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Teamwork in psychiatry is a very specific property of care organization, especially in the Italian tradition and daily practice. The purpose of the study was to define and describe the main variables that might influence and determine it.
A 15-item ad hoc questionnaire was specially designed and administered to health professionals of Modena Department of Mental Health. This questionnaire contained socio-demographic data (age, sex, longevity of service), professional characteristics, personal level of satisfaction and identification, and opinions on “ideality” and “reality” of teamwork. Statistical analysis was conducted to explore significant correlations.
Satisfaction rate was 46.2%, identification rate 59.1%. Teamwork seems to function well as far as “information circulation” and “making practical decisions”, but lacks in “reciprocal understanding” and “reciprocal emotional support”. The level of correspondence between ideal and real teamwork is strongly correlated to satisfaction (p = 0), identification (p = 0), but not to age, sex or duration of service. The priority of teamwork was “discussion of clinical cases”.
This study attempts to suggest difficulties and limits of contemporary care organization in Italian psychiatry, but also offers several ideas for organizational, administrative, clinical, and human improvements. It represents a first step to analyze and identify the qualitative determinants of psychiatric teamwork.
The ‘MORES’ (MOdena RESidenze) project was a naturalistic study designed to assess clinical outcomes and to investigate psychosocial needs in two groups of patients currently admitted in two residential facilities characterized by different intensity of care (“low protection” vs. “high protection”).
32 patients (62%) in a Sheltered Housing (SH, low protection) and 20 patients (38%) in a Psychiatric Residence (PR, high protection) were assessed by means of a multi-dimensional and multiaxial system. Socio-demographic and clinical data were collected from patient charts. Clinicianadministered instruments (BPRS, GAF, CAN) and self-rating scales (LQL, VSSS, Empowerment Scale) were administered to all 52 patients. Chi-squared test and Mann-Whitney U-test were used to compare the two groups.
The most frequent diagnosis was Schizophrenia (n=41; 79%). No differences were found in socio-demographic and clinical characteristics between the two groups, as well as in psychometric scores. Scores at the BPRS, GAF, CAN and Empowerment scales revealed in both groups a medium-low degree of psychiatric symptomatology, low global functioning, high level of care needs (many of them satisfied, 73%) and a low level of empowerment, respectively. Self-perceived quality of life was poor (LQL: SH=4,57±0,31; PR=4,4±0,33), specifically related to the housing situation and VSSS (SH=3,81±0,85; PR=3,52±0,82) suggested poor satisfaction with mental health services.
Though no difference were found between the two groups, patients’ needs emerged clearly, suggesting need for further investigation to tailor more specific rehabilitation programs.
The Social Skill Training is structured as a cognitive-behavioral therapy for rehabilitation plans whereby the patient can develop and recover social skills.
To verify the effects of a literary workshop for increase assertiveness in patients with eating disorders.
Thirty-two patients consequently admitted to the Ward for Eating Disorders at the Private Clinic “Villa Maria Luigia” in the North of Italy were recruited in the study, and all of them agreed to take part in it. Of the 32 patients, 8 were randomly assigned to treatment and 24 to care as usual, being the difference between treatment and care as usual only represented by the literary workshop. The Rathus Assertiveness Schedule and Verbal Fluency Test (phonemic and semantic) was administered to all patients in the first and last week of hospitalization. The literary workshop consists in 16 weekly 45-minute group sessions. Issues of expressiveness through the use of writing are addressed during the sessions.
A significant improvement of semantic skills (t=-5.60; p< 0.01 vs. t=1.43; p=0.17), phonetic skills (t=-3.66; p< 0.01 vs. t=1.35; p=0.19) and assertiveness (t=4.47; p< 0.01 vs. t=0.94; p=0.93) was registered in the literary workshop group.
Effectiveness of the literary workshop in a rehabilitation program for patients suffering from eating disorders is suggested: improved communication and language skills might have a positive and significant impact on patients’ levels of assertiveness.
To evaluate psychiatric features in liver post transplant HIV recipients.
An observational study was conducted. Different psychiatric rating scales to evaluate cognitive status (MMSE), anxiety and depressive symptoms (HAM-A, HAM-D), social phobia (BSPS), quality of life (SF-36), sexual satisfaction (ISS), coping strategies (Brief Cope) and alcohol-drug abuse (LDQ) were submitted to a population of 11 HIV outpatients that underwent to OLT (19% of the Italian HIV transplant recipients). Scores were statistically related to socio-demographic and clinical data.
All patients were male, aged between 33 and 54 years. In the past 8 patients were drug abusers, three suffered from depression. At the moment of the evaluation 8 patients didn't suffer from any psychiatric disease while the three youngest patients presented a mild depressive status. BASIS-32 scores were related to HAM-D and to a history of drug abuse (p< 0.01). SF-36 was related to age (p< 0.05), HAM-D (p< 0.01), BSPS and BASIS 32 (p< 0.02).
Despite the higher risk for a HIV patient of developing an anxious or mood disorder, our population isn’t affected by psychiatric diseases; this is an encouraging data considering that post transplant period can be very stressful. This result may be due to a personality organization or a coping style strengthened by a long term disease such as HIV. Further studies are needed to investigate psychosocial outcome of OLT in HIV and to improve our knowledge of this controversial issue and guarantee a better take in care of these complex patients.
Common language is a mirror of culture and society. Death and mental illness are the human deepest and most ancient taboos, which both patients and professionals have to face in the medical world. Psychiatry has strong and circular connections with culture and society. The aim of this work was to collect and analyze expressions in colloquial language originally derived from psychiatric technical terminology.
A hundred and ten fifth-year medical students (M/F% = 42/58; mean age = 23.5 ± 3.1) attending their semester in psychiatry were asked to list as many expressions as possible of their everyday colloquial use which they thought referred to psychiatry. The terms were collected and analyzed critically.
A list of 150 espressions was drawn and then classified in the following categories: technical psychiatric terms; medical-neurological terms; psycoanalytic references; terms referring to abnormality and need for care; irrelevant terms. Though an overall good level of pertinence in the use of technical psychiatric terms was observed, these usually refer to common situations, both individual and happening to others. Often these locutions are used as jokes or offences.
Due to fears and prejudices evoked by psychiatric themes, an attempt on exorcising and taking distance leads to the use of psychiatric terms as potentially offensive and despising. This work suggests the need to work - especially in training settings - on filling the gap between common and medical languages and to analyze critically the contaminations as suggestive of very relevant cultural issues.
There is little or no information comparing working experience, including burnout, amongst psychiatry residents internationally. We present preliminary findings from six of the first countries to complete data collection.
Objectives and aims
To obtain data from psychiatric residents in over twenty countries regarding rates of burnout, depression and suicidality and their associations with working conditions and personality traits.
An online survey incorporating the Maslach Burnout Inventory General Survey (MBI-GS), Areas of Work Life Survey (AWLS), Patient Health Questionnaire-9 (PHQ-9), Suicide Ideation and Behaviour Questionnaire (SIBQ), Big Five Inventory - 10 (BFI-10) and questions on demographics and working circumstances was designed, and checked by national co-ordinators for suitability in each participating country, prior to agreeing the final version. This was then translated and back-translated before being sent to participants. A stratified hierarchy sample methodology was developed and used to obtain the best possible study population in each country. This allowed us to maximise participation despite major differences in ease of access to residents across the study countries. The aim of studying the whole resident population was achieved in a large number of countries. Data was then analysed by the study statistician using SPSS. No funding was received for the study.
Results and conclusions
Data from Croatia (n=106), France (n=374), Hungary (n=81), Italy (n=180), Romania (n=52) and United Kingdom (n>2000) revealed marked differences between countries in the factors studied including in working circumstances, rates of burnout and suicidality. The associations discovered may help further improve psychiatric training experience internationally.
INTERMED is an instrument to assess bio-psycho-social case complexity in general health care by focusing on past, present and future health needs/risks of patients. It consists of a structured interview defining 20 variables and related anchor points. The total score ranges from 0 to 60, reflecting the level of complexity and the related care needs/risks. The aim of this work was to assess preliminary the effectiveness of a training program on the clinical use of INTERMED.
After a group training on the use of INTERMED carried out between April and September 2009, the method was applied to 30 female patients aged between 20 and 65, subsequently referring to three clinical settings: a GP clinic; a psychiatry day-care clinic; a CLP out-patient clinic. Demographic and clinical data were collected, together with administration of HADS and WHOQoL-bref.
The mean INTERMED score was 20.8, borderline as to definition of complex cases. Patients from the GP clinic and in the CLP setting scored lower (respectively 16.5 and 18.2) than patients from the psychiatric day-clinic (27.8), suggesting that the presence of severe psychiatric disturbances might contribute to increasing the level of case-complexity. Concordance with results at HADS and WHOQoL was high.
A clinical practice in the use of INTERMED after the theoretical phase of the training process is necessary to reinforce effectiveness of the training. These preliminary positive results will hopefully open the way to a wider diffusion of this tool in clinical practice in the area of Modena.
To construct and test the validity of a new psychometric questionnaire to assess psychological impact of facial lipoatrophy (ABCD-F), that is the most stigmatizing feature of HIV-related lipodystrophy.
Construction: The development went through Focus groups and Content Validity, Item reduction and Exploratory Factor Analysis.
Validation: ABCD-F questionnaire was administered together with ABCD and MOS HIV questionnaires. The Cronbach's Alfa was used to test internal consistency, while convergent validity and divergent validity were analyzed by the correlations with MOS, ABCD items and BMI and CD4 counts respectively.
42 HIV+ people participated to focus groups. In the EFA the 17 Items were aggregated around psychological distress and role functioning domains.
ABCD-F showed high internal consistency (Chronbach's alpha = 0.95). Both convergent and divergent validity were confirmed. ABCD-F scores were highly correlated to Physical Health Summary (B 0.59; 95% [CI] 0.35; 0.84; p< 0.0001), Mental Health Summary (B-1.54; 95% [CI] 1.15; 1.93; p< 0.0001), and weakly correlated to CD4 count (B-0.02; 95% [CI] -0.01; 0.06; p=0.54) and HIV viral load (B-0.004; 95% [CI] -2.69; 2.69; p=1.00).
ABCD-F is a valid and reliable questionnaire to assess psychological impact of facial lipoatrophy (FLA).
ABCD-F may result as a useful tool both in clinical and research settings: it's able to identify people experiencing greater psychological impact due to FLA. It may become an objective instrument to evaluate priority and efficacy of plastic surgery to treat lipodystrophy. In research setting may be used to compare different populations or different treatments of FLA.
To test the presence of significant correlations between psychopathological symptoms in patients with dementia and the stress perceived by the primary caregiver.
Primary caregivers of patients with a DSM-IV diagnosis of dementia admitted to the neuro-psycho-geriatric-rehabilitation ward of the private hospital “Villa Maria Luigia”, Parma - Italy, between May and November 2008 were asked to take part in the study. The NPI scale (UCLA Neuropsychiatric Inventory - Commings J.L. et al., 1994) and a socio-demographic data collection schedule were administered to the primary caregiver willing to be involved in the study.
Only 30 of the 40 eligible subjects agreed to take part to the study (75%). 35 significant correlations (according to Spearman's Correlation Index) were found. Those most highly significant (p< 0.001) were between stress perception and the following NPI symptom categories: delirium, hallucination, agitation, euphoria, apathy, disinhibition, aberrant physical activity and sleep disorders.
The psychopathological symptoms found to contribute mostly to distress of caregivers were those most showy and disruptive of behaviour; other symptoms, such as anxiety, depression, irritability and eating disorders are better tolerated as considered normal consequences of ageism. Interventions addressed to caregivers should provide them with detailed and structured coping instruments. Clear, therefore, the need for all health professionals, to structure an intervention aimed at caregivers characterized by two different phases:
1. To provide more tools to recognize those disorders which don’t emotionally involve them;
2. To give detailed, structured information useful to cope with these disorders in everyday life.
Eighteen percent of Italian population and 37% of admissions to general hospital are represented by over-65 subjects. Psychiatric comorbility of hospitalized elderly patients is an epidemiologically and clinically significant phenomenon for Consultation-Liaison (CL) psychiatrists. The aim of the work is to describe the experience of a CL Psychiatry Service with patients aged 65 and more.
A search through the clinical database of the Modena CL Psychiatry Service was conducted, to collect data on psychiatric consultations for over-65 patients. Demographics, data on the reason for referral and on outcome of consultations were collected and analyzed critically, with special focus on clinically relevant situations.
Over-65 patients account for 43% of all consultations (males 44%, mean age 75±13). Sixty-seven percent of referrals come from Internal Medicine wards and the most common reasons for referral are depression (42%), agitation (10%) and confusion (8%), with the distribution of frequency of reasons for referral differing significantly from that of under-65 patients (p=.003). A medical-psychiatric comorbidity was assessed in 77% of cases, with adjustment reactions and mixed anxiety-depression as most common psychiatric diagnoses (67%). Prescription of psychothropic drugs was the outcome of the psychiatric assessment in 78% of cases.
CL Psychiatry activities for elderly patients in the general hospital are frequent and clinically challenging. Unmet needs for elderly inpatients might be the underestimated question concerning coping strategies and adjustment reactions toward the presence of a medical illness.
The AMDP -system (Arbeitsgemenschaft fur Methodic und Dokumentation in der Psychiatrie) consist of a psychopathology scale (100+15 items) and of a somatic scale (40+7 items), It is widely used in the German-speaking and French-speaking countries.
To describe the development and italian validation of the (AMDP), designed to assess psychopathology in psychiatric patients.
Diagnosis of 125 patients were assessed according to DSM-IV using SCID (Structured Clinical Interview for the DSM-IV) and AMDP.
To assess sensitivity to change, 24 patients were involved in a 4-week rehabilitation program and then reassessed at the end of 4 weeks.
To evaluate inter-rater reliability, all patients were assessed by two clinicians in a joint rater session.
All AMDP-subscales showed significant improvement after 4-week rehabilitation program (P< 0.05).
Inter-rater eliability was substantial (intraclass correlation coefficient, ICC > 0.70) in all subscales of AMDP.
The AMDP is a valid, reliable instrument to evaluate severity and treatment response in psychiatry. Given its simplicity, and clinical validity, AMDP is appropriate for use in observational studies and routine clinical practice.
INTERMED is an instrument to assess bio-psycho-social case complexity in general health care by focusing on past, present and future health needs and risks of patients. It consists in a structured interview defining 20 variables and related anchor points. The total score ranges from 0 to 60, reflecting the level of complexity and the related care needs/risks. The aim of this work was to describe the training process on the use of INTERMED and to assess its effectiveness.
A training group of 9 subjects had two-hour meetings twice a month between April and September 2009. After introductory sessions on theoretical aspects and inter-trainee simulations on interviewing and scoring techniques, students were assigned the task of producing video-recorded clinical material, which was used to comment on interviewing skills and practice on scoring. Individual and consensus scores were collected at the beginning and at the end of the training and compared statistically by means of Cohen's kappa.
Motivation and involvement of students in the training was high (participation was on a voluntary basis during extra-work hours), as satisfaction. Agreement between individual and consensus scores was high already at the beginning of the training (Cohen's kappa mean value of 0.80) and slightly improved during the course.
The training process gave positive results both on the quantitative and the qualitative sides of evaluation. A six-month 25-hour training period is a reasonable time for learning how to master the instrument, although it needs to be followed by the clinical practice.
Hearing-impaired adults with hearing aids or cochlear implants have been proved to suffer from social isolation and that the under-use of these devices is possibly related to its impact on one's body image. The aim of the research was to evaluate the presence of social phobia and body image preoccupation, handicap perception, social functioning and psychopathological distress in patients with hearing aids or cochlear implant.
A clinical group of 70 hearing aid and/or cochlear implant wearers was compared with a control group of 75 healthy adults (age: 18-65) referred to the ENT Clinic of Modena University from 01/01/09 to 01/ 09/09. Both groups were administered the following psychometric instruments: Social Functioning Questionnaire, Brief Symptom Inventory, Liebowitz Social Phobia Scale, Body Uneasiness Test. Hearing-impaired subjects were also assessed by means of the following tests: International Outcome Inventory for Hearing Aids, Attitude towards Hearing Loss Questionnaire, Hearing Handicap Inventory for Adults.
the case group statistically differed from the control group as to lower level of social functioning (p< .05), higher level of somatization (p< .01), obsessive compulsive behaviour (p< .01), interpersonal sensitivity (p< .01), depression (p< .01), anxiety (p< .05), phobic anxiety (p< .01), paranoid ideation (p< .01), psychoticism (p< .01), social phobia (p< .001) and body image preoccupation (p< .05).
Social phobia and body image preoccupation are critical aspects in determining the psychosocial well-being and the compliance, the benefit and the personal satisfaction of hearing-impaired subjects in using the hearing aid and/or cochlear implant.
The process of migration has been described as a “trauma”, with psychic consequences conceptualized as post-traumatic stress disorder. As many clinical and extra-clinical variables are involved, there is a need for a better understanding.
A case report is described and discussed, under the joint perspective of three different approaches to human suffering, namely that of a neuro-rehabilitation physician, a psychiatrist and a social worker.
M. B. is a 36 year-old male, single and high school-educated, who migrated from Morocco to Italy in 2003. In 2006, he fell accidentally from a scaffolding at work, causing himself a traumatic brain injury with transient loss of consciousness, occipital fracture and bilateral frontal haematomas. He was taken in charge by Social Services. Over the following months, he developed multi-sensorial pseudohallucinations and hallucinosis, changes in character and behaviour, demoralisation, insomnia. M.B. was referred to psychiatry and to a neuro-rehabilitative outpatient service, where he was found to be suffering from severe dysexecutive syndrome, attention deficits and verbal working and long-term memory impairments. Integration of neuro-rehabilitative, psychiatric and social interventions was established to deal with M.B.’s complex needs.
In the experience of M.B., the biological head trauma pairs with the social trauma of migration and the psychological trauma of forced interruption in the migration parabola. The interrelated meanings of trauma - breaking up of a psycho-somatic balance with consequences on cognition, emotions, behaviour and social functioning - require a narrative and collaborative approach to care, addressing complex bio-psycho-social needs.
There are concerns regarding a general underutilisation of mental health services (MHS) by migrants, with a high use of emergency services. This is probably related to factors such as cultural differences and language barriers. Aim of this study is to analyze and to compare the characteristics of migrant population attended to MHS in Modena.
We studied migrant population attended to 3 Mental Health Centres (MHC), to Psychiatric Hospital (PH), to Psychiatric Consultation Service (PCS) and to Accident&Emergency (AE) during the month of September 2009, in Modena.
Socio-demographic and clinical data were collected by means of a structured culturally-oriented form.
63 patients referred to all MHS (74.6% MHC; 11.1% PH; 14.3% PCS). 46% of all diagnosis were Psychotic Disorders. PH sample presented opposite characteristics to MHC ones: 71.43% were young men (< 30 years-old) without a work, 85.71% were alone, 28.57% hadn’t the residence permit (p=0.01) and 42.86% reported psycho-social migration trauma. 57.14% had language difficulties with use of a cultural interpreter (p=0.01). Half of the sample was recently migrated (< 5 years).
Migrants had a higher rate of compulsory admission in PH than Italians (0.28 vs. 0.22) and a higher rate of AE admission (0.034 vs. 0.028).
We confirmed the frequent emergency services utilisation of migrants. People referred to MHC seem to be adjusted, well integrated and more “accultured” according the new country issues, while people admitted in the PH seem to be more weak, with socio-economic difficulties and shortly integrated.
The project “Social Point” deals in promoting integration of Mental Health Service recipients within contexts of social relationship, voluntary work and community activism. The project is still taking place in the district of Modena.
Assessment of the effectiveness of the project SP: production of a change in quality of life; development of purposeful relationships out of families and health services; development of Mental Health Service recipients’ awareness of being not only a user of the health service but also a resourceful person; change of method and approach within relationship between Mental Health and community and public services.
At the beginning and at the end of the integration courses (autumn/winter 2010 and after 6–8 months), both individuals and collectives, every Mental Health Service recipient was asked to fill in a form with socio-demographic characteristics and the WHOQOL-bref. A social network diagram was subsequently drawn.
At the end of the research (September 2010) joining courses directed to the development of social relationship is forecast to improve the quality of life of the recipients, to increment purposeful relationships and to strengthen empowerment of persons with mental disease by promoting a different project of life no more illness-based but resource-based.
The study will provide evidences about the performance of the project with regard to the promotion of the social integration of citizens with mental disease in contexts, to the empowerment and to the promotion of processes of social.
Drop-out from treatment for Eating Disorders is increasing (Campbell; 2007), and it is a risk factor for relapse and more chronic and severe course of the illness (Fassino et al.; 2009). Drop-out can be caused by interaction of concurrent, individual, familiar ad environmental factors (Sly; 2009).
Aim of the study
To examine possible risk factors of drop-out from inpatient treatment for eating disorders.
Materials and methods
The sample included 41 patients who voluntarily left the treatment before completion (’droppers’) and 88 patients who completed it (’completers’), in the period between 1st January 2006 and 31st December 2009 at Villa Maria Luigia Hospital (Monticelli Terme, PR, Italy). Patients were administered 2 self-report questionnaires and 3 psychometric tests: Eating Disorders Questionnaire, Predisposing, bringing on and maintaining risk factors for eating disorders, EDI-II, BUT, SCL-90.
Droppers appear to be more aggressive (p = 0.022), get worse scholastic results (p = 0.016) and have less friendships and less social interaction (p = 0.021). Parental break-up (p = 0.015), moving house (p = 0.006), father's death (p = 0.005), abortition (p = 0.040), father's alcohol abuse (p = 0.011) and a mother who suffers of eating disorder (p = 0.008) are more frequent in droppers than completers. Catholic religion seems to be a protective factor from drop-out (p = 0.005).
Drop-out is a multifactor phenomenon; identification of risk factors can improve treatment strategies and outcome.
Italian Reform Law 180/1978 established the closing down of mental hospitals and brought back psychiatry into medicine, the general hospital and primary care; this was the starting point of many relevant events in the history of psychiatry in Italy, one of which was the establishment of Consultation-Liaison Psychiatry (CLP). Since then, development of Italian CLP has been continuous, though heterogeneous over the national territory.
The Modena CL Service is based within a general hospital in the town area and is one of the services of the local hospital psychiatric department, also including a psychiatric ward, a day-hospital and an outpatient clinic. The CL Service provides about 1200 first consultations a year (3% of patients admitted to the hospital). It also provides an out-patient clinic for the follow-up after discharge of patients suffering from medically unexplained symptoms. Through the experience developed in Modena, one of the peculiar features of CLP in Italy is the strong background of integration between general psychiatry, CLP and psychosomatic medicine, which are neither formally nor theoretically separated in Italy. Integration is supported structurally by the existence of the Department of Mental Health, that organises psychiatric care at all levels in a certain geographical area: CLP care is coordinated to the other fields of psychiatry and to other medical Departments through this organisation. Weak points of CLP care in Italy are its very heterogeneous distribution; poor funding availability; need to improve standards of clinical practice, clinical management, training and research quality levels.
The use of standardized tools for assessment and monitoring of a rehabilitation program is strongly recommended, though not so often accomplished in clinical practice.
To describe the development and feasibility of a computerised method of assessment of rehabilitation activities based on psychometrics.
The software “SVAROSKI” was implemented by means of a relational ER (Entity-Relationship) model with a user interface managed by MS-Access. The rehabilitation activities were: Physical therapy; Locomotion, Occupational Therapy and Reality-Orientation Therapy. Patients were administered at the beginning and at the end of admission the following tests: MMSE, MODA, Barthel Index, Tinetti.
The software enables processing of test data with those obtained from rating scales at each session.
For each patient, two graphical reports are made available:
Punctual performance of each item divided by subject areas;
Overall pace of the three scales assessing rehabilitation (physical therapy was maintained for an evaluation board, partly qualitative, for the sake of the physiotherapist of the structure).
The software allows:
1) the rapid storage of the scores obtained from patients during the course of rehabilitation activities,
2) the real-time consultation of the development of therapeutic and rehabilitation,
3) the comparison of the iteration of several rehabilitation interventions on the patient.
SVAROSKY is a useful tool for analysis and monitoring of developments in the rehabilitation of the patient as a valid tool for the development of a synthesis report of the rehabilitation process.