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While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.
We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.
SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.
The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.
The refugee experience is associated with several potentially traumatic events that increase the risk of developing mental health consequences, including worsening of subjective wellbeing and quality of life, and risk of developing mental disorders. Here we present actions that countries hosting forcibly displaced refugees may implement to decrease exposure to potentially traumatic stressors, enhance subjective wellbeing and prevent the onset of mental disorders. A first set of actions refers to the development of reception conditions aiming to decrease exposure to post-migration stressors, and a second set of actions refers to the implementation of evidence-based psychological interventions aimed at reducing stress, preventing the development of mental disorders and enhancing subjective wellbeing.
The relationship between schizophrenia and violence is complex. The aim of this multicentre case–control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence.
Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process.
The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant.
This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.
The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings.
For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review.
Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterogeneous study designs and outcomes meta-analytic methods could not be applied.
Due to substantial methodological limitations it is difficult to draw any firm conclusions about the most effective pharmacological strategies to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying more rigorous methods regarding case-definition, outcome measures, sample sizes, and study designs are urgently needed.
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.
Several authors have pointed out that in the next few decades dementia will affect a considerably increasing number of the elderly. To our knowledge there exist no calculations of the number of demented persons for the whole European region. We made calculations on the number of dementia cases for the period 2000–2050 based on the population projections of the United Nations. For this purpose, we used the results of several meta-analyses of epidemiological studies. The number of prevalent dementia cases in the year 2000 was 7.1 million. Within the next 50 years, this number will rise to about 16.2 million dementia sufferers. The number of new dementia cases per year will increase from about 1.9 million in the year 2000 to about 4.1 million in the year 2050. Contrarily, the working-age population will considerably decrease during the next 50 years. In the year 2000, 7.1 million dementia cases faced 493 million persons in working-age. This equals a ratio of 69.4 persons in working-age per one demented person. Until the year 2050, this ratio will decrease to only 21.1. Thus, the financial and emotional burden placed by dementia on the working-age population will markedly rise.
Austria covers an area of some 84 000 km2 and has a population of 8.1 million. According to World Bank criteria, Austria is a high-income country. The overall health budget represents 8% of gross domestic product (World Health Organization, 2005). The state of Austria is divided into nine federal provinces, which have significant legislative rights, including in healthcare provision.
Life expectancy at birth is 76.2 years for males and 82.3 years for females (in 2005). The proportion of the population under the age of 15 years is 15% and the proportion above 65 years is 17%. Austria is among the 19 countries worldwide which are projected to have at least 10% of their population aged 80 years or over by the year 2050. Since some mental disorders, such as dementia, increase with age, the number of psychiatric patients will probably rise dramatically.
Mental health policy and services
The number of psychiatric hospital beds has decreased substantially. In the year 2001 there were 4696 psychiatric beds in total (i.e. 59 per 100 000 population), down from nearly 12 000 beds in 1974 – a decrease of more than 60%.
The National Hospital Plan includes suggestions for the establishment of psychiatric units in general hospitals. Ten psychiatric units in general hospitals have been established, and several others are planned. Most traditional mental hospitals have been transformed to meet the needs of patients with acut mental illness. In addition, some of them have extended their services to people with physical diseases.
Each of the nine provinces has developed a mental health plan. Although there are regional differences between these, the key points of all plans are: a focus on community psychiatry, the decentralisation of psychiatric services and the social reintegration of persons suffering from mental disorders. The planning and provision of community psychiatric services are the responsibility of the provinces. Although some provinces now have a comprehensive network of community services, others are less advanced. The majority of these services (for vocational rehabilitation, supported housing, counselling, etc.) are provided by private organisations, but are predominantly funded by government agencies. The staff includes a variety of different professions (e.g. psychiatrists, social workers, nurses, psychotherapists, psychologists).
The EURO–D, a 12-item self-report questionnaire for depression, was developed with the aim of facilitating cross-cultural research into late-life depression in Europe.
To describe the national variation in depression symptoms and syndrome prevalence across ten European countries.
The EURO–D was administered to cross-sectional nationally representative samples of non-institutionalised persons aged ≥50 years (n = 22 777). The effects of age, gender, education and cognitive functioning on individual symptoms and EURO–D factor scores were estimated. Country-specific depression prevalence rates and mean factor scores were re-estimated, adjusted for these compositional effects.
The prevalence of all symptoms was higher in the Latin ethno-lingual group of countries, especially symptoms related to motivation. Women scored higher on affective suffering; older people and those with impaired verbal fluency scored higher on motivation.
The prevalence of individual EURO–D symptoms and of probable depression (cut-off score ≥4) varied consistently between countries. Standardising for effects of age, gender, education and cognitive function suggested that these compositional factors did not account for the observed variation.
Austria covers an area of some 84000 km2 and has a population of 8.1 million. According to World Bank criteria, Austria is a high-income country. The overall health budget represents 8% of gross domestic product (World Health Organization, 2005). The state of Austria is divided into nine federal provinces, which have significant legislative rights, including in healthcare provision.
Background: A variety of interventions are available to support the caregivers of dementia patients. For the purposes of service planning, we developed an instrument to assess the needs of these caregivers and to determine whether needs are met. The reliability and validity of this new instrument was also investigated.
Methods: The development of the Carers' Needs Assessment for Dementia (CNA-D), was based on in-depth interviews and a focus group. The combined inter-rater and test–retest reliability was investigated among 45 dementia caregivers. Correlations of the CNA-D with the Zarit Burden Inventory were used to analyze concurrent validity. Content validity was investigated by performing a separate survey among 40 caregivers and 40 professionals.
Results: The CNA-D is a semi-structured research interview including 18 problem areas. For each problem area, the CNA-D offers several possible interventions. The relevance of the problem areas and the interventions (content validity) was confirmed by most of the study participants. Significant positive associations were found between the total score of the Zarit Burden Inventory and the number of problems and the number of unmet needs according to the CNA-D. The agreement between the interviewers was “excellent” (κ above 0.75) in 73.7% of the problem areas and in 69.9% of the interventions.
Conclusions: The CNA-D is a valid and reliable instrument for comprehensively assessing the needs of dementia caregivers.
Este artículo presenta los datos obtenidos en una investigación censal de un día en cinco países europeos (Austria, Hungría, Rumania, Eslovaquia y Eslovenia). Se rellenaron impresos de censo para 4.191 pacientes psiquiátricos hospitalizados. Con respecto a la situación legal, el 11,2% estaba hospitalizado contra su voluntad (internado) y el 21,4% recibía tratamiento en una sala cerrada. Había sólo una pequeña correlacion entre el internamiento y el tratamiento en una sala cerrada. Más frecuente que el tratamiento de pacientes internados en salas cerrados era el de pacientes internados en salas abiertas (Austria, Hungría) y el de pacientes voluntarios en salas cerradas (Eslovaquia, Eslovenia). Con respecto al empleo, el 27,7% de los pacientes de 18-60 anos de edad tenía trabajo antes del ingreso. La gran mayoría de los pacientes (el 84,8%) tenía una duración de la estancia inferior a tres meses. Una comparación de estos datos con los resultados de un estudio realizado en 1996 que utilizó el mismo método muestra una disminución de las tasas de pacientes de larga estancia. En 1996, las tasas de empleo eran significativamente mas altas en Rumania (39,3%) y Eslovaquia (42,5%) comparado con Austria (30,7%). Estas diferencias desaparecieron en 1999 debido al descenso de las tasas de empleo en Rumania y Eslovaquia. La cantidad de personal de salud mental varía entre los tipos de institución (universitaria o no universitaria) y los países, siendo más alta en Austria y más baja en Rumania. Se encontró un aumento considerable en la cantidad de personal en Eslovaquia.
Background: Large randomized controlled trials have shown that risperidone reduces the frequency and severity of behavioral and psychological symptoms of dementia (BPSD) in patients with dementia. Since such trials are obliged to use very strict inclusion and exclusion criteria, their information about the efficacy is limited by the criteria used. Thus, the aim of the present study was to investigate the efficacy of risperidone on BPSD in a sample of patients routinely treated by their primary care physicians.
Methods: A total of 938 elderly patients in Austria suffering from BPSD and routinely treated by their primary care physicians were included in this open-label prospective study. Patients received a flexible dose of risperidone, starting with 0.5 mg daily, for at least 6 weeks. Questionnaires were filled in before the start and after 6 weeks of treatment.
Results: Before starting treatment with risperidone, BPSD were severe in 36.6% of the patients, moderate in 49.3%, and mild in 14.1%. The overall efficacy of risperidone was judged as “excellent” by the general practitioners and caregivers in about half the patients. The treatment was judged as “not satisfactory” in only a very small proportion (3.3% and 4.3%, respectively). According to the physicians' judgement, the tolerability of risperidone was “excellent” in 81.5% of the patients and “satisfactory” in 17.8%. The tolerability was “not satisfactory” in only 0.7% and only 7.4% of the patients reported any adverse event.
Discussion: Overall, the results of this survey indicate that risperidone is both efficacious and well tolerated for the treatment of elderly primary care patients with BPSD.
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