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The European Foundation for Quality Management (EFQM) Excellence Model is a non-prescriptive framework based on nine criteria. The aim of this work is to describe the implementation of the EFQM model as a quality framework for the improvement of an inpatient medium-stay psychiatric unit.
In 2005 a multidisciplinary performance improvement work group was convened to begin a project with these aims:
- The definition of the unit's mission.
- The identification of the unit's main processes.
- The identification of performance and quality results.
- The establishment of an audit period of clinical outcomes.
- The creation of a protocol for admissions.
Between 2005 and 2008 the group designed the following:
- A map showing the medium-stay unit process as well as the main processes.
- The key performance indicators.
- An ECT protocol.
- The Quality Indicators.
- A patient satisfaction survey.
Every year we decide the objectives of each indicator and revise them every month. Efficiency in the use of resources improved, due to an increase in annual admissions (from 190 in 2005 to 213 in 2009) as well as a decrease in length of hospital stays (from 62 days in 2005 to 48 days in 2009).
The management through processes according to the EFQM model is an instrument for the improvement of the quality of assistance. This type of management allows for the definition of the unit's mission, the measure and analysis of results and for the establishment of areas of improvement.
According to 2008 data, there are 80.000 patients undergoing replacement opiate programs (RMP) in Spain. However, the clinical therapeutic management and the psychiatric and medical comorbidities have not been well described.
To describe the current therapeutic management and psychiatric comorbilities of opiate-dependent patients undergoing a RMP in Spain.
We carried out an observational, cross-sectional, multicenter study from September 2008 to February 2009. Patients > 18 years, with written informed consent, with a opiate-dependence according to DSM-IV-TR criteria and currently scheduled in a RMP in Spain were included.
624 patients (38.89±7.95 y.o.,84% men) were included in the study from 74 centers.
Psychiatric comorbidities were clinically detected in 68% of all valuable patients, most frequently anxiety (53%), mood (48%) and sleep disorders (41%). Patients receiving buprenorphine-naloxone suffered less sleep disorders (19% vs. 43%; p=0.0327) The proportion of patients with at least one psychiatric comorbidity was directly related to methadone dose (p=0.0066).
The most frequent replacement therapy was methadone (94%), usually in ≤ 40 mg/day (38%) and 40-80 mg/day doses (40%); mean follow up period being 45.88±51.86 months. Significant differences were found between methadone doses and retention. Patients with HIV and HCV infection received higher doses of methadone (HIV+ patients (p=0.0024) and HCV+/ HIV+ patients (p=0.0250) due to ARV treatment; and showed less PMM retention.
Patients present high rates of dual diagnosis, and infectious and non-infectious comorbidities, expecting higher doses of methadone than found (54.04±47.26 mg/day) in the study to assure a proper retention in the maintenance programs.
Oxidative stress suposses an imbalance between oxidants and antioxidants molecules. Negative and positive family environment have been related with worse and better outcomes respectively in schizophrenic patients.
Our objetive is to determine antioxidant defense in healthy controls and unaffected relatives of early onset psychosis patients and to asses its relationship with familiar environment.
We included 82 healthy controls (HC) and 14 healthy controls with second degree family history of psychosis (HCWFHP), aged between 9 to 17.
Total antioxidant status and lipid peroxidation test were determined in plasma and antioxidant enzime activities and glutathione levels were determined in erytrocytes.
We used the Global Assesment Functioning scale (GAF) and the Family Environment Scale (FES). The FES is made up of ten subscales: cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural, social, moral, organization and control.
The analyses showed a significant decrease in total antioxidant level in HCWFHP compared with the HC (U Mann Withney = 281.00, p=0.009, effect size= -0.78).
HC and HCWFHP did not differ in the GAF scale, nevertheless the scores of HCWFHP were significantly higher in cohesion and intellectual-cultural dimensions of the FES (p=0.007, p=0.025).
Adjusting by this two FES dimensions, antioxidant status remained significantly different between groups: OR= 10.86, p=0.009.
Although we cannot induce causative relations, we can state that family environment is not playing a role in inducing oxidative stress in these subjects. It could be hypothesized that families with affected relatives protect themselves with positive envionmental factors such as cohesion and intellectual-cultural activities.
Stress and trauma have been reported as leading contributing factors in schizophrenia. And certainly child abuse (neglect, emotional, physical and sexual abuse among others) has a lasting negative impact, which is well established in literature.
To consider the presence of infant trauma and its relationship with psychopathology in paranoid schizophrenics.Methods. 37 patients (mean age 29±6.3; years from onset 9.20±4.7), meeting DSM IV paranoid schizophrenia criteria, undergoing treatment in a university hospital are studied. The PANSS is administered in order to rate psychopathology.
27 patients had infant trauma (55.8%). Main traumas are: sexual abuse (12.8%), child abuse (7.7%), both sexual and child abuse (5.18%), parental separation (7.7%), extra-rigid parents (2.6%), alcoholic parents (18.2%), child abuse and mother's death in childhood (2.6%). Infant trauma and psychopathology showed a significant relationship concerning Hostility (No 1.75±1.209, Yes 2.26±1.759), Unnatural Movements and Posture (No 1.55±0.945, Yes 1.16±0.545), Depression (No 1.25±0.550, Yes 1.74±1.284) and Preoccupation (No 2.75±1.410, Yes 3.26±1.996).
Infant trauma is common in paranoid schizophrenia and our findings give some evidence to a relationship with psychopathology, especially with dimensions as Hostility, Unnatural Movements and Posture, Depression and Preoccupation. Despite sample size, a high proportion (55.8%) of the patients presented infant trauma and future research is needed in order to open new avenues in this field, particularly studies concerning infant trauma and symptomatology specificity will be greatly appreciated as well as the plausible link to personality traits and personality disorders.
Cocaine consumption can induce transient psychotic symptoms, expressed as paranoia or hallucinations. Cocaine induced psychosis (CIP) is common but not developed in all cases.
To describe the Risk Factors for developing cocaine-induced psychosis in cocaine dependent patients, according DSM-IV-TR criteria.
This is the first European study about the relationship of CIP with consumption pattern variables and personality disorders, we evaluated 220 cocaine dependents over 18 years, 80'5% males, mean age 33.9 years (SD = 7.6). Patients were recluted from an outpatient clinic department and subsequently systematically evaluated using SCID I and SCID II interviews for comorbidity disorders, and a clinical-based systematic psychotic symptoms form.
A high proportion of cocaine dependent patients reported psychotic symptoms (51.8%) under influence of cocaine. The most frequent reported psychotic symptoms were paranoid beliefs and suspiciousness (42.4%). After a logistic regression analysis we found that a model consisted of high cocaine consumption (mean of 12.01 grams per week), cannabis dependence history and to use intranasal or smoked rout of administration had a sensitivity of 63.2% and a specificity of 70.2%.
We conclude that is relevant to evaluate CIP in patients consuming high amounts of cocaine, with cannabis dependence history and who do not use intranasal rout. It could be useful for preventing consequences or risks of psychotic states for themselves or others.
We assessed parents’ perceptions of and satisfaction with daily lisdexamfetamine dimesylate (LDX; Vyvanse®, US tradename, Shire US Inc.) treatment for their children with attention-deficit/hyperactivity disorder (ADHD) previously treated with osmotic-release oral system methylphenidate (OROS-MPH).
Parents of children with ADHD were surveyed via telephone or Internet about their child's experience before and approximately 6 weeks after initiating LDX treatment. Participants received a $25 coupon toward their child's next LDX prescription after survey completion. Post hoc analyses using the Wilcoxon signed rank test were performed.
School time was the most frequently reported most bothersome time of day at baseline (41%), followed by homework time (23%). At follow-up, most parents reported improvement during their child's most bothersome time of day. Significantly less interference from ADHD symptoms with school activities, family interactions, homework, and social interactions was reported (all P< .01). LDX tolerability and convenience were rated, on average, 7.1 and 8.0, respectively (1=not at all well tolerated/convenient, 9=very well tolerated/convenient). Satisfaction with LDX was significantly higher than satisfaction with OROS-MPH treatment (6.9 and 5.0, respectively, P< .01 [1=not at all satisfied, 9=very satisfied]). Eighty-four percent of parents reported that they intend for their child to continue taking LDX.
Parents of children with ADHD who were previously treated with OROS-MPH and currently taking LDX reported less interference of ADHD symptoms with daily activities after LDX treatment and high satisfaction with LDX. LDX was also well tolerated and convenient to use.
Enhance adherence to treatment is one of the main objectives in psychiatric clinical practice. The aim of this study is to evaluate changes in the use of oral antipsychotic medication, the use of rehabilitation resources and the number and duration of income in Psychiatric Inpatient Unit, comparing one year before and one year after RLAI's introduction, in patients with different psychiatric disorders, followed up by Mental Health Center and have maintained adherence to treatment for a defined period. We performed an observational, retrospective study by reviewing medical records of patients in ambulatory monitoring. The sample consisted of all patients (112) who had maintained RLAI treatment for a year, excluding those who did not fulfill the guideline correctly (14), remaining n = 98. We included patients of various pathologies, establishing groups as qualitative variables (F.20 = 56; F.25 = 12; F.22–28 = 20; F.60 = 10); of both sexes (V = 71; M = 27) and all ages. The preliminary results obtained showed a greater use of rehabilitation resources and decreased use of oral antipsychotics.
Comorbidity between drug misuse and mental disorders affects negatively in the prognosis of psychistric illness, so it´s important to guarantee drug abstinence at least during hospitalization. This is even more significant in a medium stay unit because patients are more serious and resistant to treatment.
In February 2003, a multidisciplinary group was formed to evaluate the situation of drug use in a psychiatric hospital and a drug screening protocol was then created.
We evaluate if with the protocol, drug use decreases during hospitalization in a medium stay unit in a psychiatric hospital.
Material and methods:
It is compared drug use (positive results in urine samples) from 2000 to 2002 (before protocol: urine samples collected when there´s drug misuse suspicion) with the period after the protocol was enforced (from 2003 to 2006). In the protocol urine samples are collected when there´s a past misuse history, consumption suspicion, randomly and every time they leave for home.
It is proved that drug use decreases during hospitalization since the new protocol came into force.
The introduction and exhaustive completion of a protocol designed to decrease drug misuse in a psychiatric hospitalization unit, provokes a high reduction of drug use, so we think it´s convenient to generalize this kind of measures.
Pisa syndrome is known to be a condition in which there is sustained involuntary flexion of the body and head to one side and slight rotation of the trunk so the person appears to lean like the Leaning Tower of Pisa.
The development of Pisa syndrome is most commonly associated with prolonged treatment with antipsychotics. Although less frequently, Pisa syndrome has been reported, in patients who are receiving other medications (such as cholinesterase inhibitors and antiemetics), in those not receiving medication (idiopathic Pisa syndrome) and also patients with neurodegenerative disorders like Alzheimer's disease and multiple system atrophy.
We report a case of a 67 year- old male diagnosed with Schizophrenia for 20 years. He has been following a treatment with Clozapine 400 mg/day for 4 years. Amisulpiride was added to the established regimen of antipsychotic and increased during the last month reaching the doses of 600 mg/day. Three weeks later he was observed walking with a tilt toward the right. A first physical examination revealed sustained tonic flexion of the trunk to the right side. No deficits or mental status changes during neurological exploration were shown. We prescribed biperidene hydrochloride therapy. After 24 hour side effects disappeared.
As far as we know, no many cases of amisulpride-induced Pisa syndrome in the literature have been reported. This abstract presents a case of amisulpride induced Pisa syndrome.
Frequency of drug misuse has increased in the society and also in psychiatric patients. It´s known that drugs have a negative influence in psychiatric pathology, so its identification is very important for a better prognosis.
We aim to demonstrate that drug misuse draws out the stay in hospital of psychiatric patients and increases the number of readmissions needed, basing the hypothesis on our laboratory information of drug screening in a psychiatric hospital.
Material and methods:
It is analyzed, retrospectively, all admission to a short stay unit in a psychiatric hospital in 2000 and 2005, and compared all patient with a positive result in a urine sample obtained by a drug screening protocol with the rest of admissions to that unit, measuring in both groups the number of readmissions, and the extension of hospitalization.
Our hypothesis is confirmed, being the number of readmissions more frequent and the extension of hospitalization longer when patients are drug-users.
Prevalence of drug misuse has met increased in the last decade and more frequently among mental patients. Drug misuse difficults psychiatric treatments and increases sanitary expenses, being important stablishing diagnostic and treatment measures to face this problem So it`s important to take under consideration that this behaviour affects negatively in the progress of hospitalization, as proved in our investigation.
Comorbidity between drug consumption and several psychiatric disorders is a topic of increasing interest. It´s known that between 30% and 80% of psychiatric inpatients use drugs, and these patients often show worse prognosis, for what their identification turns out to be one of the biggest challenges for the clinician.
Based on clinical practice in a psychiatric hospital, we investigate the possible existence of underdiagnosis for misuse of drugs in psychiatric inpatients.
Material and methods:
It is analyzed, retrospectively, all admission to a psychiatric hospital in 2000 and 2005, in which diagnosis to the discharge involves drug misuse (dependence, abuse, toxic psychosis). Likewise it´s analyzed laboratory information of drug screening in urine (obtained of every patient suspicion of consumption). Both results are then compared.
Our hypothesis is confirmed, being very scanty the number of diagnosis to the discharge associated with drug misuse, compared to the high prevalence of drug use demonstrated in the laboratory screening.
Although it´s known that drugs are often used by psychiatric patients, clinicians often elude to diagnose it (probably another diagnosis, such as schizophrenia, are so important for us that we don´t pay enough attention to drugs).
This investigation should remind clinicians that drug use is frequent, adds worse prognosis, and must be specifically treated.
Alcohol and cocaine are frequently used together. Little is known about which factors are related with the development of either cocaine or alcohol dependence in dually users.
To determine variables associated with the risk fro the development of either cocaine or alcohol dependence in non-dependent drinkers with recreational cocaine use during a 4 year-follow-up period.
A prospective cohort study was performed to establish the risk factors associated with alcohol and cocaine dependence. Subjects recruited (N=336), from primary care centres. At baseline were classified as heavy drinkers and cocaine users (HD+Co, N=227) and alcohol abusers with cocaine use (AA+Co, N= 109).
At 4-year follow-up assessment, AA+Co subjects had higher rates of prevalence for cocaine (55% vs. 32%, p<0.001)) and alcohol dependence (97.5% vs. 58.2%, p<0.001) than HD+Co participants. Being alcohol abuser and single were eight and three times, respectively, more likely to develop cocaine dependence. When impulse control disorders or alcohol abuse occurred the odds ratio of developing alcohol dependence was 9 and 5.7 respectively. Also, alcohol abuse at baseline was associated with shortened time between onset of abuse and dependence for cocaine use disorders and for alcohol use disorders.
Alcohol abuse in heavy drinkers with recreational cocaine use predicted alcohol and cocaine dependence at follow-up. Our findings agree with previous findings supporting the relationship between impulsivity and risk for substance use disorders.
Chronic consumption of cocaine can induce transient psychotic symptoms, expressed as paranoia or hallucinations. The term cocaine induced psychosis (CIP) has been used to describe this syndrome. Cocaine Induce Psichotic Disorder (CIPD) have been used to describe a full psychotic state. CIP and CIPD prevalences are not well described.
To evaluate risk factors for CIPD, in cocaine-dependents according to DSM-IV criteria.
We evaluated 150 patients (mean age 34 y.o, 81.8% men) of which 143 were included, using The PRISM (Psychiatric Research for Substance and Mental Disorders) interview. Exclusion criteria were: psychotic disorder or bipolar type I disorder, intoxication at interview, severe somatic disease at interview and language barrier. We compared three groups: group I: without any psychotic symptoms (33,33%); group II: with any psychotic symptoms (28,57%) and group III: with CIPD (38,77%).
Differences were found in Patients of Group III in the Age at onset of addiction p < .0001*, past history of imprisonment p < 0,01, Alcohol Use disorders p = .006, Cannabis use disorders P < .0001* and Hallucinogens use disorders p < 0,001.All remaining after Bonferroni corrections.
CIPD is common in this population (approximately 40%). Risk factor for suffering CIPD were described, in Cocaine-dependents. Finally, professionals who work with cocaine-dependents patients should incorporate these considerations into an integral approach.
Schizophrenia is a psychiatric disorder which involves chronic or recurrent psychosis and it is commonly associated with impairment in social and occupational functioning. Antipsychotic medications are a first-line treatment, however, most patients experience disabling impairment even after benefiting from antipsychotics, including positive and negative symptoms, cognitive deficits, poor social functioning and episodes of acute symptomatic relapse.
Systematic literature review in UpToDate and Pubmed.
To identify the most relevant intervention areas of systematic rehabilitation in schizophrenia.
45 years old schizophrenic male who admitted in a Medium Stay Psychiatry Unit with severe behavioural impairment and psychotic symptoms. At least 10 hospitalizations and pronounced disability in basic life skills despite optimal treatment. Poor insight and compliance, frequent relapses, co-morbid substance abuse and difficult family support. Clozapine was added to his treatment with improvement in psychotic symptoms. A multidisciplinary intervention was also done and he was discharged home with important improvement in social skills, better insight and familiar functioning
Despite following an adequate antipsychotic treatment, including Clozapine as the main medication in resistant schizophrenia, it is often partially effective with severe impairments in social and occupational functioning. Family-based interventions, cognitive behavioural therapy and social skills training, added to this medication seem to be essential in the systematic treatment of schizoprenia. It includes a multidisciplinary team and a specific length of time but it is based on the patient's status. Despite evidence of their efectiveness, the availability of these interventions varies widely, as does the availability of clinicians to provide them.
Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.
The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.
There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.
These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.
The oculomotor system is closely linked to the neural circuits of attention. Recent evidence shows a novel role for eye vergence in orienting visual attention.
Identify patterns of attention disruption through eye vergence.
We investigated whether modulation in attention related eye vergence is disrupted in ADHD.
We measured eye vergence in children previously diagnosed with ADHD while performing a cue/no-cue task and compared the results to agematched controls.
We observed a strong modulation in the angle of vergence in the control group but not in the ADHD group. In addition, in the control group the modulation in eye vergence was different between the cue and no-cue condition. This difference was absent in the ADHD group.
Our study supports the observation of deficient binocular vision in ADHD children. We argue that the observed disruption in eye vergence modulation in ADHD children is proof of a deficient cognitive processing of sensory information. Our work may provide new insights into attention disorders, like ADHD.
To quantify knowledge among the general Spanish population of attention deficit hyperactivity disorder (ADHD).
Material and method:
We developed a telephone-administered questionnaire to ask about ADHD (acronym and full name) on a spontaneous and suggested basis. Questions were asked relating to myths, symptoms, treatment, implications and healthcare professionals involved in the disease.The study sample was 770 adults (sample precision at national level 3.5) with no personal, familial or professional relationship to ADHD.
Only 4% of the subjects spontaneously answered the question about what ADHD means, while 85.3% identified the disease after we suggested what “ADHD” meant. Only 50% admitted that the disease represents a probably genetic brain disorder. A total of 39.6% believed that there was no treatment or healthcare intervention for ADHD. the intervention most often cited as being adequate was psychological treatment (48%), followed by multimodal therapy (44%). Only 12% mentioned medication. Thus, psychological intervention was regarded as the most effective option, followed by psychoeducational measures. Most of the subjects identified the psychologist as the professional indicated to treat ADHD, followed by the pediatrician, psychiatrist and neuropediatrician. Reasonable knowledge was observed in reference to affirmations / myths in ADHD (78.3–95.3%).
There are areas for improvement among the general population regarding knowledge of ADHD, its implications and treatment.
Little is known about medical students’ interest in their training on drug addiction, their personal experience of consumption and whether these aspects influence the detection of addiction in patients.
To study the interest of medical students enrolled on the psychiatry course in the area of addictions, and evaluate the influence of such interest, a history of personal consumption and gender on the detection of addiction in patients.
Voluntary participation was offered to all students from academic years 2008–2009 to 2012–2013. Of the 505 potential students, 336 questionnaires were collected, of which 71.13% were female.
Of the respondents, 88.5% considered that drug dependence issues are important to their professional future and 63% that the approach to drug-related diseases is important. A total of 34% of the students had already assessed addicted patients in their previous clinical training. The students report consuming alcohol(69%), cigarettes(19.5%) and illegal drugs(15.8%). The female students consumed fewer illegal drugs than the men(p0.022) and more frequently considered that the list of topics to be covered was appropriate(p0.021). The male students consumed more illegal drugs more frequently(p 0.005), knew more consumers(p 0.023), and those who drink alcohol consumed more illegal drugs than women(p < 0.005). However, the men seemed to have assessed fewer addicted patients in their previous clinical experience(p0.094).
Consumption among medical students may have a normalizing role on consumption and prevent the detection of addicts. It is important to educate and raise awareness on drugs, as this may influence detection. The focus should be particularly on the male group.
Neuroleptics constitute an heterogeneus group of drugs used to treat mental illness. As known, long-acting depot neuroleptics receive increasing consideration in the maintenance treatment of individuals diagnosed of schizophrenia with low insight or poor treatment adherence. Zuclopentixol depot is a typical antipsychotic agent. It operates through a mechanism of extended release. It is characterized by antagonizing Dopamine receptors, particulary D2. It also works on alfa1 adrenergic and serotonine 2A receptors. Its effect on histamine H1 receptors is weak, and presents no affinity with cholinergic receptors. The literature reports ocular disorders due to treatment with neuroleptics. Typical antipsychotic can induce degenerative retinopathy which histologically and clinically simillar to primary pigmentary retinitis. Nevertheless, after showing initial interest, clinicians and researches no longer paid enough attention to them. Most of the cases reported are related to Phenotiazine antipsychotic family. Phenotiazines bind to melanin granules and can cause a severe phototoxic retinpathy. We have not found retinal disorders caused by Zuclopentixol in the literature reviewed. Pathogenis involved in retinopathia induced by neuroleptics is still unknown. Neuroleptics operate through a mechanism based on the antagonism of dopaminergic receptors. This blockade may influence the genesis of retinopathy. Several hypothesis emphasized in how neuroleptics, by antagonizing dopaminergic receptors, can influence melanine absortion in the uveal track and choroid. This is the reason why there could be a relation between antidopaminergic mechanism and choroid through the vascular supply.