropriate. However, there are concerns that such delivery may influence the therapeutic relationship and thus reduce therapy effectiveness. This review aimed to determine the clinical effectiveness of remotely communicated, therapist-delivered psychotherapy. Methods: Systematic review (including electronic database searching and correspondence with authors) of randomised trials of individual remote psychotherapy. Electronic databases searched included MEDLINE (1966-2006), PsycInfo (1967-2006), EMBASE (1980-2006) and CINAHL databases (1982-2006). The Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDAN-CTR). All searches were conducted to include studies with a publication date to July 2006. Results: Thirteen studies were identified, ten assessing psychotherapy by telephone, two by internet and one by videoconference. Pooled effect sizes for remote therapy versus control conditions were 0.44 for depression (95%CI 0.29 to 0.59, 7 comparisons, n=726) and 1.15 for anxiety-related disorders (95%CI 0.81 to 1.49, 3 comparisons, n=168). There were few comparisons of remote versus face-to-face psychotherapy. Conclusion: Remote therapy has the potential to overcome some of the barriers to conventional psychological therapy services. Telephone-based interventions are a particularly popular research focus and as a means of therapeutic communication may confer specific advantages in terms of their widespread availability and ease of operation. However, the available evidence is limited in quantity and quality. More rigorous trials are required to confirm these preliminary estimates of effectiveness. Future research priorities should include overcoming the methodological shortcomings of published work by conducting large-scale trials that incorporate both clinical outcome and more process-orientated measures.

Concordance between Hopkins Symptom Checklist (HSCL-10) and Pakistan Anxiety and Depression Questionnaire (PADQ), in a rural self-motivated population in Pakistan

2008-07-22

Background: There have been no previous studies conducted in Pakistan comparing the concordance of any well established Western anxiety/depression screening instrument with an indigenous scale, in a community based setting. Methods: Participants (n=1040) in the present study were recruited from the six villages of our interest from the district Gujarat of Pakistan, using a convenient sampling technique. Interview versions of the Hopkins Symptom Checklist 10-item version (HSCL-10) and the Pakistani Anxiety and Depression Questionnaire (PADQ) were used to observe the pattern of anxiety and depression among the participants. Results: The internal consistency of HSCL-10 and PADQ were 0.86 and 0.84 respectively. Exploratory factor analysis found evidence for both a one-dimensional (distress) and a two-dimensional (anxiety and depression) solution for the HSCL-10, but only a one-dimensional (distress) solution for the PADQ. The HSCL-10 and PADQ found to be moderately to highly correlated (r = 0.62, p< 0.0001, 0.73 after correction for attenuation). Conclusion: HSCL-10 has shown good screening abilities in a rural setting in Pakistan, and moderate to good concordance with an indigenous instrument measuring psychological distress. The HSCL-10 can therefore be used as a screening instrument, both in clinical and epidemiological settings in Pakistan, and for Pakistani immigrants living in Western societies.

Association study of polymorphisms in the neutral amino acid transporter genes SLC1A4, SLC1A5 and the glycine transporter genes SLC6A5, SLC6A9 with schizophrenia.

2008-07-18

Background: Based on the glutamatergic dysfunction hypothesis for schizophrenia pathogenesis, we have been performing systematic association studies of schizophrenia with the genes involved in glutametergic transmission. We report here association studies of schizophrenia with SLC1A4, SLC1A5 encoding neutral amino acid transporters ASCT1, ASCT2, and SLC6A5, SLC6A9 encoding glycine transporters GLYT2, GLYT1, respectively. Methods: We initially tested the association of total 21 single nucleotide polymorphisms (SNPs) distributed in the four gene regions with schizophrenia using 100 Japanese cases-control pairs and examined allele, genotype and haplotype association with schizophrenia. The observed nominal significance were examined in the Full-size Sample Set (400 cases and 420 controls). Results: We observed nominally significant single-marker associations with schizophrenia in SNP2 (P = 0.021) and SNP3 (P = 0.029) of SLC1A4, SNP1 (P = 0.009) and SNP2 (P = 0.022) of SLC6A5. We also observed nominally significant haplotype associations with schizophrenia in the combinations of SNP2-SNP7 (P = 0.037) of SLC1A4 and SNP1-SNP4 (P = 0.043) of SLC6A5. We examined all of the nominal significance in the Full-size Sample Set, except one haplotype with insufficient LD. The significant association of SNP1 of SLC6A5 with schizophrenia was confirmed in the Full-size Sample Set (P = 0.018). Conclusion: We concluded that at least one susceptibility locus for schizophrenia may be located within or nearby SLC6A5, whereas SLC1A4, SLC1A5 and SLC6A9 are unlikely to be major susceptibility genes for schizophrenia in the Japanese population.

The Sertindole Safety Survey: a retrospective analysis under a named patient-use program in Europe

Christophe Lancon, Mondher Toumi, Christophe Sapin and Karina Hansen — 2008-07-18

Background: After sertindole's suspension, health authorities established a specific named-patient use (NPU) program in order to supply sertindole to patients who did not respond to or did not tolerate alternative treatments. This programme provided the possibility of prospectively following an exhaustive cohort of patients treated with sertindole after its suspension. A survey was performed to assess sertindole's modalities of prescription, assess and document any serious adverse events (SAEs), and assess the mortality rate within the NPU cohort. Methods: The study comprised a survey of sertindole-treated patients in eleven European countries. All patients treated with sertindole within the NPU program were eligible for the study. Results: The reason for sertindole prescription was lack of efficacy (approximately 50%) or adverse events (approximately 20%) of other antipsychotic treatments. The mean sertindole dose was 13.4 mg daily. Lack of efficacy and adverse events were reported as reasons for sertindole discontinuation. A total of 97 SAEs were recorded, including ten fatal outcomes, which occurred during the study period or within thirty days after sertindole discontinuation. The all-cause mortality rate was 0.51 per 100 Person-Years of Exposure (95% Poisson confidence interval: [0.23-0.97]). Conclusion: Although prescribing and supplying sertindole were subject to administrative constraints, a significant number of patients were treated with sertindole, thus supporting the need for sertindole in specific cases.

Perceptions about the cause of schizophrenia and the subsequent help seeking behavior in a Pakistani population – results of a cross-sectional survey

2008-07-17

Background: There is a cultural variability around the perception of what causes the syndrome of schizophrenia. Generally patients with schizophrenia are considered dangerous. They are isolated and treatment is delayed. Studies have shown favorable prognosis with good family and social support, early diagnosis and management. Duration of untreated psychosis is a bad prognostic indicator. We aimed to determine the perceptions regarding the etiology of schizophrenia and the subsequent help seeking behavior. Methods: This cross-sectional study was carried out on a sample of 404 people at the out patient departments of Aga Khan University Hospital Karachi. Data was collected via a self-administered questionnaire. Questions were related to a vignette of a young man displaying schizophrenic behavior. Data was analyzed on SPSS v 14. Results: The mean age of the participants was 31.4 years (range = 18–72) and 77% of them were males. The majorities were graduates (61.9%) and employed (50%). Only 30% of the participants attributed 'mental illness' as the main cause of psychotic symptoms while a large number thought of 'God's will' (32.3%), 'superstitious ideas' (33.1%), 'loneliness' (24.8%) and 'unemployment' (19.3%) as the main cause. Mental illness as the single most important cause was reported by only 22%. As far as management is concerned, only 40% reported psychiatric consultation to be the single most important management step. Other responses included spiritual healing (19.5%) and Sociachanges (10.6) while 14.8% of respondents said that they would do nothing. Gender, age, family system and education level were significantly associated with the beliefs about the cause of schizophrenia (p < 0.05). While these variables plus 'religious inclination' and 'beliefs about cause' were significantly associated with the help seeking behavior of the participants. Conclusion: Despite majority of the study population being well educated, only a few recognized schizophrenia as a mental illness and many held superstitious beliefs. A vast majority of Pakistanis have non-biomedical beliefs about the cause of schizophrenia. Their help seeking behavior in this regard is inappropriate and detrimental to the health of schizophrenic patients. Areas for future research have been identified.

Attitudes toward psychopharmacology among hospitalized patients from diverse ethno-cultural backgrounds

Gabriel Thorens, Marianne Gex-Fabry, Daniele F Zullino and Ariel Eytan — 2008-07-09

Background: Biological factors influencing individual response to drugs are being extensively studied in psychiatry. Strikingly, there are few studies addressing social and cultural differences in attitudes toward psychotropic medications. The objective of this study was to investigate ethno-culturally determined beliefs, expectations and attitudes toward medication among a sample of hospitalized psychiatric patients. Methods: An ad hoc questionnaire was designed to assess patients' expectations, attitudes and prejudice toward medication. The study included 100 adult patients hospitalized in Geneva, Switzerland. Results: Patients were in majority male (63%), originated from Switzerland (54%) and spoke the local language fluently (93%). They took on the average 3 different psychotropic drugs. Sixty-eight percent of patients expected side effects and 60% were ready to stop medication because of them. Thirty percent of patients expected negative personal changes with treatment and 34% thought that their mental disorder could have been treated without drugs. Thirty six percent of the sample used alternative or complementary medicines. 35% of immigrant patients believed that medication had different effects on them than on local patients. When compared with Swiss patients, they more often reported that significant others had an opinion about medication (p = 0.041) and more frequently valued information provided by other patients about treatment (p = 0.010). Conclusion: Patients' attitudes toward medication should be investigated in clinical practice, as specific expectations and prejudice exist. Targeted interventions, especially for immigrant patients, might improve adherence.

Understanding the explanatory model of the patient on their medically unexplained symptoms and its implication on treatment development research: a Sri Lanka Study

2008-07-08

Background: Patients with medically unexplained symptoms (MUS) are often distressed, disabled and dissatisfied with the care they receive. Illness beliefs held by patients have a major influence on the decision to consult, persistence of symptoms and the degree of disability. Illness perception models consist of frameworks to organise information from multiple sources into distinct but interrelated dimensions: identity (the illness label), cause, consequences, emotional representations perceived control and timeline.Our aim was to elicit the illness perceptions of patients with MUS in Sri Lankan primary care to modify and improve a CBT intervention.MethodAn intervention study was conducted in a hospital primary care clinic in Colombo, Sri Lanka using CBT for MUS. As a part of the baseline assessment, qualitative data was collected using; the Short Explanatory Model Interview (SEMI), from 68 patients (16–65 years) with MUS. We categorised the qualitative data in to key components of the illness perception model, to refine CBT intervention for a subsequent larger trial study. Results: The cohort was chronically ill and 87% of the patients were ill for more than six months (range six months to 20 years) with 5 or more symptoms and 6 or more visits over preceding six months. A majority were unable to offer an explanation on identity (59%) or the cause (56%), but in the consequence domain 95% expressed significant illness worries; 37% believed their symptoms indicated moderately serious illness and 58% very serious illness. Reflecting emotional representation, 33% reported fear of death, 20% fear of paralysis, 13% fear of developing cancer and the rest unspecified incurable illness. Consequence and emotional domains were significant determinants of distress and consultations. Their repeated visits were to seek help to alleviate symptoms. Only a minority expected investigations (8.8 %) or diagnosis (8.8%). However, the doctors who had previously treated them allegedly concentrated more on identity than cause. The above information was used to develop simple techniques incorporating analogies to alter their perceptions Conclusion: The illness perception model is useful in understanding the continued distress of patients with persistent symptoms without an underlying organic cause. Hence it can make a significant contribution when developing and evaluating culturally sensitive patient friendly interventions.