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Workshop War in Ukraine – a Big Challenge for the Mental Health Care
Abstract of presentation Mental health of internally and externally displaced persons in war period (Ukrainian experience)
“Institute of Neurology, Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine” State Institution
The presentation is devoted to mental health problems of internally and externally displaced persons during the war. Issues of etiology, pathogenesis and clinic-psychopathological manifestations of mental disorders in displaced persons are considered.
The main focus is on risk, anti-risk factors and stress coping strategies that prevent the development of mental disorders.
The presentation also provided a system of therapy and rehabilitation for internally and externally displaced persons, as well as an evaluation of their effectiveness.
Digital technologies help to improve the work of psychiatric services through the use of modern approaches.
The use of telepsychiatry (TP) during war allows people with psychiatric disorders to receive quality treatment that would otherwise be unavailable.
TP and other digital technologies are an important resource for providing psychiatric care to internally and externally displaced persons affected by war.
As our experience shows, the conditions for effective use of TP are availability of legislative, technical and staff base. The services are implemented according to the protocol, which defines the methods of treatment’s effectiveness evaluation.
The presentation will provide methodological approaches to the use of TP and other digital tools.
The pathogenesis of mental disorders occurring during the coronavirus pandemic 2 (SARS-COV-2) includes biological and psychosocial factors. Psychopathological consequences associated with the coronavirus disease COVID-19 may occur in different groups of individuals, including patients with a history of COVID-19 and patients with psychiatric disorders preceding COVID-19.
To investigate the peculiarities of the initial psychopathological manifestations in patients with newly diagnosed mental disorders who suffered from COVID-19 and were exposed to the stressors of the SARS-CoV-2 pandemic.
The study involved 97 patients with newly diagnosed mental disorders who suffered from COVID-19 and were exposed to the stressors of the SARS-CoV-2 pandemic (F 32.0-32.2 – 34 patients, F 40-45 – 32 patients, F 06.3-06.6 – 31 patient). The average age of the examined group was 44.82 ± 5.64 years. Clinico-psychopathological, psychodiagnostic, statistical methods were used.
In the structure of initial psychopathological manifestations detected in patients, the following prevailed: with depressive episodes - weakness and fatigue / asthenia ((87.50 ± 5.94) %), low mood / depression ((71.88 ± 8.07) %) and sleep disturbances ((65.63 ± 8.53) %); with neurotic, stress-related and somatoform disorders – weakness and fatigue / asthenia ((72.73 ± 7.87) %), decreased concentration of attention, memory / cognitive disorders ((66.67 ± 8.33 ) %) and feeling of inner tension ((60.61 ± 8.64) %); with mental disorders of organic genesis – a feeling of internal tension ((75.00 ± 7.78) %), anxiety ((62.50 ± 8.70) %) and weakness and fatigue / asthenia ((59.38 ± 8 .82) %).
In patients with depressive episodes, initial psychopathological manifestations in the form of asthenia, low mood, cognitive disorders, and sleep disorders were detected in a significantly greater number of cases compared to patients with mental disorders of organic genesis (р < 0,05). In the examined subjects of this subgroup, initial psychopathological manifestations in the form of a decrease in mood were recorded in a significantly greater number of cases compared to patients with neurotic, stress-related and somatoform disorders (р < 0,05). In patients with neurotic, stress-related and somatoform disorders, initial psychopathological manifestations in the form of anxiety, fears and obsessions were noted in a significantly smaller number of cases compared to those examined with mental disorders of organic genesis (р < 0,05).
The obtained data will make it possible to improve the effectiveness of diagnosis and therapy of mental disorders, the formation, course and clinical picture of which were affected by the coronavirus disease COVID-19.
At the current stage of psychiatry development, special attention is paid to studying the influence of hereditary factors on the occurrence of recurrent depression (RD). The study can be informative in predicting the risk of the RD occurrence RD. Therefore, studies related to this problem are designed to identify the specificity “familial” forms of RD.
To study the influence of hereditary factors on the RD formation.
Based on the clinical and genealogical data study, a statistically significant excess of the individuals with psychiatric disorders proportion in the main group (108 patients with RDD whose family history included relatives with depression, main group) was found: The percentage of individuals on psychiatric registry (18%, CI: 14.5-22.1) was 15 times higher than the control group (46 individuals without RDR in the pedigree) (p<0.05), individuals with depression (33%, CI: 28.5-37.8) were 7.3 times higher (p < 0.05), suicides (7.9%, CI: 5.6-11.0) were 4.2 times higher (p < 0.05), cases of alcohol dependence (25.6%, CI: 21.6-30.2) were 1.8 times higher (p < 0.05). In the main group family tree examinees, this pathology occurred most frequently in I and II degree of kinship relative. When comparing heredity factors with peculiarities of the RD course, we found a specific weight in correlations of such factors as: depressive disorders predominantly in first-degree relatives (p ≤ 0.005), suicidal behavior in first- and second-degree relatives (p ≤ 0.005).
The findings should be taken into account in diagnostic and preventive measures.
International experience convincingly shows the prevalence of mental disorders secondary to COVID-19, the pathogenesis of which includes biological and psychosocial factors, which characterizes this area of research as relevant and timely.
Analysis of the structure of the most common forms of psychopathology within consequences in COVID-19.
The study involved 45 patients with depressive episodes of varying severity (F 32.0, 32.1, 32.2) and 37 ones with anxiety disorders (F 40, 41). The average age of the examined groups was 39.42 ± 5.68 and 31.54 ± 4.36 years respectively. Clinico-psychopathological, psychodiagnostic, statistical methods were used.
Significantly more patients with depressive disorders before the first clinical manifestations of the disease experienced COVID-19 in mild and moderate form (31.82% and 68.18% of individuals, respectively) (p <0.05), while patients with anxiety disorders were more affected to some stressors of the SARS-COV-2 pandemic (including threatening information background (83.78% of people), quarantine measures in the form of self-isolation (75.66% of people), uncertainty of the impact of coronavirus infection on the socio-economic situation) (62.16% of people)) (p < 0.05). It was found that the examined patients with a history of coronavirus COVID-19 are more likely to have depressive and asthenic syndromes in the clinical picture (p < 0.05), while patients with psychogenic effects of the pandemic - anxiety-phobic and somato-autonomic syndromes (p < 0,05).
Data on the influence of coronavirus disease COVID-19 and stressors of the SARS-CoV-2 pandemic on the formation of mental disorders of various genesis will allow to develop prevention algorithms and personalize therapeutic programs.
There are about 1.5 million internally displaced persons (IDPs) in Ukraine, which requires an assessment of their mental health.
To develop a psychoeducational program aimed at informing about the clinical manifestations (markers of symptoms) of mental disorders, the possibilities of preventing their formation and options for action in conditions of the formation or exacerbation of a mental state.
270 IDPs were examined. Methods: clinical-psychopathological, psychometric, statistical.
Evaluation of the mental state of IDPs with symptoms of mental disorders (risk group (31.92%)) indicates the presence of various emotional disorders that formed individual syndromes – asthenic (41.18%), agrypnic (45.59%), somato-vegetative (30.88%), anxiety-depressive (20, 59%). The risk factors for the development of mental disorders in IDPs were identified - the older age is from 50 to 59 and the average age is from 40 to 49 years; lack of a complete family, lack of work, low level of social employment, lack of satisfactory living conditions, a significant decrease in the level of well-being, the preservation of the significance of factors of mental trauma, the presence of certain prenosological syndromes. The proposed psychoeducational program is built on the principle of thematic seminars with elements of social and psychological training.
The implementation of the program provides a comprehensive impact on the cognitive, emotional, psychophysiological, behavioral and social aspects of personality functioning.
Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.
The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.
We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.
We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.
The aim of this study was to develop a system for diagnosis and prevention of suicides in elderly patients with depressions. 87 elderly patients with depressions (F 41.2) were examined. The clinico-psychopathological, pathopsychological and statistical methods were used.
It was found out that elderly patients with depressions had suicidal attempts in 53.1%, suicidal thoughts in 19.4%, suicidal intentions in 27.6%. In the structure of suicidal attempts true suicidal attempts (44.9%) predominated over demonstrative ones (8.2%), and non-complete suicidal attempts (50.0%) prevailed over compete ones (3.1%).
It was defined that in elderly patients with depressions and a suicidal behavior a manifested (29.1±4.6 points on Hamilton Scale) anxiety (agitated) (53.1%) and senesto-hypochondriacal (25.5%) depression prevailed. A suicidal behavior in these patients manifested on the background of introversion (78.6%), explosive (62.2%), psychasthenic (55.1%) personality peculiarities; a low neuropsychic stability (77.6%); a predomination of autoaggression (62.2%) and suspiciousness (43.9%) in the behavior.
Predictors of a suicidal behavior in elderly patients with depressions were autoaggression (38.1±3.5 points), impulsiveness (35.2±5.6 points), a narrowing of cognitive functions (28.9±5.7 points), impairments of interpersonal contacts (22.2±4.6 points).
The analysis of a clinico-psychopathological structure, mechanisms, regularities of formation and development of a suicidal behavior, its motivation, suicidal and antisuicidal factors in elderly patients with depressions allowed us to work out and implement a system for prevention of a suicidal behavior, which based on principles of systematic, differentiation of approaches, timing, complexity, and division on stages.
The aim of this study was to investigate clinico-psychopathological peculiarities in patients with the first psychotic episode (FPE) to ameliorate their therapy. 124 patients with FPE were examined. In this examination the clinico-psychopathological, pathopsychological and statistical methods were used.
It was found out that an average age of the episode development was 26.3±5.2 years, an average duration of the episode was 389±47.9 days, and a preliminary usage of neuroleptics was determined in 79.2% of cases.
The most frequent symptoms in these patients were lack of insight, ideation of reference, suspiciousness, delusional mood, thought alienation, thought echo.
In patients with FPE negative manifestations such as flattening of affect, illogical features, apathy, unhedonia, unsociability, attention disorders were pointed out.
A typical syndromal structure of a manifested psychotic attack expressed with the hallucinatory-paranoid (53.9%), paranoid (24.8%), depressive-paranoid (18.8%), and maniacal-paranoid (2.4%) syndromes.
In patients with FPE it was registered a worsening of cognitive functions such as attention, a verbal and operative memory, executive functions, that was combined with local changes of the brain volume.
A treatment for patients with FPE involved pharmacological strategies, a psychosocial therapy and a psychosocial rehabilitation. Atypical antipsychotics are the first line medications in treatment of these patients. A choice of antipsychotic was discussed with a patient and his/her relatives. Basic methods of a psychosocial rehabilitation were mental health educative activities, family therapy, group social therapy, a training of social skills and cognitive functions, social occupational therapy.
A conception of a mental health is treated very ambiguous. Along with this an assessment of treatment efficacy for mentally ill persons includes a significant number of criteria which are changed continuously in time. Always there is a number of factors influencing on a development, course and outcome of disease. All of them might be considered as predictors of treatment efficacy and must be taken into account in a choice of criteria for therapeutic efficacy.
At the “Institute of Neurology, Psychiatry, and Narcology of the AMS of Ukraine” State Institution an investigation of 184 patients with neurotic disorders had been performed with analysis of predictors of therapeutic efficacy and on the base of data obtained criteria for assessment of treatment efficacy were improved. 81 male and 103 female patients from 18 to 60 years old were examined.
Clinical-psychopathological and pathopsychological predictors with a negative and positive influence on therapeutic efficacy were defined. The most significant of them were included into an integrative index of therapeutic efficacy for patients with neurotic disorders. It consists of such parameters as structure of psychopathological manifestations, level of psychotrauma generalization, level of compliance between the patient and his/her physician and surrounding, peculiarities of personality accentuations, level of a subjective self-control, patient's anxiety and rigidity, importance of a social and personal self-realization, type of attitude to the disease. These actual issues must be taken into account in a psychotherapeutic process. That will allow to increase its efficacy and to prevent recurrence of the disease.
Individual ethnogenetic and psychophysiological characteristics influence on peculiarities of risk, incidence, diagnosis, and course of a number of diseases.
An investigation of ethnogenetic characteristics (on phenotypic variants (PhV)) was performed in comparison with psychophysiological parameters (temper structure, personality anxiety, and parameters of strength, stability and mobility of the nervous system (NS)) of 123 patients with neurotic disorders and 105 persons without them.
Patients with neurasthenia represented more often Alpine PhV (30.56%); patients with anxious disorders represented more often Dinaric (18.64%), Armenoid (11.86%), and Paleo-European (11.86%) PhVs; patients with somatoform disorder more often represented Alpine (28.57%), Atlanto-Baltic (21.43%), and Uralic (10.71%) PhVs. Among patients with neurotic disorders presence of PhVs, which were non-typical for the general population (Atlanto-Baltic and Armenoid PhVs), was also determined. Patients of Alpine PhV demonstrated a high rigidity (91.66%), personality anxiety (80.00%), reaction pace (83.33%), a moderate NS stability (46.34%), and a low NS mobility (48.00%), which were a prerequisite for neurasthenia formation. Patients of Atlanto-Baltic, Uralic, and Alpine PhVs predominantly showed a high rigidity (94.11%), a moderate extraversion (52.94%) and reaction pace (64.70%), a low NS activeness (76.74%) and stability (47.05%), which were associated with somatoform disorders. Patients of Dinaric, Armenoid, and Uralic PhVs demonstrated a high personality anxiety (78.75%), emotional excitability (84.61%), extraversion (69.23%), passivity (76.47%) and inertness (42.85%) of nervous processes, and a moderate NS stability (54.17%), which were factors of anxious disorders formation.
These data should be taking into account in diagnosis and treatment of neurotic disorders.
A substantial obstacle to carry out a timely diagnosis and an effective therapy of depressive disorders (DD) is their combination with other forms of pathologies. Specific difficulties occur in diagnosis and treatment of DD with comorbid other mental disorders.
The aim of the study was to investigate typologies of DD with comorbid anxious disorders, alcohol dependence, and personality disorders.
A complex of methods included clinical-psychopathological and psychometric methods with application of the Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale. In the study 189 patients with DD (F32.0-F32.1) accompanied by anxious disorders (F41.0 and F41.1), personality disorders (F60.3 and F60.0), and alcohol dependence (F10.20) were examined. The control group consisted of 52 patients with DD without comorbid pathology.
It was demonstrated that patients with comorbid anxious disorders predominantly had senesthopathic-hypochondriac depression (42.9%, p<0.05) with an expressed somatization, somatic anxiety, and hypochondriac equivalents. For DD with comorbid personality disorders a clinical picture of depression was determined by a predominance of mournful (41.8%) and obsessive (32.7%) variants with anhedonia and obsessive-compulsive symptoms. Depression with comorbid alcohol dependence was characterized with a presence of asthenic-anergic (24.0%) and apathic-adynamical (21.3%) variants with expressed somatic-vegetative manifestations.
These results stipulate a necessity of using of differentiated approaches to pharmacotherapy and psychotherapy in patients with comorbid DD.
The problem of prevalence and medical-social consequences of depressions stipulates for necessity of improvement of diagnosis and efficacy of therapy for such patients. In this aspect an important role belongs to adherence to the therapy which provides both cure and preventive influence of pharmacotherapy.
The aim of the study was to investigate medication compliance in male patients with depression.
The clinical-psychopathological method, the investigation of the compliance level and type, statistical methods were used. In the study 117 male patients with depressive disorders (62 with F43.21 and 55 with F32.0, F32.1) were examined. The control group consisted of 98 female patients (51 with F43.21 and 47 with F32.0, F32.1).
It was demonstrated that male patients had a complete compliance in 25.6%, a partial compliance in 36.8%, and a poor compliance in 37.6% of cases. In male patients with depression a passive compliance type prevailed in 28.3% and a formal compliance type prevailed in 24.8% of cases. Wherein a formal compliance type predominated in male patients with depressive reaction F43.21 (32.2%) and a passive compliance type predominated in male patients with depressive episode F32.1 (41.48%). As compared with the control group, a statistically significant predominance of partial and poor compliances was detected in the group of male patients with depressions.
These data suggest that derelictions of adherence to the therapy occur more often in male patients with depressions than in female patients. It determines a necessity of measures to improve the compliance.
The problem of emigration and re-emigration in Ukraine is among the most actual state and social problems.
To research clinical-psychopathological peculiarities of depressions in “working” emigrants and re-emigrants.
The investigation was carried out in Ternopil Region. Psychogenic depressive disorders (F43.21 and F43.22 according to ICD-10) were diagnosed in 69 non-emigrants, 68 emigrants, and 67 re-emigrants; endogenous ones (F31.3, F31.4, F32.1, F32.2, F33.1, and F33.2 according to ICD-10) were diagnosed in 65, 66, and 63 persons correspondingly; and organic ones (F06.3 according to ICD-10) were diagnosed in 64, 62, and 61 persons correspondingly.
It was found out an influence of emigration and re-emigration factors on psychoemotional sphere of the patients. The influence of the emigration factor was the most manifested in patients with psychogenic depressive disorders and was a less manifested in patients with endogenous and organic depression. Re-emigrants had the most severe depressive symptoms that might be explained by an impact of psychosocial factors. In the syndromological structure of depressive disorders it was determined that re-emigrants were more affected by typical affective syndromes – vital and apathic depression, whereas emigrants were more affected by atypical affective syndromes, including anxious-depressive and agitation ones. It might be explained by an influence of objective social-psychological factors as well as an intrapsychic transformation of actual stressors connected with emigration and re-emigration.
Emigration should be considered as a factor promoting a pathologically characterological development towards anxious-depressive changes, whereas re-emigration should be considered as a factor of asthenic-depressive and apathic-depressive transformations.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
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