Voluntary vs. involuntary hospital admission in acute mania of bipolar disorder: results from the Swiss sample of the EMBLEM study

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Bipolar Disorder and Polysubstance Use Disorder: Sociodemographic and Clinical Correlates

INTRODUCTION

Patients with bipolar disorder (BD) often show comorbidity with substance use disorder (SUD) with a negative impact on clinical course, prognosis, and functioning. The role of polysubstance use disorder (polySUD) is understudied. The aim of the present paper is to evaluate the sociodemographic and clinical characteristics associated with BD and comorbid SUD, focusing on polySUD, in order to phenotype this specific group of patients and implement adequate treatment and prevention strategies.

METHODS

A cross-sectional study was conducted involving 556 patients with a primary diagnosis of BD (376 without SUD, 101 with SUD, and 79 with polySUD). A semi-structured interview was administered to collect sociodemographic variables, clinical characteristics, and pharmacological treatment. ANOVA and chi-square tests were used to compare the three groups. Significantly different variables were then inserted in multivariate logistic regression.

RESULTS

Patients affected by BD and polySUD were younger, and more frequently males and single, than patients with SUD or without SUD. Indeed, the prevalence of patients affected by BD and polySUD living in residential facilities was higher than in the other groups. Moreover, earlier age at onset, higher prevalence of psychotic and residual symptoms, involuntary hospitalization, and a family history of psychiatric disorders were associated with polySUD in patients suffering from BD. Lastly, patients with BD and polySUD were more likely to take four or more medications, particularly benzodiazepines and other drugs. At the multinomial regression, younger age, male gender, early age at onset, psychotic and residual symptoms, positive family history of psychiatric disorders, and use of benzodiazepines remained significantly associated with polySUD in patients with BD.

CONCLUSION

Our findings show a specific profile of patients with BD and polySUD. It is important to conduct research on this topic in order to adopt specific therapeutic strategies, minimize the use of polypharmacy, and aim at full remission and mood stabilization.

Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders

The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.

Factors associated with involuntary admissions: a register-based cross-sectional multicenter study

BACKGROUND

Despite the EU recommendations on mental health, involuntary admission has been under researched in Italy for a long time and the overall picture of involuntary admission still appears fragmentary. The aims of this study are to evaluate involuntary admission rates in the Piedmont Region (Italy) and to investigate clinical and service-related variables associated with involuntary admission.

METHODS

This is a cross-sectional retrospective multicenter study involving all psychiatric inpatients units of the general hospitals of Piedmont Region. Data on hospitalizations during 2016 were collected by consulting hospital discharge registers. The analyses were performed on two samples: 6018 patients (data analysis was run on first hospitalization during the study period for those with multiple admissions) and 7881 inpatient episodes. The association between involuntary admission and socio-demographic and clinical characteristics was examined through t-test for continuous variables, and Pearson's Chi-square test for categorical variables. Multilevel modeling was applied in logistic regression models with two levels: for the first model center and participants and for the second model center and inpatient episodes.

RESULTS

Of 6018 inpatients, 10.1% were admitted involuntarily at first hospitalization, while the overall compulsory treatment rate was slightly lower (9.1%) in the inpatient episodes sample (n = 7881). The involuntary admission rates ranged from 0.8 to 21% among study centers. Involuntary admissions were primarily associated with younger age, diagnosis of schizophrenia or substance use disorders, longer duration of hospital stay, mechanical restraint episodes, and fewer subsequent hospitalizations during the study period.

CONCLUSIONS

The rate of involuntary admission in the Piedmont Region was lower than the mean rate across countries worldwide. There were noteworthy differences in rates of involuntary admission among psychiatric units, although no relationship was found with characteristics of the psychiatric wards or of the areas where hospitals are located.

Gender and mental health service use in bipolar disorder: national cohort study

BACKGROUND

Despite evidence of gender differences in bipolar disorder characteristics and comorbidity, there is little research on the differences in treatment and service use between men and women with bipolar disorder.

AIMS

To use routine data to describe specialist mental health service contact for bipolar disorder, including in-patient, community and support service contacts; to compare clinical characteristics and mental health service use between men and women in contact with secondary services for bipolar disorder.

METHOD

Cross-sectional analysis of mental health patients with bipolar disorder in New Zealand, based on complete national routine health data.

RESULTS

A total of 3639 individuals were in contact with specialist mental health services with a current diagnosis of bipolar disorder in 2015. Of these 58% were women and 46% were aged 45 and over. The 1-year prevalence rate of bipolar disorder leading to contact with specialist mental health services was 1.56 (95% CI 1.50-1.63) per 100 000 women and 1.20 (95% CI 1.14-1.26) per 100 000 men. Rates of bipolar disorder leading to service contact were 30% higher in women than men (rate ratio 1.30, 95% CI 1.22-1.39). The majority (68%) had a diagnosis of bipolar I disorder. Women were more likely to receive only out-patient treatment and have comorbid anxiety whereas more men had substance use disorder, were convicted for crimes when unwell, received compulsory treatment orders and received in-patient treatment.

CONCLUSIONS

Although the prevalence of bipolar disorder is equal between men and women in the population, women were more likely to have contact with specialist services for bipolar disorder but had a lower intensity of service interaction.

Retrospective Chart Review of Voluntary Admissions to an Inpatient Psychiatric Hospital in New York City: A Demographic Breakdown

The current paper evaluates psychiatric needs of voluntary admissions in a large urban psychiatric hospital through a retrospective chart review, as this research is limited within the United States. A total of 581 voluntary adult psychiatric admission charts were reviewed. Continuous variables were evaluated using an ANOVA while associations between variables were examined by an unadjusted Pearson correlation coefficient a stepwise linear regression analysis. Men were significantly more likely to have a past admission for psychiatric services (p = .016), suicidal ideation (p < .001) and test positive for substances (p < .001) than women, and were more likely to be unemployed, homeless and without insurance. Women were more likely to have a past suicide attempt and a depressive disorder. A significant relationship between gender and rationale for seeking voluntary admission (p < .001) was found. This study offers understanding of male and female voluntary admissions, and a foundation for improving treatment interventions to reduce recurrent readmissions.

Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis

BACKGROUND

Use of involuntary psychiatric hospitalisation varies widely within and between countries. The factors that place individuals and populations at increased risk of involuntary hospitalisation are unclear, and evidence is needed to understand these disparities and inform development of interventions to reduce involuntary hospitalisation. We did a systematic review, meta-analysis, and narrative synthesis to investigate risk factors at the patient, service, and area level associated with involuntary psychiatric hospitalisation of adults.

METHODS

We searched MEDLINE, PsycINFO, Embase, and the Cochrane Controlled Clinical Register of Trials from Jan 1, 1983, to Aug 14, 2019, for studies comparing the characteristics of voluntary and involuntary psychiatric inpatients, and studies investigating the characteristics of involuntarily hospitalised individuals in general population samples. We synthesised results using random effects meta-analysis and narrative synthesis. Our review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is registered on PROSPERO, CRD42018095103.

FINDINGS

77 studies were included from 22 countries. Involuntary rather than voluntary hospitalisation was associated with male gender (odds ratio 1·23, 95% CI 1·14-1·32; p<0·0001), single marital status (1·47, 1·18-1·83; p<0·0001), unemployment (1·43, 1·07-1·90; p=0·020), receiving welfare benefits (1·71, 1·28-2·27; p<0·0001), being diagnosed with a psychotic disorder (2·18, 1·95-2·44; p<0·0001) or bipolar disorder (1·48, 1·24-1·76; p<0·0001), and previous involuntary hospitalisation (2·17, 1·62-2·91; p<0·0001). Using narrative synthesis, we found associations between involuntary psychiatric hospitalisation and perceived risk to others, positive symptoms of psychosis, reduced insight into illness, reduced adherence to treatment before hospitalisation, and police involvement in admission. On a population level, some evidence was noted of a positive dose-response relation between area deprivation and involuntary hospitalisation.

INTERPRETATION

Previous involuntary hospitalisation and diagnosis of a psychotic disorder were factors associated with the greatest risk of involuntary psychiatric hospitalisation. People with these risk factors represent an important target group for preventive interventions, such as crisis planning. Economic deprivation on an individual level and at the population level was associated with increased risk for involuntary hospitalisation. Mechanisms underpinning the risk factors could not be identified using the available evidence. Further research is therefore needed with an integrative approach, which examines clinical, social, and structural factors, alongside qualitative research into clinical decision-making processes and patients' experiences of the detention process.

FUNDING

Commissioned by the Department of Health and funded by the National Institute of Health Research (NIHR) via the NIHR Mental Health Policy Research Unit.

Manic episode, aggressive behavior and poor insight are significantly associated with involuntary admission in patients with bipolar disorders

Objectives

Serious mental illnesses, such as bipolar disorders and schizophrenia, are closely associated with involuntary admission. Many studies have focused on involuntary admission in people with schizophrenia, but little is known about the factors associated with involuntary admission in Chinese patients with bipolar disorders. This study aimed to investigate socio-demographic and clinical factors associated with involuntary admission in Chinese patients with bipolar disorders.

Methods

In this multi-center cross-sectional survey in China, a total of 155 newly admitted patients with bipolar disorders were consecutively recruited from 16 psychiatric institutions from 15 March to 14 April, 2013. Patients' socio-demographic and clinical data were collected from their medical records. The Modified Overt Aggression Scale and the Insight and Treatment Attitudes Questionnaire were used to measure patients' level of aggression and insight of current psychiatric illness.

Results

The prevalence of involuntary admission was 52% in this sample of Chinese inpatients with bipolar disorders. In multiple logistic regression, a high level of aggression (odds ratio (OR) = 2.48), diagnosis of manic episode (OR = 3.65), poor insight (OR = 7.52), and a low level of education (OR = 3.13) were significantly associated with involuntary admission.

Conclusion

Manic episode, aggressive behavior, and poor insight were the significant contributing factors to involuntary admission in Chinese patients with bipolar disorders.

The role of the affective temperament in the treatment adherence in psychiatry

Introduction

Adherence to psychotropic medications is affected by factors related to the treatment, to the physician, to the environment and to the patient himself. The purpose of the present study was to investigate the influence of affective temperaments on treatment adherence.

Methods

Thirty six stabilized outpatients were recruited from the aftercare consultation of Psychiatry to perform Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto questionnaire version (TEMPS-A) for affective temperaments and the Medication Adherence Rating Scale (MARS) for treatment adherence.

Results

The total MARS score was negatively correlated with the irritable temperament score. The MARS’s score relative to the attitude of patients to psychotropic medications and their negative side effects was negatively correlated with the cyclothymic, the irritable and anxious temperaments. Patients having a diagnosis of psychotic disorder had a significantly greater medication adherence and behaviour toward medication score compared to those having a diagnosis of affective disorder. A greater MARS’s score for the negative side effects and attitudes to psychotropic medication was associated with medication by neuroleptics with prolonged action.

Conclusion

The results of the present study suggest that patients with irritable temperament may have more difficult to follow psychotropic medications, and that patients with cyclothymic, irritable and anxious temperaments may be more attentive and sensitive toward psychotropic medications and their negative side effects.

Thwarted interpersonal needs and suicide ideation: Comparing psychiatric inpatients with bipolar and non-bipolar mood disorders

Psychiatric inpatients are at heightened risk for suicide, and evidence suggests that psychiatric inpatients with bipolar mood disorders may be at greater risk for suicide ideation compared to those with non-bipolar mood disorders. There is a paucity of research directly comparing risk factors for suicide ideation in bipolar versus non-bipolar mood disorders in an inpatient sample. The current study sought to clarify the association between two constructs from the interpersonal theory of suicide (i.e., perceived burdensomeness and thwarted belongingness) in leading to suicide ideation among psychiatric inpatients with bipolar and non-bipolar mood disorders. Participants were (N=90) psychiatric inpatients with a bipolar (n = 20) or non-bipolar mood disorder (n=70; per their medical charts). Perceived burdensomeness, but not thwarted belongingness, was significantly associated with suicide ideation after adjusting for other covariates. This suggests perceived burdensomeness may play a key role in suicide ideation among psychiatric inpatients with any mood disorder and highlights the importance of assessment and intervention of perceived burdensomeness in this population. Contrary to our hypothesis, mood disorder group (i.e., bipolar versus non-bipolar) did not moderate the relations between perceived burdensomeness/thwarted belongingness and suicide ideation.

The Low Proportion and Associated Factors of Involuntary Admission in the Psychiatric Emergency Service in Taiwan

Background

The involuntary admission regulated under the Mental Health Act has become an increasingly important issue in the developed countries in recent years. Most studies about the distribution and associated factors of involuntary admission were carried out in the western countries; however, the results may vary in different areas with different legal and socio-cultural backgrounds.

Aims

The aim of this study was to investigate the proportion and associated factors of involuntary admission in a psychiatric emergency service in Taiwan.

Methods

The study cohort included patients admitted from a psychiatric emergency service over a two-year period. Demographic, psychiatric emergency service utilization, and clinical variables were compared between those who were voluntarily and involuntarily admitted to explore the associated factors of involuntary admission.

Results

Among 2,777 admitted patients, 110 (4.0%) were involuntarily admitted. Police referrals and presenting problems as violence assessed by psychiatric nurses were found to be associated with involuntary admission. These patients were more likely to be involuntarily admitted during the night shift and stayed longer in the psychiatric emergency service.

Conclusions

The proportion of involuntary admissions in Taiwan was in the lower range when compared to Western countries. Dangerous conditions evaluated by the psychiatric nurses and police rather than diagnosis made by the psychiatrists were related factors of involuntary admission. As it spent more time to admit involuntary patients, it was suggested that multidisciplinary professionals should be included in and educated for during the process of involuntary admission.

Cross-cultural adaptation, validation and factor structure of the Insight Scale for Affective Disorders

BACKGROUND

In the last few decades, several tools for studying insight in bipolar disorders have been used. Olaya and colleagues developed the Insight Scale for Affective Disorders (ISAD), which consists of a scale measuring insight through hetero evaluation for patients with mood disorders. The objective of this work is to translate and adapt the original English version of the ISAD to Brazilian Portuguese (ISAD-BR) and to conduct an evaluation of its psychometric properties.

METHODS

Adaptation procedures included translation/back-translation and consultation with a panel of experts. 95 patients with the diagnosis of Type 1 bipolar disorder were evaluated with the final version of the ISAD-BR, which was applied, simultaneously, but independently, by two examiners. Internal consistency and inter-rater reliability were explored and the latent structure of the scale was investigated with principal axis factoring and promax rotation. A second-order factor analysis was conducted to test if the scale had a hierarchical factor structure.

RESULTS

The ISAD-BR showed good internal consistency and good inter-rater reliability. The analysis pointed to a four-factor solution of the ISAD-BR: awareness of symptoms associated with activity/energy; awareness of having a disorder; awareness of self-esteem and feelings of pleasure; and awareness of social functioning and relationships. The second order factor analysis indicated a hierarchical factor structure for the ISAD-BR, with the four lower-order factors loading on a single higher-order factor.

CONCLUSIONS

Insight into bipolar disorder is a multidimensional construct, covering different aspects of the condition and its symptomatology. Nevertheless, insight about activity/energy changes may be a crucial aspect of insight into bipolar disorder.

Involuntary outpatient treatment for mental health problems in Switzerland: a literature review

BACKGROUND

In 2008, the Swiss Civil Code was amended. From 1 January 2013, each Swiss canton may propose specific provisions for involuntary outpatient treatment (community treatment orders (CTOs)) for individuals with mental disorders.

AIM

This review catalogues the legal provisions of the various Swiss cantons for CTOs and outlines the differences between them. It sets this in the context of variations in clinical provisions between the cantons.

METHODS

Databases were searched to obtain relevant publications about CTOs in Switzerland. The Swiss Medical Association, Swiss Federal Statistical Office, Swiss Health Observatory and all the 26 Cantonal medical officers were contacted to complete the information. Conférence des cantons en matière de protection des mineurs et des adultes (COPMA), the authority which monitors guardianship legislation, and Pro Mente Sana, a patients' right association, were also approached.

RESULTS

Three articles about CTOs in Switzerland were identified. Psychiatric provisions vary considerably between cantons and only a few could provide complete or even partial figures for rates of compulsion in previous years. Prior to 2013, only 6 of the 20 cantons, for which information was returned, had any provision for CTOs. Now, every canton has some form of legal basis but the level of detail is often limited. In eight cantons, the powers of the measure are not specified (for example, use of medication). In 12 cantons, the maximum duration of the CTO is not specified. German speaking cantons and rural cantons are more likely to specify the details of CTOs.

CONCLUSION

Highly variable Swiss provision for CTOs is being introduced despite the absence of convincing international evidence for their effectiveness or good quality data on current coercive practice. Careful monitoring and assessment of these new cantonal provisions are essential.

O insight no transtorno bipolar: uma revisão sistemática

Objetivos Realizar uma revisão sistemática para compreender que fatores estão relacionados a uma maior ou menor consciência de morbidade no transtorno bipolar (TB), como o insight varia em função do estado afetivo e estabelecer uma comparação com outros transtornos mentais. Métodos Realizou-se uma revisão sistemática da literatura científica sobre o insight em pacientes com TB. Foram buscados estudos clínicos originais sobre o tema nas bases de dados Medline, ISI e SciELO. Os termos de busca empregados foram: “insight” OR “awareness” AND “bipolar” OR “mania” OR “manic”. Resultados Foram selecionados 55 artigos. O insight no TB parece ser mais prejudicado do que na depressão unipolar, porém menos do que na esquizofrenia. Com relação ao TB, um menor nível de insight está relacionado à presença de sintomas psicóticos e de alterações cognitivas. Além disso, um comprometimento do insight está associado a uma menor adesão ao tratamento. Por outro lado, uma maior preservação do insight pode estar associada a maior ideação suicida. Finalmente, a fase maníaca cursa com um nível inferior de insight quando comparada à fase depressiva ou de eutimia. Conclusão No TB, o insight está significativamente prejudicado, especialmente na mania. Diversos fatores clínicos parecem influenciar o nível de insight.

Mixed states with predominant manic or depressive symptoms: baseline characteristics and 24-month outcomes of the EMBLEM cohort

BACKGROUND

While factors associated with mixed states have been extensively studied, data are scant regarding the clinical heterogeneity of mixed states. The EMBLEM study was a prospective, observational study on patients with manic and mixed states. We describe and compare baseline characteristics and 24-month clinical course of mixed states with predominant depressive symptoms (MSDS) and mixed states with predominant manic symptoms (MSMS).

METHODS

Adult inpatients/outpatients with bipolar disorder were enrolled within the standard course of care if they initiated or changed oral medication for acute mania or mixed states. A logistic regression was used to identify the baseline factors associated with each polarity. Comparisons with mixed episode without symptom predominance (OMS) were performed for informational purpose only.

RESULTS

About 573 mixed patients were analyzed (23.7% of the cohort): 59.5% (n=341) had MSMS, 11.9% (n=68) had MSDS, and 28.6% (n=164) had OMS. At baseline, hallucinations/delusions during the index episode, inpatient status, high CGI-BP overall score, and low education level were more often associated with MSMS versus MSDS. Alcohol abuse or dependence and selective serotonin reuptake inhibitor (SSRI) or benzodiazepine use at inclusion were significantly more frequent with MSDS. MSDS had a significantly lower 24-month recurrence rate than MSMS; MSMS experienced more switches to mania whereas MSDS switched more to depression.

LIMITATIONS

The post hoc dimensional definitions in the study require caution in the interpretation of the results.

CONCLUSION

These results present evidence of clinical heterogeneity within mixed states. Predominant manic or depressive symptoms within mixed episode could influence clinicians' decisions in term of hospitalization, treatment, and perception of bipolar severity.

Development of the insight scale for affective disorders (ISAD): modification from the scale to assess unawareness of mental disorder

BACKGROUND

Research on insight in patients with mood disorders has grown in recent years. Several instruments to assess insight have been used, but most of them have been specifically designed for psychosis and may not appear relevant to mood disorders. The aim of the present study is to develop a short, multidimensional, reliable and valid scale to measure insight in patients with mood disorders, based on the Amador's Scale to Assess Unawareness of Mental Disorders (SUMD).

METHOD

A Delphi method was used to facilitate expert participation and ensure face and content validity. The SUMD structure and items were used as a reference in the scale development. A new scale with 17 items was obtained. Internal consistency, test-retest and inter-rater reliability and validity were studied in a sample of 76 outpatients with a DSM-IV diagnosis of major depression or bipolar disorder (type I or II).

RESULTS

Internal consistency of the general items was moderate, and high for the symptoms awareness subscale. Scores on ISAD correlated with other measures of insight and with some clinical measures, thus supporting its validity.

LIMITATIONS

The majority of the sample came from community services. Future studies should use inpatients or patients with severe symptoms to broaden the range of responses. Moreover, the rating of insight and other measures by the same clinician might introduce a methodological bias.

CONCLUSION

The ISAD, with a multidimensional approach, appears as a short, reliable and valid measure of insight in mood disorders. Expert consensus ensures its face and content validity.

Mixed states vs. pure mania in the French sample of the EMBLEM study: results at baseline and 24 months--European mania in bipolar longitudinal evaluation of medication

BACKGROUND

To describe the clinical course and treatment patterns over 24 months of patients experiencing an acute manic/mixed episode within the standard course of care.

METHODS

EMBLEM was a 2-year European prospective, observational study on outcomes of patients experiencing a manic/mixed episode. Adults with bipolar disorder were enrolled within the standard course of care as in/outpatients if they initiated or changed oral medication for treatment of acute mania. After completing 12 weeks of acute phase, patients were assessed every 3-6 months during the maintenance phase. We present the 24 month results, with subgroup analysis for mixed states (MS) and pure mania (PM). These subgroup analyses are driven by the high proportion of antidepressants prescribed in this cohort.

RESULTS

In France, 771 patients were eligible for the maintenance phase. 69% of patients completed the follow up over 24 months. The mean age was 45.5 years (sd = 13.6) with 57% of women. 504 (66%) patients were experiencing a PM and 262 (34%) a MS at baseline. The main significant differences in MS vs. PM at baseline were: a higher rate of women, and in the previous 12 months, a higher frequency of episodes (manic/mixed and depressive), more suicide attempts, more rapid cycling, fewer social activities and more work impairment. Over the 24 months of follow-up the MS group had a significantly lower recovery than PM (36% vs. 46%, p = 0.006). Overall, 42% of all patients were started on monotherapy and 58% on combination therapy; of those 35% and 30% respectively remained on their initial medication throughout the 24 months. At baseline, 36% were treated with an antidepressant, this proportion remains high throughout the follow-up period, with a significantly higher rate for MS vs. PM at 24 months (55% vs. 27%, p < 0.001).

CONCLUSION

In this large sample, MS occur frequently (34%), they are more severe at baseline and have a worse functional prognosis than PM. Although antidepressants are not recommended in MS and PM, they were frequently prescribed at baseline and are maintained during the 24 months of follow-up.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy

BACKGROUND

A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy.

METHOD

Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales.

RESULTS

Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions.

CONCLUSIONS

In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Mania in the Nordic countries: patients and treatment in the acute phase of the EMBLEM study

In bipolar disorder, mood stabilizers and second-generation antipsychotics have a central role in pharmacotherapy. There are, however, substantial differences in how the treatment is realized in different countries. The aim of this paper was to compare the treatment of acute mania in the Nordic countries with other European countries during the first 12 weeks of the EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) study. Adult patients with bipolar disorder were enrolled within standard course of care as in/outpatients if they initiated/changed oral medication with antipsychotics, anticonvulsants or lithium for treatment of acute mania. Five hundred and thirty European psychiatrists including 23 Nordic psychiatrists enrolled 3459 patients including 79 Nordic patients eligible for analysis using the same study methods assessing demographics, psychiatric history, clinical status, functional status and pharmacological treatment. Psychiatric status at inclusion measured by the Young Mania Rating Scale (YMRS) and the Clinical Global Impression-Bipolar Disorder (CGI-BP) were similar in the Nordic and European patient groups, which is surprising as 73% of the Nordic patients compared with 38% of the European patients were inpatients. In the Nordic group of patients, more patients were living independently. Before inclusion in the study more patients in the Nordic group had combination therapy, but after inclusion in the study the prescription pattern of psychopharmacy was similar in the Nordic and the European patient groups. This study indicated differences in admission patterns, patient social functioning and medical treatment in the Nordic patients compared with the European patients.

Recognition of mental illness and suicidality among individuals with serious mental illness

This preliminary study investigated the association of insight (defined as a patient's recognition of having a mental illness) with depression and suicidality among individuals with schizophrenia (N = 1009), bipolar I disorder (N = 297), and recurrent major depression (N = 162). Participants completed interviews at 2 time periods, 6-months apart. Individuals who were recognized having a mental illness reported significantly greater depression than those who denied having a mental illness. Recognition of mental illness was significantly related, both retrospective and prospectively, with suicidal ideation and attempts. No significant differences were found between the diagnostic groups in these relationships. Although there are many clinical benefits associated with insight, these findings suggest there may possibly be cause for concern in attempting to increase insight among individuals with a serious mental illness. However, current evidence suggests that certain forms of treatment may be beneficial in improving insight, while resulting in a decrease in negative affect, rather than an increase.