Predictive capacity of prodromal symptoms in first-episode psychosis of recent onset

BACKGROUND

Both the nature and number of a wide range of prodromal symptoms have been related to the severity and type of psychopathology in the psychotic phase. However, at present there is an incomplete picture focused mainly on the positive pre-psychotic dimension.

AIM

To characterize the prodromal phase retrospectively, examining the number and nature of prodromal symptoms as well as their relationship with psychopathology at the onset of first-episode psychosis.

METHODS

Retrospective study of 79 patients experiencing a first-episode psychosis of less than 1 year from the onset of full-blown psychosis. All patients were evaluated with a comprehensive battery of instruments including socio-demographic and clinical questionnaire, IRAOS interview, PANSS, stressful life events scale (PERI) and WAIS/WISC (vocabulary subtest). Bivariate associations and multiple regression analysis were performed.

RESULTS

Regression models revealed that several prodromal dimensions of IRAOS (delusions, affect, language, behaviour and non-hallucinatory disturbances of perception) predicted the onset of psychosis, with positive (22.4% of the variance) and disorganized (25.6% of the variance) dimensions being the most widely explained.

CONCLUSION

In addition to attenuated positive symptoms, other symptoms such as affective, behavioural and language disturbances should also be considered in the definitions criteria of at-high-risk people.

Complex interaction between symptoms, social factors, and gender in social functioning in a community-dwelling sample of schizophrenia

Social functioning (SF) is the ultimate target aimed in treatment plans in schizophrenia, thus it is critical to know what are the factors that determine SF. Gender is a well-established variable influencing SF, yet it is not known how social variables and symptoms interact in schizophrenia patients. Furthermore, it remains unclear whether the interaction between social variables and symptoms is different in men compared to women. Our aim is to test whether social variables are better predictors of SF in community-dwelled individuals with schizophrenia, and whether men and women differ in how symptoms and social variables interact to impact SF. Community-dwelling individuals with schizophrenia (N = 231) were randomly selected from a register. Participants were assessed with symptom measures (PANSS), performance-based social scale (LSP), objective social and demographic variables. Stratification by gender and stepwise multivariate regression analyses by gender were used to find the best-fitting models that predict SF in both gender. Men had poorer SF than women in spite of showing similar symptom scores. On stepwise regression analyses, gender was the main variable explaining SF, with a significant contribution by disorganized and excitatory symptoms. Age of onset made a less marked, yet significant, contribution to explain SF. When the sample was stratified by gender, disorganized symptoms and 'Income' variable entered the model and accounted for a 30.8% of the SF variance in women. On the other hand, positive and disorganized symptoms entered the model and accounted for a 36.1% of the SF variance in men. Community-dwelling men and women with schizophrenia differ in the constellation of variables associated with SF. Symptom scores still account for most of the variance in SF in both genders.

[One year prevalence of mental disorders comorbidity and associated socio-demographic risk factors in the general population of Spain. Results of the ESEMeD-Spain study]

INTRODUCTION

Comorbidity among mental disorders in the general population is common, affecting more than the 50 % of individuals with a lifetime mental disorder. In Spain, there are no data describing it or its associated risk factors.

METHOD

The ESEMeD-Spain study is an epidemiological study assessing mental disorders in a sample of 5,473 individuals from the general population of Spain aged 18 years or older. The aims of the present study were to evaluate the frequency of mental disorders comorbidity in Spain (assessed with the Composite International Diagnostic Interview: CIDI 3.0) and associated sociodemographic risk factors. Response rate was 78.6%.

RESULTS

Mood disorders showed the highest comorbidity frequency. Analysing specific disorders, generalized anxiety disorder, dysthymic and panic disorders showed the highest comorbidity percentages. Female gender, ages above 24 years old and being previously married were found to be risk factors associated to the presence of comorbid mood and anxiety disorders.

CONCLUSIONS

As it has been suggested for other European countries and for the United States, in the general population of Spain mental disorders, specially mood disorders, are frequently comorbid. When treating mental disorders, comorbidity should be taken into account.

[Spanish adaptation and validation of the brief form of the Life Skills Profile-20: an instrument to assess daily living skills in real clinical settings]

INTRODUCTION

The Life Skills Profile (LSP) is an assessment instrument of general function in activities of daily life, especially developed for people diagnosed of a severe mental illness. There are different versions of the LSP. The aim of this paper is to validate and adapt the brief form of the LSP (LSP-20) to the Spanish population.

METHODS

Two different samples have been recruited for this study. The first sample was made up of 231 outpatients with a clinical diagnosis of schizophrenia who were randomly selected. The following analyses were performed: principal axis factoring analysis, internal consistency and convergent and discriminant validity between the LSP-20 and the Positive and Negative Symptoms Scale (PANSS). The second sample was recruited in order to assess interrater reliability and was composed of 30 long-stay inpatients with a diagnosis of chronic schizophrenia.

RESULTS

Factor analysis produced four factors accounting for 41.22 % of the total variance. The following labels were suggested for the factors: compliance, social initiative, self-care and antisocial behavior. Internal consistency ranged from 0.69 (antisocial behavior) to 0.79 (social initiative). Correlations between the LSP-20 and the PANSS were moderate and clinically significant. Interrater reliability ranged from 0.58 (to have defined interests) to 0.89 (to wear clean clothes usually).

CONCLUSIONS

The brief form of LSP can be useful in real clinical settings to help to personalize the aims of the rehabilitation interventions and to evaluate the health care model.

Treatment adequacy for anxiety and depressive disorders in six European countries

The aims of this study are to describe the adequacy of treatment for anxiety and depressive disorders in Europe and how itdiffers between providers, using data from the ESEMeD study. The overall proportion of adequate treatment was 45.8% (57.4% in the specialised sector and 23.3% in the general medical care sector). Between-country differences were found in treatment adequacy in the specialised setting. Organisational and political aspects may explain these findings.

Needs and its relation to symptom dimensions in a sample of outpatients with schizophrenia

OBJECTIVE

To analyse the association between symptom dimensions in schizophrenia and number and type of met and unmet needs.

METHOD

A sample of 231 outpatients randomly selected from a register that included all patients treated in 5 mental health care centres (MHCC) was evaluated. Assessment instruments included the Camberwell Assessment of Needs (CAN) questionnaire and the PANSS.

RESULTS

Number of needs are related to overall severity of psychopathology. Patients with more symptoms have more total needs (p < 0.001) and unmet needs (p < 0.001). A multiple lineal regression model showed that the disorganized and excited dimensions of the PANSS are the most important components for explaining the variance of number of needs. Type of needs is related to subtypes of schizophrenia, specially with disorganized and excited symptoms.

CONCLUSION

Psychosocial needs are related to schizophrenia subtypes. Patients with more needs are those with more disorganized and excitatory symptoms.

Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

This manuscript examines the impact of mental health state and specific mental and physical disorders on work role disability and quality of life in six European countries.

METHOD

The ESEMeD study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an in-home computer-assisted interview. Common mental disorders, work loss days (WLD) in the past month and quality of life (QoL) were assessed, using the WMH-2000 version of the CIDI, the WHODAS-II, and the mental and physical component scores (MCS, PCS) of the 12-item short form, respectively. The presence of five chronic physical disorders: arthritis, heart disease, lung disease, diabetes and neurological disease was also assessed. Multivariate regression techniques were used to identify the independent association of mental and physical disorders while controlling for gender, age and country.

RESULTS

In each country, WLD and loss of QoL increased with the number of disorders. Most mental disorders had approximately 1.0 SD-unit lower mean MCS and lost three to four times more work days, compared with people without any 12-month mental disorder. The 10 disorders with the highest independent impact on WLD were: neurological disease, panic disorder, PTSD, major depressive episode, dysthymia, specific phobia, social phobia, arthritis, agoraphobia and heart disease. The impact of mental vs. physical disorders on QoL was specific, with mental disorders impacting more on MCS and physical disorders more on PCS. Compared to physical disorders, mental disorders had generally stronger 'cross-domain' effects.

CONCLUSION

The results suggest that mental disorders are important determinants of work role disability and quality of life, often outnumbering the impact of common chronic physical disorders.

Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comprehensive information about access and patterns of use of mental health services in Europe is lacking. We present the first results of the use of health services for mental disorders in six European countries as part of the ESEMeD project.

METHOD

The study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an computer-assisted interview done at home. The 21 425 participants were asked to report how frequently they consulted formal health services due to their emotions or mental health, the type of professional they consulted and the treatment they received as a result of their consultation in the previous year.

RESULTS

An average of 6.4% of the total sample had consulted formal health services in the previous 12 months. Of the participants with a 12-month mental disorder, 25.7% had consulted a formal health service during that period. This proportion was higher for individuals with a mood disorder (36.5%, 95% CI 32.5-40.5) than for those with anxiety disorders (26.1%, 95% CI 23.1-29.1). Among individuals with a 12-month mental disorder who had contacted the health services 12 months previously, approximately two-thirds had contacted a mental health professional. Among those with a 12-month mental disorder consulting formal health services, 21.2% received no treatment.

CONCLUSION

The ESEMeD results suggest that the use of health services is limited among individuals with mental disorders in the European countries studied. The factors associated with this limited access and their implications deserve further research.

Psychotropic drug utilization in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

To assess psychotropic drug utilization in the general population of six European countries, and the pattern of use in individuals with different DSM-IV diagnoses of 12-month mental disorders.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000), a cross-sectional psychiatric epidemiological study in a representative sample of 21 425 adults aged 18 or older from six European countries (e.g. Belgium, France, Germany, Italy, the Netherlands and Spain). Individuals were asked about any psychotropic drug use in the past 12 months, even if they used the drug(s) just once. A colour booklet containing high-quality pictures of psychotropic drugs commonly used to treat mental disorders was provided to help respondents recall drug use.

RESULTS

Psychotropic drug utilization is generally low in individuals with any 12-month mental disorder (32.6%). The extent of psychotropic drug utilization varied according to the specific DSM-IV diagnosis. Among individuals with a 12-month diagnosis of pure major depression, only 21.2% had received any antidepressants within the same period; the exclusive use of antidepressants was even lower (4.6%), while more individuals took only anxiolytics (18.4%).

CONCLUSION

These data question the appropriateness of current pharmacological treatments, particularly for major depression, in which under-treatment is coupled with the high use of non-specific medications, such as anxiolytics.

Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries.

METHOD

A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI).

RESULTS

Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders.

CONCLUSION

ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.

Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

The European Study of Epidemiology of Mental Disorders (ESEMeD) project was designed to evaluate the prevalence, the impact and the treatment patterns in Europe. This paper presents an overview of the methods implemented in the project.

METHOD

ESEMeD is a cross-sectional study in a representative sample of 21 425 adults, 18 or older, from the general population of Belgium, France, Germany, Italy, the Netherlands and Spain. The Composite International Diagnostic Interview (WMH-CIDI) was administered by home interviews from January 2001 to August 2003 using Computer Assisted Personal Interview (CAPI) technology. Data quality was controlled to ensure reliability and validity of the information obtained.

RESULTS

Response rate varied from 78.6% in Spain to 45.9% in France. Less than 4% of the individuals had errors in the checking procedures performed.

CONCLUSION

The sampling methodologies, comprehensive psychiatric instruments and quality control procedures used have rendered the ESEMeD database a unique and important source of information about the prevalence, the disability burden and unmet medical needs of mental disorders within Europe.

12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comorbidity patterns of 12-month mood, anxiety and alcohol disorders and socio-demographic factors associated with comorbidity were studied among the general population of six European countries.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional psychiatric epidemiological study in a representative sample of adults aged 18 years or older in Belgium, France, Germany, Italy, the Netherlands and Spain. The diagnostic instrument used was the Composite International Diagnostic Interview (WMH-CIDI). Data are based on 21 425 completed interviews.

RESULTS

In general, high associations were found within the separate anxiety disorders and between mood and anxiety disorders. Lowest comorbidity associations were found for specific phobia and alcohol abuse-the disorders with the least functional disabilities. Comorbidity patterns were consistent cross-nationally. Associated factors for comorbidity of mood and anxiety disorders were female gender, younger age, lower educational level, higher degree of urbanicity, not living with a partner and unemployment. Only younger people were at greater risk for comorbidity of alcohol disorder with mood, anxiety disorders or both.

CONCLUSION

High levels of comorbidity are found in the general population. Comorbidity is more common in specific groups. To reduce psychiatric burden, early intervention in populations with a primary disorder is important to prevent comorbidity.

Met and unmet needs of schizophrenia patients in a Spanish sample

Deinstitutionalization of people with schizophrenia increases the importance of evaluating their needs. This study set out to identify the most common needs of people with schizophrenia who live in the community, analyze how those needs differ when evaluated by staff or by patients, describe the kind of help patients receive, and find out the variables that correlate with having unmet needs. A random sample of 231 outpatients with schizophrenia were evaluated with the Camberwell Assessment of Need and other predictor and outcome variables. Staff detected more needs than patients did. Mean number of needs as rated by patients was 5.36 and staff 6.6 (p < 0.001). Mean number of unmet needs was also greater when assessed by staff than by patients: 1.38 versus 1.82 (p < 0.001). The most frequently detected needs by patients involved psychotic symptoms, house upkeep, food, and information. Staff most often detected needs involving psychotic symptoms, company, daytime activities, house upkeep, food, and information. In a multiple regression model, needs were weakly associated with the clinical variables and quality of life. Needs assessment is complementary to clinical evaluation in schizophrenia.

[Epidemiology of mental disorders in Spain: methods and participation in the ESEMeD-Spain project]

INTRODUCTION

The ESEMeD-Spain study is part of a European project on the epidemiology of mental disorders, which is also part of a World Health Organization initiative called World Mental Health Surveys. The main objectives of the study are to estimate the prevalence of mental disorders in Spain; to analyze their association with sociodemographic variables and predisposing and protective factors; to evaluate their impact on the quality of life; and to describe and evaluate the health care received by people with mental disorders.

METHODS

A representative sample of the noninstitutionalized Spanish population older than 18 years is interviewed. Sample size is 5,500 people. The instrument used in the interviews is the Composite International Diagnostic Interview (CIDI), a questionnaire designed to be used by lay interviewers that allows the diagnosis of psychiatric disorders. Strict quality control of field work has been established. Furthermore, approximately 200 subjects are re-interviewed by a psychiatrist using the Structured Clinical Interview for DSM-IV (SCID) and several questionnaires to measure clinical severity.

RESULTS

Field work started in September 2001 and finished in November 2002. Up to Ap ril 2002, more than 4,300 people have been interviewed. Preliminary response rate has been 68.7%. Comparison of the age and gender of the study sample with the general Spanish population shows high representativeness.

CONCLUSIONS

The ESEMeD-Spain project will produce un - precedented scientific information about the epidemiology of mental disorders in Spain.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) is a new cross-sectional study investigating the prevalence and the associated factors of mental disorders, as well as their effect on health-related quality of life and the use of services in six European countries. This paper describes the rationale, methods and the plan for the analysis of the project. A total of 22,000 individuals representative of the non-institutionalized population aged 18 and over from Belgium, France, Germany, Italy, the Netherlands and Spain are being interviewed in their homes. Trained interviewers use a computer-assisted personal interview (CAPI) including the most recent version of the Composite International Diagnostic Interview (CIDI, 2000), a well-established epidemiological survey for assessing mental disorders. This is the first international study using the standardized up-to-date methodology for epidemiological assessment. Sizeable differences in prevalence, impact and level of need that is met by the health services are expected. The analysis of these differences should facilitate the monitoring of ongoing mental health reform initiatives in Europe and provide new research hypotheses.

[Comparative study of the needs of patients with schizophrenia by gender]

OBJECTIVES

To evaluate the gender differences in the needs of the people with schizophrenia who live in the community.

METHOD

We randomly selected 231 patients with schizophrenia who were receiving treatment in one of the five mental health care centres that participated in the study. Patients were evaluated with a socio-demographic questionnaire, the Positive and Negative Syndromes Scale (PANSS) and Camberwell Assessment of Need (CAN) questionnaire. The CAN evaluate 22 needs, that we could be grouped into five subscales: service needs, basic needs, functioning need, health needs and social needs. All needs were evaluated by the professional and the user independently.

RESULTS

Professionals detected more needs in men than in women, but users did not report such difference. Both professionals and users detected more service needs for women (p< 0.005) and more basic needs for men (p< 0,01-0.005). Only professionals detected more functioning needs in men (p< 0.05).

CONCLUSIONS

Professionals detect more needs than users and detect more needs for men than for women. Women have less needs in food, personal care, home care, and daily activities. These gender differences should be taken into account when designing treatment programs for schizophrenia.

Cervical cystic lymph node metastasis as first manifestation of occult papillary thyroid carcinoma: report of seven cases

BACKGROUND

Cervical cystic lymph node metastases as first and sole manifestation of occult papillary thyroid carcinoma are observed exceptionally rarely. In the seven patients here reported, a cystic, ovoid mass in the lateral aspect of the neck was the initial symptom of the papillary microcarcinoma.

METHODS

There were six men and one woman, aged between 17 and 54 years (mean 31.7 years), who complained of round, movable, painless masses in the lateral aspect of the neck. Two patients were first seen with two cervical tumors. Tumors had been present from a few days to 12 months (mean 5.1 months). The cystic nature of tumors was demonstrated by echographic studies. In all cases, thyroid tumors were not palpable on physical examination and no abnormalities of the thyroid gland were shown by other diagnostic procedures.

RESULTS

The diagnosis was made preoperatively by fineneedle aspiration cytology of the nodes in five of the seven cases. All patients underwent thyroidectomy with conservative neck dissection followed by radioactive iodine therapy. After a follow-up period from 1 to 7 years, all patients are alive with no apparent signs of recurrence or metastasis.

CONCLUSIONS

In a young patient with solitary lateral cervical cyst, the diagnosis of lymph node metastasis from occult papillary thyroid carcinoma should be considered. Any lateral mass requires tissue diagnosis, and fine-needle aspiration is usually adequate for clarification of the histology. Ipsilateral modified neck dissection and total thyroidectomy followed by radioactive iodine therapy offers a favorable prognosis.

[Verruciform xanthoma of the penis]

Verruciform xanthoma is a rare benign lesion. The most common presentation is at the oral mucosa level, although it has also been described at other locations. Our case is the twelfth verruciform xanthoma of the penis ever published. We highlight the relevance of the differential diagnosis and its excellent prognosis, the choice treatment being the simple exeresis of the lesion.

Mesenchymal chondrosarcoma of the foot, an unusual location: case report and review of the literature

We present a case of primary mesenchymal chondrosarcoma of the proximal phalanx of the first toe. The bones of the foot represent an infrequent primary site for this neoplasm. The tumour consisted of layers of undifferentiated round cells with scanty cytoplasm and hyperchromatic nuclei. The presence of brain, lung, and left auricle metastasis was demonstrated, and the patient died due to brain edema 18 days after admission. Mesenchymal chondrosarcoma is a rare tumor that more frequently involves the pelvic bones, the femur, and the humerus. To our knowledge, only nine cases of primary mesenchymal chondrosarcoma arising from the bones of the foot have been previously reported, with none involving the phalanx of the toe.

Bezafibrate induced rhabdomyolysis

The case is presented of a 70 year old woman with mild hypercholesterolaemia and hypertension who was readmitted to hospital six months after a previous admission for angina pectoris. The patient was treated with verapamil, nifedipine, and aspirin, and had been receiving bezafibrate (400 mg every 12 hours) for the previous 40 days. Twenty four hours after admission she developed podagra, which was treated with indomethacin (100 mg daily). Eight days after admission myocardial infarction was suspected, and the next day she presented with symptoms of rhabdomyolysis, which was confirmed by laboratory tests. Bezafibrate was withdrawn and the patient became asymptomatic after seven days. It is recommended that doctors should be aware of the possibility of patients, especially those with impaired renal function, developing rhabdomyolysis while being treated with bezafibrate.

Breast cancer melanosis in a postmastectomy scar

Pigmented skin lesions developed in the postmastectomy scar of a 42-year-old woman, 3 years after mastectomy, clinically mimicking malignant melanoma. A histologic study of the skin showed neoplastic mucin secreting glands and melanocyte colonization. Literature pertaining to melanin pigmentation of epithelial tumors not primary in the skin is reviewed.

Retrorectal cyst-hamartomas. Report of two cases with adenocarcinoma developing in one

The clinical and pathological features of two cases of retrorectal cyst-hamartoma are presented. Both lesions were characterized by the presence of cysts lined by mucus-producing, ciliated and transitional epithelium. The anatomical and histological findings in our cases of retrorectal cyst-hamartoma are in favor of an embryologic origin from remnants of the postanal gut. The differential diagnosis includes teratomas, dermoid cysts, duplication cysts of the rectum, anal gland cysts, and anal gland carcinomas. To avoid complications, particularly malignant transformation, early complete excision is recommended.