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Social disability is a key outcome measure for severe mental illness, being a pivotal variable, that modulates the effectiveness of treatments and might be modified by the treatments themselves.
The aims of the studies presented were: 1) to determine changes overtime in symptoms and social disability in a 1 year treated prevalence cohort of subjects affected by psychosis vs. those affected by non psychotic disorder receiving community-based mental health care, and to explore 2) predictors of clinical and social outcome; 3) the effect of clinical course on disability and quality of life.
Three hundred fifty four patients treated in the South-Verona CMHS were followed-up over 6 years (with assessments made at baseline, at 2 and 6 years) by using a set of standardised measures exploring psychopathology (BPRS), social disability (WHO-DAS) and quality of life (LQoLP). GLLAMM models were used to explore longitudinal predictors of clinical and social outcome. The effect of clinical course on disability was explored by consulting retrospectively the clinical records.
In psychotic patients relationships with partners were more frequently severely impaired, followed by dysfunction in the occupational and parental role. Longitudinal analyses displayed a clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are not fatally prone to a destiny of chronicity. Models explained 69% of the total variance for social disability. Predictors for disability were clearly differentiated from those for clinical status, but the two domains appeared entwined: the main clinical predictor of social disability was the negative component of psychotic symptoms (the higher negative symptoms, the lower social functioning) and higher disability predicted in turn a worsening of negative symptoms. Continuous course was associated with higher disability and lower quality of life.
Psychopathology and disability are distinct outcome domains only partially overlapping, which do not directly co-vary overtime and are influenced, at least in part, by separate predictors susceptible to specific interventions. However, they are entwined in a vicious cycle leading overtime to a progressive reciprocal worsening with deleterious effect on patients' daily living and independence. Modern mental health services should be capable of shaping treatments to address these patients' multifaceted problems.
In Italy, considerable variations exist in the organisation of out- and in-patient mental health care. One main issue is whether to prioritise specialisation (distinct clinicians for inpatient and outpatient care) or personal continuity of care (same primary clinician for a given patient within the two settings).
To study the use of psychiatric in-patient units in the Veneto region (Italy) and to evaluate differences between personal continuity of care and specialization systems.
Study conducted in the context of the COFI, multisite naturalistic EU-funded research aiming to compare the two care approaches in 5 European countries. In Italy, baseline data collection was carried out in 14 in-patient units. Data on hospitalisation, diagnosis, severity of the illness (Clinical Global Impression Scale- CGI) and patients’ appraisal of inpatient care (Client Assessment of Treatment Scale- CAT) were collected.
Overall, 1118 patients were assessed. Most frequent diagnostic categories were mood (41.6%) and psychotic (38.3%) disorders, while anxiety disorders were less represented (11.9%). The majority of patients were at least at their second admission (69.4%) and had been voluntary admitted (91.5%). Length of stay and CGI scores were significantly higher for patients with mood and psychotic disorders. No difference in CGI score between the two systems was found. Patients in the continuity of care systems reported higher level of satisfaction with initial treatment and longer hospital stay (P < .001).
These preliminary findings suggest higher service satisfaction for personal continuity system, possibly reflecting a more individualised and comprehensive focus on the patient's needs, rather than on symptoms reduction only.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
International treatment guidelines recommend that key elements to reduce the burden of psychosis are the early identification of people and the adoption of specific evidence based interventions.
To investigate the pathway to care and patterns of interventions provided by community based-mental health services (CMHS) to a cohort of first-episode psychosis (FEP) patients over 5-years period, exploring in which degree guidelines are met in routine clinical practice.
Study conducted in the context of the Psychosis Incident Cohort Outcome Study (PICOS), a multisite naturalistic research conducted in the Veneto Region (Italy) on FEP patients in a 4.6 million inhabitants catchment area. A comprehensive set of standardized measures was used, including ad hoc schedules to collect information on referrals to psychiatric services and on pharmacological and psycho-social treatments according to a multiwave follow-up design (1-, 2- and 5 years).
Three hundred and ninety-seven FEP patients were assessed at BL, 286 at 1 year, 233 at 2 years and 205 at 5 years. 47.4% of patients were helped to seek care by a relative and more than one half entered the treatment route through an emergency access. Regarding the interventions received, 96% of patients had been prescribed neuroleptics and atypical were the most prescribed class (66.9%). Only half received a psychosocial intervention during the first year and this percentage progressively decreased at each FU.
Findings highlight discrepancies between interventions provided by CMHS and the best treatment options recommended by guidelines, suggesting the need to implement specific initiatives aiming to close the gap between research and clinical practice.
Despite international guidelines, cognitive behavioural therapy for early psychosis (CBTep) is still under-used in daily clinical practice, mainly due to the lack of specific skills among mental health professionals. The aim of the study was to evaluate the feasibility and efficacy of a CBTep training course and to investigate the impact of trainees’ variables on the level of skills acquisition. An intensive and graded CBTep training programme consisting of 112 hours of plenary lectures, 30 hours of group supervision and 3 months of practical training was offered to mental health professionals of 65 Italian community Mental Health Centers (CMHCs). CBT expert psychologists were used as the comparison group. Participants underwent pre-planned exams to test the level of skills acquisition and were requested to complete a satisfaction survey. The vast majority of participants (93%) completed the training with medium–high evaluation scores and reported to be highly satisfied with the course. CMHCs staff members achieved high scores in the examinations and no major differences between them and CBT expert psychologists were found in most of the final exam scores. Our results support the feasibility and the efficacy of the training to build specific CBTep capacity in a large cohort of professionals working in Italian Generalist Mental Health Services.
Key learning aims
(1) To understand the capacity building of a short training programme in CBT for early psychosis dedicated to community mental health professionals.
(2) To consider the optimal characteristics of a CBT training programme for early psychosis.
(3) To reflect on the feasibility of a CBT training programme for early psychosis in the context of Italian Community Mental Health Services.
Childhood trauma has been significantly associated with first-episode psychosis, affective dysfunction and substance use.
To test whether people with first-episode psychosis who had experienced childhood trauma, when compared with those who had not, showed a higher rate of affective psychosis and an increased lifetime rate of substance use.
The sample comprised 345 participants with first-episode psychosis (58% male, mean age 29.8 years, s.d.=9.7).
Severe sexual abuse was significantly associated with a diagnosis of affective psychosis (χ2=4.9, P=0.04) and with higher rates of lifetime use of cannabis (68% v. 41%; P = 0.02) and heroin (20% v. 5%; P=0.02). Severe physical abuse was associated with increased lifetime use of heroin (15% v. 5%; P = 0.03) and cocaine (32% v. 17%; P = 0.05).
Patients with first-episode psychosis exposed to childhood trauma appear to constitute a distinctive subgroup in terms of diagnosis and lifetime substance use.
Heterogeneity of schizophrenia is known to be reflected in neuropsychological functioning of patients, but its expression in relatives is understudied. This study aims at exploring relationship between executive functioning and clinical profiles of first-degree relatives of patients who are classified as having or not having the deficit subtype of schizophrenia (DSRELs v. non-DSRELs), with the prediction of greater executive impairment in DSRELs.
DSRELs (n = 15) and non-DSRELs (n = 40) were compared with community controls (CCs, n = 55) on executive functioning measured by the Wisconsin Card Sorting Test (WCST) and the phonemic verbal fluency (PVF), and clinical measures. Effects of psychopathology and intelligence quotient (IQ) measures were investigated to determine their association with executive performance.
DSRELs showed more executive dysfunction on WCST and poorer social functioning than CCs and more severe negative symptoms than non-DSRELs. Differences on WCST-categories achieved (WCST-CA) remained significant after adjustment for clinical confounders and IQ. WCST-CA was associated with apathy and paranoid ideation only within the DSREL subgroup.
Executive functioning and negative symptoms are severely impaired in first-degree relatives of deficit syndrome patients, thus suggesting that some neurocognitive deficits in patients may be transmitted within families according to the pathophysiology of the probands.
This paper aims at providing an overview of the background, design and initial findings of Psychosis Incident Cohort Outcome Study (PICOS).
PICOS is a large multi-site population-based study on first-episode psychosis (FEP) patients attending public mental health services in the Veneto region (Italy) over a 3-year period. PICOS has a naturalistic longitudinal design and it includes three different modules addressing, respectively, clinical and social variables, genetics and brain imaging. Its primary aims are to characterize FEP patients in terms of clinical, psychological and social presentation, and to investigate the relative weight of clinical, environmental and biological factors (i.e. genetics and brain structure/functioning) in predicting the outcome of FEP.
An in-depth description of the research methodology is given first. Details on recruitment phase and baseline and follow-up evaluations are then provided. Initial findings relating to patients' baseline assessments are also presented. Future planned analyses are outlined.
Both strengths and limitations of PICOS are discussed in the light of issues not addressed in the current literature on FEP. This study aims at making a substantial contribution to research on FEP patients. It is hoped that the research strategies adopted in PICOS will enhance the convergence of methodologies in ongoing and future studies on FEP.
This paper examined the hypothesis that males with first-episode psychosis (FEP) experience lower pre-morbid adjustment, greater social disability and more self-perceived needs at illness onset than females (by controlling for duration of untreated psychosis, diagnosis, age and symptoms at onset). Results disconfirming this hypothesis were thought to suggest the potentially mediating role of social context in determining the impact of symptoms and disability on the everyday lives of male patients in the early phase of psychosis.
A large epidemiologically representative cohort of FEP patients (n=517) was assessed within the Psychosis Incident Cohort Outcome Study (PICOS) framework – a multi-site research project examining incident cases of psychosis in Italy's Veneto region.
Despite poorer pre-morbid functioning and higher social disability at illness onset, males reported fewer unmet needs in the functioning domain than females did. An analysis of help provided by informal caregivers showed that males received more help from their families than females did. This finding led us to disconfirm the second part of the hypothesis and suggest that the impact of poorer social performance and unmet needs on everyday life observed in male patients might be hampered by higher tolerance and more support within the family context.
These findings shed new light on rarely investigated sociocultural and contextual factors that may account for the observed discrepancy between social disability and needs for care in FEP patients. They also point to a need for further research on gender differences, with the ultimate aim of delivering gender-sensitive effective mental health care.
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