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The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services.
This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures.
As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.
Recent evidence has questioned modern psychiatric clinical practice, specifically the prescribing of “atypical” antipsychotics. Our Pan-European Research Group wished to ascertain clinical practice amongst European trainees, which treatments trainees would desire for themselves, and factors influencing this.
A semi-structured survey was constructed from prior literature, piloted, and a homogenous sample size of at least 50 was agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, with questions on preference of antipsychotic for patients in given scenarios, and factors influencing choice. Physicians were asked for their preference should they develop psychosis.
i) Treatment choice of antipsychotic for patients
93% (n=600) of respondents chose to prescribe “atypical” antipsychotics (excluding Clozapine), 6% (n=42) choosing “typical” antipsychotics, 1% (n=6) choosing Clozapine as first-line therapy.
ii) Treatment choice if trainees developed psychosis
89% (n=530) of responders chose to prescribe “atypical” antipsychotics (excluding Clozapine), 7% (n=40) choosing “typical” antipsychotics, 4% (n=23) choosing Clozapine as first-line therapy.
iii) Factors influencing choice
These mapped onto three domains: cost, efficacy and side-effect profile (less than 5% other reasons). 79% (n=458) of those who responded felt efficacy most important, 46% (n=270) felt side-effect profile most important and 3% (n=16) considered cost of paramount importance.
38% (n=272) of those who responded to the survey stated that the CATIE trial had influenced their decision-making.
Psychiatry trainees’ choice of antipsychotic medication for both patients and themselves is based on perceived benefits, as opposed to evidence base and recent literature.
Guidelines produced for management of Bipolar Disorder illustrate change in evidence-base for treatment of acute and maintenance phases of illness. Our Pan-European Research Group assessed clinical practice and desired treatments amongst amongst Psychiatry trainees.
A semi-structured survey was piloted, and homogenous sample size (at least 50) agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, questioning preference of mood stabiliser for patients, trainees themselves and factors influencing choice.
Tables 1 summarise choices.
Lithium and Sodium Valproate
2nd Generation Atypical antipsychotics
[Choice of mood stabiliser for patient/themselves]
Factors influencing decision-making mapped onto cost, efficacy and side-effect profile (less than 4% other reasons). 66% (n=538) of respondents felt efficacy most important, 25% (n=202) felt side-effect profile most important and 3% (n=24) considered cost of most importance.
No clear difference exists in choice of mood stabiliser for European trainees and their patients, and decisions based on perceived efficacy are generally in keeping with established guidelines.
Many studies describing print media representations of mental illnesses have showed that these depictions are frequently negative and contribute to consequent stigmatization of people with mental illness. The main objective of this international study was to identify predictors of stigmatizing and nonstigmatizing articles on mental illness in Czech Republic, Croatia and Slovakia.
The study sample comprised all articles pertaining to the topic of mental illness (N=450) chosen from 6 most widely read newspapers and magazines identified during five weeklong periods in 2007. The presence of stigmatization and destigmatization statements was coded and articles were grouped in positive, neutral, mixed and negative clusters. Negative/positive ratio (NPR) was used to assess the predictor value of different features of the article regarding stigmatization.
61.8% of articles contained some stigmatizing statements towards persons with mental illness. The highest NPR was found in articles published in tabloids (6.8), on the front page (3.7) and in the articles where psychotic disorder was mentioned (7.4) and mentally ill person figured as a source of information (1.8). Lowest NPR was found in magazines (0.6), articles in later sections (1.7) that mentioned eating disorders (0.3) and scientific surveys (0.1).
There is a high level of stigmatizing statements in the studied articles. As the strongest predictors of stigmatizing content we have identified articles that are published in tabloids and articles with reference to psychosis. Contrary to this, eating disorders had the least stigmatizing depiction as well as articles containing scientific data.
There is growing concern about the influence of the pharmaceutical industry on psychiatric teaching and psychiatric professionalism as a whole. As a consequence, several national and international medical and psychiatric associations have issued guidelines to regulate the interactions between physicians and industry.
The EFPT-PRIRS study aims to provide the lacking data on the extent and nature of these interactions among psychiatric trainees across Europe.
Study objectives were determined by the EFPT research group (EFPT-RG), after discussion with national and international experts. A survey was then devised compiling previously published questionnaires extending them by questions with specific relevance to psychiatric trainees. The resulting questionnaire was piloted amongst members of the EFPT-RG, modified accordingly and subsequently distributed to the national study coordinators. All 24 EFPT member countries were invited to participate in the study and data collection is currently ongoing.
Preliminary analysis reveals the vast differences in industry - trainee relationships across European countries as well as major differences in personal attitudes towards these interactions.
EFPT-PRIRS will potentially have an impact on the regulation of the interactions between the pharmaceutical industry and psychiatric trainees.
Despite recent recent evidence and subsequent guidelines that have suggested factors such as side-effect profile and cost should be taken into account when prescribing antidepressant medication, relatively little evidence exists on decision-making in clinical practice.
Our Pan-European Research Group looked at clinical practice regarding antidepressants amongst Psychiatry trainees, treatments trainees would desire themselves, and factors influencing decision-making.
A semi-structured survey was constructed from recent literature, was piloted, and a homogenous sample size of at least 50 agreed upon from each country, with 50% the minimum response rate. It was distributed via web-link, questioning preference of antidepressant for patients, and factors influencing choice. Trainees were asked for their preference should they develop a moderate to severe depressive episode, and require medication.
Treatment choices are summarised in Table 1. 79% of trainees would prescribe similar antidepressants for themselves as for patients.
Factors influencing decision-making mapped onto three main domains: cost, efficacy and side-effect profile (5% other reasons). 86% (n = 548) of those who responded felt efficacy most important, 38% (n = 237) felt side-effect profile most important and 6% (n = 33) considered cost of most importance.
Some differences exist in choice of antidepressant for European trainees and their patients, and factors affecting choice conflict with evidence base and guideline suggestions.
This paper presents data obtained in a one-day census investigation in five European countries (Austria, Hungary, Romania, Slovakia, Slovenia). The census forms were filled in for 4191 psychiatric inpatients. Concerning legal status, 11.2% were hospitalised against their will (committed) and 21.4% were treated in a ward with locked doors. There was only a small correlation between commitment and treatment in a locked ward. More frequent than treatment of committed patients in locked wards was treatment of committed patients in open wards (Austria, Hungary) and treatment of voluntary patients in closed wards (Slovakia, Slovenia). Concerning employment, 27.7% of patients aged 18–60 held a job before admission. The vast majority of patients (84.8%) had a length of stay of less than 3 months. A comparison of these data with the results of a study performed in 1996 and using the same method shows a decrease of rates of long-stay patients. In 1996 the rates of employment were significantly higher in Romania (39.3%) and Slovakia (42.5%) compared to Austria (30.7%). These differences disappeared in 1999 due to decreasing rates of employment in Romania and Slovakia. The numbers of mental health personnel varies between types of institution (university or non-university) and countries, being highest in Austria and lowest in Romania. A considerable increase in the numbers of staff was found in Slovakia.
There are significant differences in psychiatric training across Europe. In the light of the current direction of Europe (without borders with free movement of workforce) it is inevitable to harmonize at least basic standards of psychiatric education across Europe. Ideally by working in partnership with relevant national and international bodies (European Union of Medical Specialists, Board of Psychiatry - UEMS, European Psychiatric Association - EPA and European Federation of Psychiatric Trainees - EFPT). A qualitative data analysis on the most important challenges of psychiatric trainees across Europe, carried out by the EFPT in 2009, revealed several interesting findings which might be of interest not only for trainees, but for all involved in the process of psychiatric education. As the most important issue trainees reported the imperfect structure of the training programs and problems with implementation of new ones. That is why new training programs based on a competency based framework are being developed lately in number of countries (e.g. United Kingdom, Ireland, Netherlands). However, not only the structure of the training and its implementation remains an issue, trainees are concerned also with topics related to working conditions, insufficient training opportunities, lack of supervision, funding and availability of psychotherapy courses, etc. Based on these findings EFPT will undertake specific actions which in cooperation with other organizations shall lead in the future to better postgraduate training opportunities in Europe.
Even if technology and information are omnipresent, they rarely meet harmoniously. Either the lack of sufficient means prevents good information to reach its target or the technology is too complex to integrate flawlessly in the daily workflow.
The use and misuse of information technologies (internet, email, e-learning, social networks) has recently significantly increased among psychiatrists and patients and the changes in behavior of communication and seeking informations are real challenges.
Using the European Federation of Psychiatric Trainees network, the self-questionnaires concerning the usage of information technologies and the local patients-therapists communication were distributed among psychiatric trainees of 31 European countries.
A review of the results of this study, as well as recommendations about netiquette and useful websites for psychiatrists and scientists will be presented in detail.
Patients suffering from psychotic disorders are the most common to be admitted to psychiatry departments and treated against their will. All patients in this study were included in the international project EUNOMIA, which is focused on the contemporary use of coercive measures in psychiatry. The purpose of this study was to compare the voluntary and involuntary admitted patients, measured as improvement of psychopathology and social functioning.
120 involuntary and 18 voluntary patients, who met the criteria for an F2 disorder and subjective felt coercion at the admission measured by the McArthur Scale were included. They were assesed three times, in the first week and at the end of first and third month after admission with Brief Psychiatric Rating Scale - BPRS and Global Assessment of Functioning - GAF Scale. Outcome was defined as a change in the total BPRS and GAF scores between first and third observation.
There was no significant difference in the total BPRS (voluntary T1 48.6±13.3, T3 35.5±10.2, and involuntary T1 50.5±12.8, T3 32.2±8.6) or GAF (voluntary T1 38.1±14.7, T3 63.6±10.3 and involuntary T1 29.8±12.8, T3 63.6±17.1) changes, (p<0,05). In the lenght of stay both groups significantly differ, voluntary 30.8±15.9 resp. involuntary 51.5±51.6 days.
Inpatients with schizophrenia who were treated involuntary, improved at the same level as the voluntary ones, however the lenght of hospital stay was shorter by voluntary patients.
Available evidence suggests that, compared with women, men have earlier age of onset of schizophrenia, poorer course and medication response, fewer affective symptoms and worse premorbid social and intellectual functioning. However there is a lack of data concerning gender differences in patients treated against their will.
54 male and 65 female patients, who met the criteria for an F2 disorder according to the ICD-10 at the admission were included. They were assessed three times, in the first week and at the end of first and third month after admission. A broad range of structured assessment instruments has been used to assess psychopathology, social functioning, subjective quality of life, perceived coercion concerning admission, satisfaction with the treatment, socio-demographic characteristics, etc.
The results indicates that there is no significant difference when comparing changes in total scores in psychopathology, satisfaction with therapy and quality of life. But there is a gender discrepancy when comparing certain single items from the scales, e.g. men were more severely impaired in ratings of grandiosity and unusual thought content, while women manifesting slightly better social functioning. Also in some socio-demographic features, in the use of coercive measures and in the reasons why are they applied gender plays a role.
In the majority of observed aspects concerning involuntary treatment, we have not found radical differences when it comes to gender. However, there are distinct disparities mainly in social functioning sphere, particular quality of life components and the motives for using coercive measures.
Depression and dementia are the most frequent mental disorders at senior age. It is assumed that long-term depressions grow into dementia and the relationship between both syndromes has been discussed. The purpose of our study was to establish whether there exists mutual relationship between dementia and depression and whether depression resistant to therapy is a risk factor for dementia development.
25 patients who suffered prolonged phases of depression resistant to therapy were included and monitored for two years. Their average age was 75.4 years (range 65 to 88). The diagnosis of the group was as follows: 11 patients suffered from periodical depressive disorder, 7 patients from depressive phase, 1 patient from bipolar affective disorder and 6 patients from organic depressive disorder. The patients met the diagnostic criteria of severe depression according to ICD-10, the depression grade was assessed by the Geriatric Depression Scale by Yessavage. The diagnosis of dementia was based on clinical examination, CT of the brain, cognitive functions were assessed using the MMSE test.
11 patients of the 25 observed persons with chronified depression symptoms passed into dementia in the course of 2 years. They were 4 patients suffering from periodical depressive disorder, 4 patients with depressive phase and 3 patients with organic depressive disorder.
Our study implies that the development of dementia in depressive patients is significantly more frequent than in non-depressive persons of comparable age. Chronic depression resistant to therapy represents a risk factor for the development of dementia.
In an effort to acquire detailed overview regarding postgraduate training in psychiatry together with gaining opinions on the present and ideal postgraduate programm, our Young Psychiatrists Section in Czech Republic decided to undertake a survey.
The questionnaire was addressed to all current PhD students in the field of psychiatry and to those who finished the studies previously, maximum 10 years ago. We distributed the questionnaires via mail and e-mail to all 7 psychiatric clinics and put it also on our website. 32 participants from 5 institutions responded. The questionnaire encompasses questions related to the metodology of the project, tutor engagement, working schedule, financial situation and other funding oportunities. Second part contained requests on various aspects of ideal training programm.
The majority of the participants is satisfied with tutor involvement (92%) and the metodology of the project (85%) but less with the financial support of the project (69%) and time devoted to work on it (69%). The ideal organization of the PhD programm should be in blocks (81%), for a certain period of time for PhD project and the rest for clinical work.
The survey revealed some weak spots of our contemporary PhD studies programm in Czech Republic, e.g. lack of time for working on PhD project and poor funds for covering it. Beside various models for organizing postgraduate studies, PhD students are in sum mainly satisfied with it. Suggestions on ideal organisation of the programm are meant to serve as potential models for consideration.
To assess the social disability of people with different psychiatric disorders.
Cross-site survey in five psychiatric hospitals (Dresden, Wrocław, London, Michalovce and Prague). Working-aged patients diagnosed (ICD-10) with schizophrenia and related disorders (F2), affective disorders (F3), anxiety disorders (F4), eating disorders (F5) and personality disorders (F6), were assessed at admission (n = 969) and 3 months after discharge (n = 753) using the Brief Psychiatric Rating Scale and the Groningen Social Disability Schedule. The main outcome measure was Interviewer-rated social disability.
During acute episodes patients with personality, eating and schizophrenic disorders functioned less effectively than those with affective or anxiety disorders. After controlling for age and severity of psychopathology, there was no significant effect of the diagnosis (during remission), sex, education and history of disorder on disability. Site, employment and partnership were significant factors for the level of social disability in both measure points.
Severity of psychopathological symptoms, not the diagnosis of a mental disorder, was the most significant factor in determining the level of social functioning, particularly during the remission period. Site, employment and partnership appeared as significant factors influencing the level of social disability.
This study aimed to establish whether psychiatric patients’ subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period.
We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge.
After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge.
SIR can predict outcomes of complex interventions over a one-year period. Patients’ initial views of acute hospital and day treatment should be elicited and considered as important.
Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients’ rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.
Training schemes in psychiatry are developed and evaluated by national education policy makers in the majority of European countries. However, the requirements that a training program in psychiatry should meet are also defined on the European level in a form of recommendations by the Board of Psychiatry - European Union of Medical Specialists (UEMS).
Recently, the European Federation of Psychiatric Trainees (EFPT) which represent trainees from more then 30 European countries, reported data pertaining to the structure of training programs and to the evaluation of training programs in 30 European countries. Whereas in the majority of European countries the structure of training programs and methods of assessment of trainees' competencies are partially compatible with one another and with the existing recommendations at the European level, the quality assurance of training programs varies significantly among countries. Regular evaluations of training programs and mentors, however, contribute to the proper implementation of training programs and help that the theoretical training principles are followed through in practice. As quality assurance of training schemes is an important mechanism how to improve the delivery of training programs, it should gain more focus by responsible authorities who structure the psychiatric training on the national and international European level.