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A community based early intervention program for schizophrenia developed by a psychiatric department in the suburbs of Lisbon is described. The program included treatment with psychotropic drugs, regular evaluations by a multidisciplinary community team (outpatient clinic and home visits), family interventions, psycho educational groups, individual psychotherapy, family and occupational therapy, and cognitive remediation intervention.
A group of 77 patients with a first episode of psychosis diagnosed between January 2001 and October 2006, and followed for no more than two years at first assessment was enrolled in the program. The patients were predominantly males (82%), single (94%), living with their parents (72.7%), and between 18 and 25 years old (53.2%). One third of the sample had 9 years of education, and 72.7% met ICD-10 criteria for schizophrenia, while 69% met DSM-III-R criteria for prodromic symptoms.
During follow-up 16 patients (20%) dropped out, 18.1% were admitted as inpatients during the first 6 months after the diagnosis (Phase II), and 15.5% in the following 18 months (Phase III). There was a decline in occupational/employment rates, mainly in the male gender. Most female patients had Duration of Untreated Psychosis (DUP) between 1-2 years and most male patients had a DUP higher than 2 years.
The protocol was useful in the development of a Multidisciplinary Community Team Intervention for the assertive follow-up of patients with a first episode of schizophrenia. Its main limitation is the lack of comparison with a standard care treated sample.
In meridional European countries such as Portugal, informal caregivers are almost always close relatives, either key-relatives (those more involved) or not. There are few systematic comparisons between the experience of key-relatives/primary caregivers (PC) and other/secondary caregivers (SC) in psychogeriatrics. We present some preliminary data from the FAMIDEM (Families of People with Dementia) survey.
Non-randomised cross-sectional study comparing two related samples of caregivers (PC versus SC) of 41 patients with DSM-IV dementia from outpatient practices in Lisbon (Portugal). Caregivers’ assessments included: Zarit Burden Interview, Caregiver Activity Survey (CAS), Positive Aspects of Caregiving, GHQ-12, Social Network Questionnaire and Dementia Knowledge Questionnaire.
Patients’ mean age was 78,7 years (SD 7,9). 24 (58,5%) were women and 58,5% had Alzheimer disease.PC were older than SC (p=0,000) and tended to live with the patient (p=0,000). They reported less emocional support (p=0,021) but higher objective burden-CAS (p=0,002). Regarding all other outcome variables, significant differences between groups were not found. Within the global sample, comparing spousals (n=23) and adult children/other relatives (n=59) yielded interestingly different preliminary results, eg higher GHQ-12 levels (p=0,010).
The experience of caregiving is possibly different regarding PC and SC, but further research is warranted in order to define who really is at risk. Being a spouse may be much more determinant, although most spouses are PC as well. for the moment, it seems prudent not to exclude SC from risk assessments. the final FAMIDEM results, even lacking generalizability, will probably provide interesting clues.
Inmates present higher prevalence of mental and physical disorders and are subject of some kind of social exclusion than the general population. The assessment of unmet needs is crucial for care planning.
To assess and compare the need for care between male and female inmates undergoing psychiatric treatment.
Delivery of health and social care in prisons.
A cross-sectional, descriptive study of a non-probabilistic convenience sample of inmates referenced to a forensic psychiatric clinic in Lisbon region, during a year, was performed. The research protocol, besides a specific questionnaire, includes MINI; BPRS; GAF and Camberwell Assessment of Need, Forensic Version (CANFOR).
Seventy nine males (median age 36) and 35 females (median age 32) were receiving psychiatric treatment at the time of the study. Anti-social personality disorder in men (62%) and major depression in women (62.9%) were the most frequent disorders found. Males more often present moderate to high suicide risk (36.7%) than females (28.6%). The number of unmet needs was significantly increased in males (average 6 ± 2.2) than females (4.3 ± 2.2; p< o.oo1). For males, the more frequent unmet needs concerns sexual expression (79.7%), social benefits (77.2%) and psychological distress (63.3%) and for females it was psychological distress, social benefits (62.9% each) and company (51.4%).
The results indicate that male inmates have higher behavioral risk and more unmet needs than female inmates. The assessment of needs in prisons is important for the development of strategies concerning care, social integration and prevention of criminal recidivism.
Gender differences in mental health disorders may serve as a useful heuristic for integrating epidemiological and psychobiological data. The vast majority of mental disorders may express major gender-related variations in prevalence, natural history, symptoms, prognosis, and treatment outcome.
To compare demographic and clinical characteristics of women and men admitted to a psychiatric unit.
Retrospective data of all the patients admitted to a psychiatric inpatient unit, from January 2004 to December 2007, were reviewed. The demographic and clinical characteristics of the two genders were compared.
Of a total of 1114 patients admitted, 53.1% were women. They differed significantly from male inpatients in being older (46.7 vs. 40.7 years), less frequently black (14.6 vs. 25.4%), more frequently diagnosed with bipolar and delusional disorders, and in receiving fewer diagnosis of schizophrenia. Women had a longer average length of stay, a different seasonal pattern in admissions, with a much lower rate of admissions than men in December (38.6 vs. 61.4%), and a lower percentage of patients with three or more readmissions. Only 37.2% of the 180 compulsory admissions were of women.
There are significant differences in clinical and demographic characteristics of female and male psychiatric inpatients. While some results may be explained by gender specific biological factors (as in the type of diagnosis), others are probably associated with different gender roles (as in the seasonality of admissions).
Large discrepancies in psychiatric compulsory admission rates have been found in the different European countries. However, some trends seem to exist in most studies: compulsorily admitted patients are more frequently male, unemployed, with a lower level of education, are more likely to belong to racial minorities (mainly black), and the most frequent diagnosis is schizophrenia.
To compare demographic and clinical characteristics of patients voluntarily and compulsorily admitted to a Portuguese psychiatric unit.
Retrospective data of all the patients admitted to a psychiatric inpatient unit, from January 2004 to December 2007, were reviewed. The demographic and clinical characteristics of compulsorily and voluntarily admitted patients were compared.
In a total of 1434 admissions, 180 were compulsory (11.2%). Compared to voluntarily admitted patients, those admitted compulsorily were significantly younger (38.2 vs. 43.6 years), more frequently male (62.8 vs. 47.1%), and black (27.8% vs. 19.9%), received more often a diagnosis of schizophrenia (34.4 vs. 19.0%), and had a longer average length of stay (27.0 vs. 18.5 days). There were no statistically significant differences in the seasonality of admissions or the number of readmissions in both groups.
The results are similar to those obtained in other studies, except for a higher rate of compulsory admissions. That can be explained by, among other factors, the low socioeconomic level and high percentage of immigrants in the local population. The comparison with voluntarily admitted patients helps identify characteristics associated with the two groups.
To study the short-term effect of treatment with quetiapine on prepulse inhibition (PPI) deficits of the startle reflex in schizophrenia patients.
Subjects and methods
Using PPI, we studied a group of 21 schizophrenia patients and 16 controls. Seventeen of the patients were re-tested with PPI after 21 days of treatment with quetiapine.
At baseline, an almost significant decrease in PPI was found in the patients as compared to the controls. PPI measurements did not change in the patients after 21 days of treatment with quetiapine, despite their clinical improvement.
Our results suggest that short-term quetiapine treatment may not modify PPI measures in schizophrenia patients.
The term somatoparaphrenia was firstly used by Gerstmann to describe a form of asomatognosia in which unawareness of ownership is accompanied by delusional misidentification and/or confabulation. This is a rare phenomenon and the few published case reports showed an association of this psychopathological entity with brain-damage. We present a patient with schizophrenia who believed his right arm and right foot were not his own. According to his delusion of foreign ownership, his foot didn’t belong to him because it was a “big foot only suited for work” and his right arm belonged to Maria, a woman from his neighbourhood. Remarkably, no organic causes were found to exist. To our knowledge, this is one of the rare cases of schizophrenia in which somatoparaphrenia can be identified. We further elaborate on the phenomenology of this particular patient.
The DEMoBinc study's main objective is to develop an instrument for assessing the living conditions, the quality of care, and the human rights of long-term mentally ill patients in psychiatric and social residential care. It started on March 2007, with 11 centres and 10 countries participating.
The Portuguese centre has carried out a national literature review of mental health legislation, standards of care related with residential care for mental patients, and mandatory procedures for physical restraint and seclusion.
A three-round Delphi exercise with four groups of experts - advocates, mental health professionals, service users, and carers - was also developed. In the first round the participants were asked to state the ten more important components of care helping recovery in institutional care for the long-term mentally ill. The results were sent back to be rated for their importance on a 5-point scale. Finally, the participants were asked to confirm or change their own scores in comparison with the calculated group median. Between twelve and 18 participants by group were contacted, and the overall rate of participation was 73%.
A pilot study using the first draft of the DEMoBinc instrument was done, and refinement of the instrument is being carried out in twenty institutions and will be completed during the next months.
The results of the Portuguese centre on the national literature review, the Delphi exercise, and the first phase refinement of the DEMoBinc instrument will be presented and discussed.
Deinstitutionalisation of the mentally ill is an ongoing process in European countries. Quality of care in residential facilities, however, was seldom assessed in part due to the lack of adequate instruments.
To assess the quality of care in Portuguese residential facilities for long term mental patients.
Quality of care in residential facilities was assessed with the toolkit developed by the DEMoBinc study using interviews with the units’ managers, and the users.
The 20 units assessed across Portugal were mainly located in the city; 13 were in a hospital setting and 7 in the community. Most of the units (90%) had no maximum length of stay, and 60% were mixed-gender; 85% of the users were not compulsory. Most of the units (60%) had no one-bedrooms, and their aim was rehabilitative in 40%, and rehabilitative plus providing support in 40%. The rate of patients with a bank account was 49.4%, 32.4% were in charge of their finances, while only 14.1% had voted.
In hospital vs. community units patients were more frequently men (80.5 vs. 53.8%) and older (51.1 ± 13.7 vs. 43.3 ± 9.6, p < .001). In community units the treatment was more frequently explained (50 vs. 26.3%), patients’ involvement was higher (40.4 vs. 19.5%), while mean GAF scores (64.9 vs. 60.2) did not differ.
Portuguese results show that in spite of the effort to create new facilities for the longer term mentally ill, a lot still has to be done to improve the quality of care they provide.
A small subset of patients with above average admissions to psychiatric inpatient units is recognized in clinical practice. These frequent users tend to be younger and to have a diagnosis of schizophrenia or affective disorder. Social conditions and the severity of the illness seem to be associated with this increased number of admissions.
To study demographic and clinical characteristics of frequent and non-frequent users of a psychiatric inpatient unit.
Retrospective data of all the patients admitted to a psychiatric inpatient unit from January 2004 to December 2008 were reviewed. Frequent-users were defined as patients with 3 or more admissions over that period of time, and non-frequent users as those with less than 3 admissions. The two groups were compared in terms of age, gender, ethnicity, psychiatric diagnosis and compulsory admissions
In a total of 2018 admissions and 1348 patients, the frequent-user group represented 10.2% (n = 137) of the patients and 28.9%(n = 584) of the admissions. Frequent-users were significantly younger (39.5 vs. 44.5 years, p = .001), more frequently black (22.6 vs. 19.4%, p < .001) and compulsorily admitted (27.7 vs. 14%, p < .001) than non-frequent users. Patients with bipolar disorder (p = .001), schizophrenia (p = .003) belonged significantly more to frequent-users group, while unipolar depressive patients (p = .016) and other diagnosis (p = .011) was more significantly represented in the non-frequent users group. Frequency of admission did not differ with gender.
The results concerning age and psychiatric diagnosis are consistent with previous studies. Compulsory admissions and black ethnicity were significantly higher among frequent- users.
Psychoeducation is currently considered an essential intervention in the management of bipolar disorders. A psychoeducation group programme for patients with bipolar disorders named “Porta Aberta” (Open Door) has been implemented since 2007 at the Day-hospital of our psychiatric department.
Objectives and aims
To assess the efficacy of group psychoeducation in reducing the average number and duration of readmissions and to determine the individual characteristics (gender, marital status and disorder subtype) that might influence these outcomes.
Review of the clinical records of a consecutive sample of patients with bipolar disorders discharged from the inpatient unit, attending at least 4 out 8 programme sessions, and with a one-year follow-up since 2007. Variables assessed were: gender, age, marital status, subtype of bipolar disorder (I or II), and number and duration of psychiatric admissions in the year before and in the year following the programme attendance.
The 69 patients included were 37.3 ± 10.7 years old, mainly women (68.1%), and single (47.8%). A statistically significant reduction in the average duration of readmissions (24.7 versus 17.3 days, p = .028), and in the average number of readmissions (1.3 versus 0.3, p = .032) was found. Only 15 patients were readmitted. Patient's gender and marital status, as well as disorder subtype had no influence in the results.
Group psychoeducation is an effective intervention in reducing the number and duration of readmissions in bipolar patients despite gender, marital status and subtype of bipolar disorder.
Rehabilitation or terciary prevention refers to the set of appropriate measures to minimize the consequences of disease and reintegration the patients in their home environment, social and professional. Patients with severe mental illness need of psychosocial rehabilitation programs through the training of activities of daily life, especially in areas that present the greatest difficulties.
The advantage in the group approach is that the patient is confronted with its limits and possibilities. This observation allows us to recognize another important similarities and contrasts, expanding your vision of treatment and enhancing its effect. Group assistance seems to be more motivating and can further reduce costs in attendance with good results.
The creation of this psychoeducational group appears to foster the promotion / preservation of independence and functional capacity of patients in its maximum exponent, mean they can live without assistance for activities of daily living. The rehabilitative scheme is performed without isolating the patient from his family and his social environment. Looking for a comprehensive care that meets individual needs and possibilities, centered on the patient, with a view to their rehabilitation and social reintegration. Involves both professionals and patients, actively, in the development of skills that may lead to a better quality of life.
Somatic comorbidities are common among elderly patients with mental health problems, namely dementia and depression. Quite often, somatic problems are associated with a substantial impairment in daily routines, as well as to a worse outcome of the neuropsychiatric condition.
to investigate the level of impairment due to comorbid somatic problems in the elderly, as part of the implementation of the 10/66- Dementia Research Group Population-based Research Protocol in Portuguese settings.
A cross-sectional survey was implemented of all residents aged 65 in a semi-rural area in Southern Portugal. Evaluation included a cognitive module and the Geriatric Mental State-AGECAT (GDS). Training of the field researchers was conducted with the supervision of the 10/66-DRG coordinators (CF, MP).
703 elderly participants were evaluated. Interference with daily activities was present in every area assessed, with moderate to severe impact in the following areas: Arthritis or rheumatism (36,9%), eyesight problems (19,8%), hypertension (10,5%) and gastro-intestinal conditions (10,4%). 48,9% of the participants had at least one contact with a primary care health centre in the last three months, and 22,5% had at least one contact with a doctor in a general hospital.
Results showed a relevant degree of impairment due to somatic conditions, and a high use of services, namely at primary care level. The significant prevalence of comorbid somatic conditions should be taken into account regarding the organization of services directed to older patients with mental health problems, that has been considered a priority in the Portuguese Mental Health Plan 2007–2016.
Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patient's health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness.
The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. all four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted.
To raise awareness to the importance of this rare but highly disabling disease.
Review of clinical records and complementary exams.
All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis.
Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.
There is robust evidence recommending electroconvulsive therapy (ECT) in treating severe acute affective disorders. The clinical use of bitemporal electrode placement is still favoured to unilateral placement with just a relative disadvantage in cognitive side effects. Recently, bifrontal placement has gained popularity but there is still limited evidence on its relative benefits.
Compare bitemporal and bifrontal ECT efficacy in patients with pharmacologically resistant affective disorders, based on the number of acute phase treatments required to reach symptomatic remission.
Review of all patients' charts submitted to acute phase ECT, between June 2006 and June 2011. A total of 70 ECT treatment courses performed in a group of 67 patients met inclusion criteria. Thirty-eight of the total 70 courses received bitemporal ECT, and 32 received bifrontal ECT. A statistical analysis was performed. An attempt to use t-test was foiled due to breach of population variance homogeneity (p = 0,021). The non-parametric Mann-Whitney test was the alternative choice (M-W = 534;p = 0,377).
Bitemporal and bifrontal groups matched for age and sex. Bitemporal patients received on average five ECT treatments, while the average of bifrontal treatments to remission was six, but this difference was not statistically significant (p > 0.05).
Our results showed that bitemporal and bifrontal placements are equally effective. According to the largest randomised controlled trial conducted on ECT in depressive illness (Kellner et al,2010), bitemporal placement led to a faster rate of improvement. Additional studies and larger samples are required to understand if bifrontal placement's efficacy and cognitive advantages justify its popularity.
The co-occurrence of mania and delirium, named “delirious mania”, is an under-recognized entity not listed in major diagnostic classifications. Literature about this syndrome is still scarce and lacking evidence. Usually, reports of affective syndromes with delirium tend to be subdued in the manic descriptor
We report the case of a 44 year old female patient with a simultaneous affective episode and delirium.
To demonstrate the co-occurrence of depressive/mixed symptoms and delirium
Review of clinical records and complementary exams.
The patient was admitted after a three week long depressive syndrome with psychomotor agitation, followed by a week-long fluctuating pattern of delirious and mixed affective features. Shortly after admission the patient exhibited a stuporous state, with nocturnal agitation. A fluctuating pattern of symptoms ensued, with disorientation, disorganized behavior, cognitive impairment, anxiety and depressive features. the patient was put on mood stabilizers, antipsychotics and benzodiazepines. She was discharged symptom-free two months later and re-admitted 4 weeks later due to recurrence of symptoms. Electroconvulsive treatment was applied,with quick remission of affective symptoms. Yet, it took another two months until discharge, due to persistent cognitive symptoms. Medical conditions were excluded.
This case shows the simultaneous occurrence of an affective syndrome alongside delirium. the strongest treatment response occurred with ECT. the presence of depressed mood highlights the fact that this syndrome can begin without clear-cut manic symptoms. We suggest that its name should be changed to Delirious Affective Disorder, which might help to avoid misdiagnosis. Persistent cognitive deficits raise some questions in this case.
Bipolar mixed states were systematically described for the first time by Emil Kraepelin. Since then, their high prevalence has been repeatedly recognized, but they still remain poorly understood. These patients appear to be extremely difficult to treat, many being refractory to pharmacological approaches. Clinical experience supports the use of electroconvulsive therapy (ECT) in mixed states, but there is little information on its effectiveness in scientific literature.
Report our experience in using acute phase ECT (aECT) in mixed states.
The authors reviewed the clinical records of all patients submitted to aECT between June 2006 and June 2011. The inclusion criteria were: a) presence of a mixed state according to Akiskal's criteria (Akiskal et al,2005); b) completed treatment course with aECT. The following variables were collected: demographic characteristics, previous response to pharmacotherapy, presence of psychotic symptoms, number of aECT sessions, referral to continuation or maintenance ECT (c/mECT), number of readmissions. Relation between the diagnostics and the number of ECT sessions was validated with Eta-coefficient. Comparison between these two groups was carried out with One-Way-ANOVA.
Eighteen patients met inclusion criteria and were resistant to pharmacotherapy. Eight patients had psychotic features. All patients but one showed a positive clinical response, as documented on CGI. The average number of ECT sessions was five, while the mean of ECT treatments in manic and depressive patients was seven and six respectively. Thirteen patients were scheduled for c/mECT.
Our results confirm the effectiveness of ECT in medication nonresponsive patients experiencing a mixed state.
Collaboration between primary care and mental health services has positively progressed in the last ten years in Portugal. The 2007 National Mental Health Plan, emphasizing the community intervention model, has promoted closer articulation between both services. Progressively a greater number of mental health services have adopted the new model and developed since some kind of collaboration with primary care services in their catchment area. In this context, the two affiliated departments of psychiatry of the New University of Lisbon developed different models of a close collaboration between the mental health teams and primary care centers.
To give a general overview of the main characteristics and an analysis of the first results of mental health and primary care collaboration in these two departments.
Each affiliated department of psychiatry carried out a specific model of articulation: in one case, common and severe mental disorders are managed by separate mental health teams, while in the other they are managed by the same teams, using rules for referral of patients to mental health, articulation of interventions and back referral to general practitioners, and triage on the urgency of the referrals. Regular meetings to discuss cases and training takes place in both models.
The pros and cons of the two models of collaboration will be presented and discussed. However, shortage of general practitioners and their reorganization in new family health units have added difficulties to the collaboration with mental health services, stressing the need for new possible models.
Mental illness results from biological, psychological, social and contextual factors and is influenced by global events such as economic crises.
To describe the profiles of psychiatric admissions in four Portuguese hospitals located in the metropolitan areas of Lisboa and Porto, and to assess their evolution in 2002, 2007 and 2012, and the changes associated with the economic crisis effects.
The information was retrieved from the medical charts of all patients (n= 3,647) admitted at three periods: 2002 (no crisis), 2007 (pre-crisis) and 2012 (crisis). Demographic, social and clinical variables were obtained. The statistical binomial test was used to verify the existence of significantly differences between 2007 and 2012.
The number of admissions increased from 2007 to 2012, with greater variation (22%) in the Disorders related to substance use (ICD-9: 291, 292, 303, 304 e 305). Statistically significant positive changes were found in the admissions of: i) patients aged 50 to 64 years (17%, p=0.022), divorced (25%, p=0.032), and unemployed (58%, p<0.001); ii) patients 50 to 64 that referred having attempted suicide (26%, p=0.067) and suicidal ideation (34%, p=0.022) during that year; iii) women 50 to 64 referring attempted suicide (39% p=0.044) and suicidal ideation (39% p=0.044).
Our findings suggest the influence of the economic crisis in the number and profile of people admitted for mental disorders (greater effect in unemployed patients), and its association with an increase of admissions in people with suicide attempts and suicidal ideation, and particularly in women aged 50 to 64.
Above 60 years, prevalence rates of neuropsychiatric disorders double with every 5.1 years of age (from 0.7% at 60-65 years to 23.6% for those aged 85 or older). As aged people are dramatically increasing in Portugal, a Country under a serious financial crisis, it is important to understand whether health services are being used appropriately.
to characterize the use of health services among the elderly, as part of the implementation of the 10/66-Dementia Research Group Population-based Research Protocol in Portugal.
A cross-sectional survey was implemented of all residents aged 65 or more in a semi-rural area in Southern Portugal. Core evaluation included a cognitive module and the Geriatric Mental State-AGECAT (GDS). A structured questionnaire assessed the use of services, including health care providers (public, private), inpatient episodes, medication and costs.
703 participants were evaluated. Almost half of the participants (48,9%) were in contact with public primary care facilities, but only 22,5% had a contact with a hospital service. In both settings, nurses and other non-doctor professionals were rarely involved (6,4%) as principal care providers. 11,8% had at least one contact with a private doctor. Inpatient episodes in the last 3 months were very infrequent (3%). The National Health Service covered most costs.
Previous research strongly suggests that health services are not provided equitably to people with mental disorders, namely the elderly. Reliable and cross-culturally comparable information about patterns of care may guide the implementation of adequate management in this area in Portugal.