Childhood neglect, the neglected trauma. A systematic review and meta-analysis of its prevalence in psychiatric disorders

Traumatic events increase risk of mental illnesses, but childhood neglect prevalence in psychiatric disorders is understudied. This systematic review and meta-analysis assessed neglect prevalence, including emotional neglect (EN) and physical neglect (PN), among adults with psychiatric disorders. We conducted a systematic search and meta-analysis in 122 studies assessing different psychiatric disorders. Prevalence was 46.6% (95%CI[34.5-59.0]) for unspecified neglect (Ne), 43.1% (95%CI[39.0-47.4]) for EN, and 34.8% (95%CI[30.6-39.2]) for PN. Although a moderating effect of the psychiatric diagnostic category was not confirmed, some clinical diagnoses had significantly lower prevalence rates than others. Patients with bipolar disorder and major depressive disorder showed lower prevalence rates of EN and PN, whereas lower prevalence was found in psychotic disorders and eating disorders for PN only. Neglect assessment was a significant moderator for Ne and PN. No moderating effect of age and sex on neglect prevalence was found. Heterogeneity levels within and between psychiatric diagnostic categories remained high. This is the first meta-analysis examining diverse types of neglect prevalence considering different psychiatric diagnoses. Our results explore the prevalence of childhood neglect and its subtypes among adults with psychiatric disorders, contributing to understanding the nuanced interplay between neglect and specific psychiatric conditions, and guiding interventions for affected individuals.

Empathy in the Care of Individuals With Schizophrenia: A Vital Element of Treatment

Although therapist empathy has long been recognized as one of the most important ingredients of successful psychotherapy, its role in the treatment of schizophrenia has been neglected, relative to the treatment of other psychiatric disorders. In this article, the authors aimed to explore historical and modern conceptions of the use of empathy in work with patients with schizophrenia, review the research on empathy as applied generally in psychotherapy and as it pertains to this population, and offer a case study demonstrating empathy's instrumental role in the management of schizophrenia. Empathic understanding of patients with schizophrenia has relevance across treatment settings: in psychotherapy, on inpatient psychiatric units, in the emergency department, and at home with family or caregivers. An empathic understanding of the psychological process occurring in schizophrenia is a vital component of effective treatment.

Structural validity of the 5-item World Health Organization Well-being Index (WHO-5) in patients with schizophrenia spectrum disorders

BACKGROUND

When monitoring the severity and impact of schizophrenia spectrum disorders, a measure of subjective well-being should ideally accompany measures of symptom severity and medication side effects. The self-reported 5-item World Health Organization Well-being Index (WHO-5) is a brief, generic, and widely used measure of subjective well-being. However, the structural validity of the WHO-5, namely, whether the individual item scores can be combined to produce a meaningful total score, has not been examined among patients with schizophrenia spectrum disorders.

METHOD

Utilizing data from 399 Danish patients with schizophrenia spectrum disorders attending the Psychiatric Services of the Central Denmark Region, we employed Rasch analysis to examine the structural validity (i.e., unidimensionality, overall fit to the Rasch model, and differential item functioning) of the WHO-5.

RESULTS

The WHO-5 was found to be unidimensional with no differential item functioning for age, sex, or inpatient/outpatient status. However, in the initial analysis, some misfit to the Rasch model, partially caused by the disordering of response categories, was evident. In adjusted analyses in which the item response categories 2 (Less than half of the time) and 3 (More than half of the time) were merged, overall fit to the model was improved.

CONCLUSIONS

When two item response categories were merged, the Danish version of the WHO-5 was found to be structurally valid for patients with schizophrenia spectrum disorders. This suggests that the WHO-5 holds promise as a measure of subjective well-being in this patient population.

The resting metabolic rate of people with severe mental illness: a systematic review and meta-analysis

People with severe mental illness (SMI), including schizophrenia and related psychoses and bipolar disorder, are at greater risk for obesity compared with people without mental illness. An altered resting metabolic rate (RMR) may be a key driving factor; however, published studies have not been systematically reviewed. This systematic review and meta-analysis aimed to determine whether the RMR of people with SMI assessed by indirect calorimetry differs from (i) controls, (ii) predictive equations and (iii) after administration of antipsychotic medications. Five databases were searched from database inception to March 2022. Thirteen studies providing nineteen relevant datasets were included. Study quality was mixed (62 % considered low quality). In the primary analysis, RMR in people with SMI did not differ from matched controls (n 2, standardised mean difference (SMD) = 0·58, 95 % CI -1·01, 2·16, P = 0·48, I2 = 92 %). Most predictive equations overestimated RMR. The Mifflin-St. Jeor equation appeared to be most accurate (n 5, SMD = -0·29, 95 % CI -0·73, 0·14, P = 0·19, I2 = 85 %). There were no significant changes in RMR after antipsychotic administration (n 4, SMD = 0·17, 95 % CI -0·21, 0·55, P = 0·38, I2 = 0 %). There is little evidence to suggest there is a difference in RMR between people with SMI and people without when matched for age, sex, BMI and body mass, or that commencement of antipsychotic medication alters RMR.

Diagnostic terms psychiatrists prefer to use for common psychotic and personality disorders

OBJECTIVE

There are ongoing discussions on updating various standard psychiatric terms, including schizophrenia, which can be confusing, and personality disorders, which can be pejorative. To contribute to this process, suggestions and recommendations on terminology were sought from academic psychiatrists with substantial clinical experience.

METHODS

In an online survey, 263 psychiatrists were asked how often they used alternative instead of standard terms for the diagnosis or symptom description of psychotic disorders and DSM Cluster B personality disorders. They were also asked what specific terms they preferred to use. Reasons for their views and choices were obtained.

RESULTS

125 clinicians (48%) responded. Only a minority of clinicians (31%) tended to use the term schizophrenia often, preferring to say psychosis or to refer to thinking and perceptual problems. Even lower proportions of clinicians (7-14%) often use the terms for Cluster B personality disorder subtypes: antisocial, narcissistic, histrionic, and borderline. Alternatives suggested for these disorders included discussing emotional dysregulation, traits of sensitivity and reactivity, and relational difficulties. Reasons cited for choosing alternative terms were to avoid miscommunication (71% of responders) and to avoid offending the patient (78% of responders).

CONCLUSIONS

There are practical alternatives to standard psychiatric terminology that may improve communication with patients and be more respectful choices, as well. The suggestions of the psychiatrists responding to this survey might be of immediate value to others in their practices and might be worthy of consideration by those writing the next versions of the standard manuals, both the DSM and the ICD.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis

OBJECTIVE

To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors.

STUDY DESIGN

Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies.

DATA SYNTHESIS

Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06).

CONCLUSIONS

We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians.

PROSPERO REGISTRATION

CRD42021235979 (prospective).

Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

Persons with serious mental illness face adverse psychiatric and medical outcomes, and their care is associated with a large burden of health care costs. Care management, in which assessment, care planning, and care coordination are provided, is a common model of support, yet the evidence supporting its use among psychiatric populations is mixed. A systematic review and a meta-analysis were undertaken to determine the impact of care management on clinical outcomes, acute care utilization, cost, and satisfaction among adults with serious mental illness.

METHODS

A multidatabase literature search was performed. Articles were included if they compared standard outpatient care plus care management with standard outpatient care alone for adults with serious mental illness and reported on one or more predefined outcomes. Randomized controlled trials (RCTs) and other study designs were permitted for inclusion in the systematic review. The meta-analysis included only RCTs.

RESULTS

For the systematic review, 34 articles representing 28 unique studies were included. Fifteen of these articles, representing 12 unique studies, were included in the meta-analysis, which indicated that care management was associated with small, statistically significant improvements in psychiatric symptoms, overall quality of life (QOL), and mental QOL (Hedges' g range 0.13-0.26). In addition, care management was associated with a small, statistically significant reduction in inpatient psychiatric hospital days (Hedges' g=0.16, p=0.02).

CONCLUSIONS

Care management is associated with fewer psychiatric symptoms and greater QOL for persons with serious mental illness. Further work is needed to determine which components of the intervention are associated with effectiveness.

Psychiatric hospitalization during the two SARS-CoV-2 pandemic waves: New warnings for acute psychotic episodes and suicidal behaviors

BACKGROUND

The subsequent waves of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have represented a dramatic health emergency characterized by significant consequences on mental health. Diachronic variations in the incidence rates of acute relapse of psychiatric disorders may represent significant "sentinel events" for assessing the mental health response to an unprecedented stressful event.

AIM

To investigate the variation in psychiatric hospitalization rates and differences in sociodemographic and clinical-psychopathological peculiarities at Bologna "Maggiore" General Hospital Psychiatric Ward (GHPW) between the first two waves SARS-CoV-2 pandemic and the same periods of the previous 3 years. The secondary purpose of the study was to suggest a diachronic response pathway to stress by reporting additional literature data on coping strategies.

METHODS

This observational and retrospective study collected information on admission to the GHPW at the "Maggiore" Hospital in Bologna in the index periods defined as follows: the first period between February 24, 2020 and April 30, 2020 (first epidemic wave) and the second period between October 8, 2020, and January 7, 2021 (second pandemic wave). Absolute numbers and proportion of admitted patients, their sociodemographic and clinical-psychopathological characteristics were compared with the same parameters recorded in the two same periods of the previous 3 years. No strict inclusion or exclusion criteria were provided in the data collection to collect information on all patients requiring acute psychiatric hospitalization.

RESULTS

During the first wave, there was a significant reduction in hospitalization rates, although there was a simultaneous increase in compulsory hospitalizations and the acute relapse of schizophrenia spectrum and other psychotic disorders. During the second wave, hospitalization rates reached those recorded during the same period of the previous 3 years, mainly due to the rise of bipolar and related disorders, depressive disorders, anxiety disorders, trauma- and stressor-related disorders and suicidal behaviors.

CONCLUSION

The coping strategies adopted during the first wave of the SARS-CoV-2 pandemic protected the vulnerable population from the general risk of clinical-psychopathological acute relapse, even if they increased the susceptibility to run into schizophrenia spectrum and other psychotic disorder relapses. In the medium-long term (as in the second pandemic wave), the same strategies do not play protective roles against the stress associated with the pandemic and social restriction measures. Indeed, during the second wave of the SARS-CoV-2 pandemic, an increase in total hospitalization rate, suicidal behaviors and the incidence rate of bipolar and related disorders, depressive disorders, anxiety disorders, trauma- and stressor-related disorders was observed.

Living conditions of patients with schizophrenia spectrum disorders in the region of 'Tâmega e Sousa' (Portugal)

BACKGROUND

Schizophrenia spectrum disorders (SSD) are the most impairing psychiatric disorders and are a major cause of social exclusion. Despite that, there are only two studies published assessing the socioeconomic characteristics of SSD patients living in Portugal.

AIMS

The purpose of this study is to assess the degree of social and family support for SSD patients living in the region of 'Tâmega e Sousa', in northern Portugal.

METHOD

We conducted a cross-sectional observational study using patients under home-based care provided by the Department of Psychiatry and Mental Health of Centro Hospitalar do Tâmega e Sousa. We retrieved sociodemographic data from clinical records. The study was approved by the Hospital Ethics Committee.

RESULTS

Our sample consists on 67 patients with SSD, mostly men (74.6%). Although the majority was single (69.2%) and childless (85.7%), only a minority lived alone (21.2%). In relation to their professional status, only 5.0% were employed and 78.3% got a disability pension. Among the patients that lived accompanied, 68% lived with their parents or grandparents, and a quarter lived with family members affected by psychiatric disorders.

CONCLUSIONS

These findings highlight the dependence of SSD patients on their family's support. Lack of labour market integration, economic dependence and difficulty establishing stable relationships further aggravate their social exclusion. Although our results are consistent with a previous observational study held in Portugal, our patients display a worse functional status. Even considering the possible patient selection bias, there is evidence supporting the need for more investment in psychosocial rehabilitation that should take into account the sociodemographic idiosyncrasies of this Portuguese region.

Measuring personal recovery in people with a psychotic disorder based on CHIME: A comparison of three validated measures

Living well in spite of residual symptoms of mental illness is measured with the construct of personal recovery. The CHIME framework might be suitable to evaluate personal recovery measures and guide instrument choice. Three validated measures were evaluated in Dutch patients with a psychotic disorder (N = 52). We compared the Recovery Assessment Scale (RAS), the Mental Health Recovery Measure (MHRM), and the Netherlands Empowerment List (NEL). The measures were assessed on six criteria: content validity (based on CHIME), convergent validity with a social support measure, internal consistency, floor and ceiling effects, item interpretability, and ease of administration. The MHRM scored high on content validity with a balanced distribution of items covering the CHIME framework. The MHRM and the NEL showed moderate convergent validity with social support. In all three measures, internal consistency was moderate and floor and ceiling effects were absent. The NEL scores demonstrated a high degree of item interpretability. Ease of administration was moderate for all three measures. Finally, the CHIME framework demonstrated good utility as a framework in guiding instrument choice and evaluation of personal recovery measures. The MHRM showed the best overall result. However, differences between measures were minimal. Generalization of the results is limited by cultural and linguistic factors in the assessment for the subjective measures (i.e. content validity and item interpretability). The broad and multidimensional construct of personal recovery might lead to ambiguous interpretations. Scientific consensus on a well-defined personal recovery construct is needed.

Schizophrenia in ICD-11: Comparison of ICD-10 and DSM-5

The conceptualization of schizophrenia has changed from its initial conception in the 19th century to the recent publication of the ICD-11. The changes incorporated in this latest version were made based on the evaluation of the current ICD, the available scientific evidence, and the consensus reached by its developers. In this paper we describe the conceptualization changes (diagnostic criteria and specifiers) of ICD-11 schizophrenia with respect to those of ICD-10 and DSM-5. The changes found are discussed based on the scientific literature published in Medline, Scopus and Scielo until July 2019 and the information on the Wordl Health Organization and American Psychiatric Association websites. Given that the diagnosis of schizophrenia is based on the diagnostic criteria of the diagnostic classification systems, it is important to know the changes made in its conceptualization and the evidence supporting such modifications.

Urbanicity and risk of first-episode psychosis: incidence study in Brazil

We estimated the incidence of first-episode psychosis over a 3-year period in a Brazilian catchment area comprising the region's main city, Ribeirão Preto (1 425 306 persons-years at risk), and 25 other municipalities with a total of 1 646 556 persons-years at risk. The incidence rates were estimated and adjusted by gender and age, using the direct standardisation method to the world population as reference. The incidence of psychosis was higher in the younger groups, men, and among Black and minority ethnic Brazilians. Psychosis incidence was lower in Ribeirão Preto (16.69/100 000 person-years at risk; 95% CI 15.68-17.70) compared with the average incidence in the remaining municipalities (21.25/100 000 person-years at risk; 95% CI 20.20-22.31), which have lower population density, suggesting a distinct role for urbanicity in the incidence of first-episode psychosis in low- and middle-income countries.

Self-disorders in Early Stages of the Schizophrenia Spectrum

The pathogenic nucleus of schizophrenia has varied according to the different eras and influences of distinguished clinical researchers. Self-disorders have also been recognised to be at the heart of this disorder, although they have seldom been studied due to their subjective nature. Recently, due to the growing interest in the study of the early stages of schizophrenia, the study of self-disorders has been resumed. The self-disorders in schizophrenia model, developed by Sass and Parnas, proposes that in this disorder the person suffers loss of the first-person perspective and experiences hyperreflexibility, diminished self-affection and disturbance of the field of awareness. Therefore, the person experiences feelings of strangeness about him/herself, difficulty in understanding the common sense of things and difficulty interacting with his/her environment. Based on this model, self-disorder evaluation instruments have been developed and empirical studies have been conducted to evaluate people at risk of developing a schizophrenia spectrum disorder. These studies show that self-disorders are found in prepsychotic stages and that their manifestation may predict the transition to schizophrenia spectrum disorders. These results have important clinical implications as they enable people in the early stages of the disorder to be identified and create the opportunity to apply early therapeutic interventions.

Exploring Heterogeneity on the Wisconsin Card Sorting Test in Schizophrenia Spectrum Disorders: A Cluster Analytical Investigation

OBJECTIVES

The Wisconsin Card Sorting Test (WCST) is a complex measure of executive function that is frequently employed to investigate the schizophrenia spectrum. The successful completion of the task requires the interaction of multiple intact executive processes, including attention, inhibition, cognitive flexibility, and concept formation. Considerable cognitive heterogeneity exists among the schizophrenia spectrum population, with substantive evidence to support the existence of distinct cognitive phenotypes. The within-group performance heterogeneity of individuals with schizophrenia spectrum disorder (SSD) on the WCST has yet to be investigated. A data-driven cluster analysis was performed to characterise WCST performance heterogeneity.

METHODS

Hierarchical cluster analysis with k-means optimisation was employed to identify homogenous subgroups in a sample of 210 schizophrenia spectrum participants. Emergent clusters were then compared to each other and a group of 194 healthy controls (HC) on WCST performance and demographic/clinical variables.

RESULTS

Three clusters emerged and were validated via altered design iterations. Clusters were deemed to reflect a relatively intact patient subgroup, a moderately impaired patient subgroup, and a severely impaired patient subgroup.

CONCLUSIONS

Considerable within-group heterogeneity exists on the WCST. Identification of subgroups of patients who exhibit homogenous performance on measures of executive functioning may assist in optimising cognitive interventions. Previous associations found using the WCST among schizophrenia spectrum participants should be reappraised. (JINS, 2019, 25, 750-760).

Traditional test administration and proactive interference undermine visual-spatial working memory performance in schizophrenia-spectrum disorders

Introduction Working-memory (WM) is a core cognitive deficit among individuals with Schizophrenia Spectrum Disorders (SSD). However, the underlying cognitive mechanisms of this deficit are less known. This study applies a modified version of the Corsi Block Test to investigate the role of proactive interference in visuospatial WM (VSWM) impairment in SSD. Methods Healthy and SSD participants completed a modified version of the Corsi Block Test involving both high (typical ascending set size from 4 to 7 items) and low (descending set size from 7 to 4 items) proactive interference conditions. Results The results confirmed that the SSD group performed worse overall relative to a healthy comparison group. More importantly, the SSD group demonstrated greater VSWM scores under low (Descending) versus high (Ascending) proactive interference; this pattern is opposite to that of healthy participants. Conclusions This differential pattern of performance supports that proactive interference associated with the traditional administration format contributes to VSWM impairment in SSD. Further research investigating associated neurocognitive mechanisms and the contribution of proactive interference across other domains of cognition in SSD is warranted.

The Sardinian Puzzle: Concentration of Major Psychoses and Suicide in the Same Sub-Regions Across One Century

BACKGROUND

Sardinia, the second largest Mediterranean island has long been considered a privileged observatory for the study of several medical conditions. The peculiar epidemiology of mood disorders and suicide across Sardinian sub-regions has long intrigued clinicians and researchers.

OBJECTIVE

The principal aim of the present study was to test whether the geographical distribution of suicides committed in Sardinian over the last three decades are comparable with the geographical origin of patients hospitalized up to half a century ago.

METHOD

The distribution of the municipalities of origin of the patients hospitalized in Sardinia between 1901 and 1964 for schizophrenia, bipolar disorder, and depression was reanalyzed and compared with the distribution of municipalities where suicides were committed between 1980 and 2013. Data were also analyzed by the altitude above the sea level and by the population size of the municipalities.

RESULTS

There was a significant variation of hospitalization and suicide rates across Sardinian sub-regions. The sub-regions of origin of the patients hospitalized for schizophrenia and bipolar disorder correlated with each other (P = 0.047). Both hospitalizations and suicides were more incident in municipalities with a higher altitude and a smaller population size. The incidence of hospitalizations and suicides correlated significantly with each other both at the municipality (P = 1.86 x 10-7) and at the sub-region level (P = 1.71 x 10-7).

CONCLUSION

The present study confirms the peculiar geographical distribution of major psychoses and suicide in Sardinia. The two phenomena appear to have been correlated for as long as one century.

Hippocampal activation and memory performance in schizophrenia depend on strategy use in a virtual maze

Different strategies may be spontaneously adopted to solve most navigation tasks. These strategies are associated with dissociable brain systems. Here, we use brain-imaging and cognitive tasks to test the hypothesis that individuals living with Schizophrenia Spectrum Disorders (SSD) have selective impairment using a hippocampal-dependent spatial navigation strategy. Brain activation and memory performance were examined using functional magnetic resonance imaging (fMRI) during the 4-on-8 virtual maze (4/8VM) task, a human analog of the rodent radial-arm maze that is amenable to both response-based (egocentric or landmark-based) and spatial (allocentric, cognitive mapping) strategies to remember and navigate to target objects. SSD (schizophrenia and schizoaffective disorder) participants who adopted a spatial strategy performed more poorly on the 4/8VM task and had less hippocampal activation than healthy comparison participants using either strategy as well as SSD participants using a response strategy. This study highlights the importance of strategy use in relation to spatial cognitive functioning in SSD. Consistent with a selective-hippocampal dependent deficit in SSD, these results support the further development of protocols to train impaired hippocampal-dependent abilities or harness non-hippocampal dependent intact abilities.