EPA guidance on mental health and economic crises in Europe.

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

A randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia.

BACKGROUND: Patient's relatives usually care for patients with schizophrenia, and as informal caregivers they experience negative consequences. The aim of the EDUCA-III trial is to test the efficacy of a psychoeducational intervention program (PIP) versus standard care to reduce the caregiver burden at post-intervention (4 months), and at follow-up (8 months). METHOD: A two-arm, evaluator blind, multicentre, randomized controlled trial. The PIP group had 12 weekly group sessions. The control intervention group had the usual support and standard care. Primary outcomes were change scores since baseline on the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ). RESULTS: One hundred and nine caregivers were randomized to PIP and 114 to control condition from 23 research sites. The decrease of ZBI scores was significantly higher on the PIP arm at 4 months (mean difference [MD]=-4.33; 95% CI -7.96, -0.71), and at 8 months (MD=-4.46; 95% CI -7.79, -1.13). There were no significant decreases in the IEQ scores (MD at 4 months=-2.80; 95% CI -6.27, 0.67; MD at 8 months=-2.85; 95% CI -6.51, 0.81). CONCLUSIONS: The PIP condition seems to reduce caregiver burden. TRIAL REGISTRATION: ISRCTN32545295.

Anxiety as a marker of severity in acute mania.

OBJECTIVE: Anxiety has scarcely been studied in acute mania. The aim of this study was to assess anxiety symptoms during manic episodes and their impact on clinical outcomes. METHOD: Observational, cross-sectional multicentre study. Anxiety was measured using the Hamilton Anxiety Rating Scale (HARS). Bivariate and multiple linear regression analyses were performed using the HARS score as the dependent variable. RESULTS: Two hundred and forty-two patients admitted with a diagnosis of acute manic episode according to DSM-IV TR criteria and a Young Mania Rating Scale>20 were analysed. Mean age was 43 years (SD=11.9) and 57% were women. Forty-six per cent of patients (n=104) presented moderate to severe anxiety symptoms (HARS score>14). Anxiety was significantly associated with severity of manic symptoms (P<0.0001). Patients with anxiety had 20% longer hospitalizations (mean 21 days, CI95% 19.7-23.7). CONCLUSION: An association of anxiety symptoms with greater severity in acute mania was demonstrated. The close relationship between anxiety and manic symptoms highlights the need for greater clinical attention to anxiety in this population. Further studies are necessary to determine whether effective treatment of anxiety symptoms could improve clinical and care outcomes.

Consensus of the SEPG on depression in the elderly.

BACKGROUND: The limitation of clinical-epidemiological know-how and evidence regarding therapeutic efficiency in depression among the elderly and extremely elderly patients has given rise to an excessive variety of practices in clinical care of these patients in the Spanish health system. The Spanish Society of Psychogeriatrics (SEPG) has raised the question of the need to unify criteria through a structured approach based on professional consensus. OBJECTIVES: To develop an expert consensus of clinical recommendations to improve the clinical treatment of depression in elderly patients in Spain, sponsored by the Spanish Society of Psychogeriatrics (SEPG). METHODS: Modified Delphi Consensus, in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee, project promoter and responsible for bibliographic review and formulation of recommendations for discussion 2) constitution of a multicenter Panel of Experts with representatives from this specialist field 3) postal survey comprised of two rounds, with interim processing of opinions and a report for the experts and 4) discussion of results during an on-site meeting of the Scientific Committee. RESULTS: The survey evaluation was completed by 61 experts consulted, in two rounds. In the first round, consensus was reached in 39 of the 54 questions analyzed. Following interaction by the panel, this consensus was increased to a total of 46 survey items (85% of the proposed contents). It was impossible to obtain a sufficiently unanimous consensus on the remaining 8 questions, either due to differences of opinion among the professionals or a lack of established criterion in most of the experts. CONCLUSIONS: A full list of criteria and clinical recommendations for the purpose of rationalizing the treatment of depression in elderly patients and reducing excessive variability in clinical practice is presented. The recommendations are qualified in accordance with the degree of consensus of the professionals endorsing them and can be considered valid until new scientific information becomes available that justifies their review.

EDUCA study: Psychometric properties of the Spanish version of the Zarit Caregiver Burden Scale.

OBJECTIVES: The Zarit Caregiver Burden Scale, translated and validated into Spanish, is sensitive to the application of a Psychoeducational Intervention Program (PIP) for the prevention and reduction of burden in caregivers of Alzheimer's disease (AD) patients (EDUCA study). The data obtained in EDUCA was used to reanalyse its psychometric properties and the cut-off points of the Zarit scale. METHODS: The scale was administered to 115 caregivers of patients with AD who were randomised to receive a PIP or standard care for four months. Internal reliability and a factorial analysis of principal components were assessed, and the impact of PIP on each of the subscales was evaluated. A cut-off point was defined for the Zarit scale to identify the caregivers most sensitive to receiving a PIP. RESULTS: A good internal reliability (Cronbach alpha coefficient of 0.92) was obtained, with three principal components (burden, competency and dependence) explaining 54.75% of the variance. The application of PIP showed statistically significant differences versus standard care for the dependence subscale (p = 0.0082) (p = 0.062 for the burden scale). The Zarit scale cut-off points which combine better sensitivity and specificity were 56/57 and 59/60, for the 5/6 and 6/7 cut-off points of the General Health Questionnaire (GHQ-28) scale, respectively. CONCLUSIONS: This study confirms the good psychometric properties of the Zarit scale found in previous studies. The dependence component appeared to be most influenced by the application of a PIP in the clinical trial. Caregivers with a Zarit scale score of 60 or more benefit most from the PIP.

[Effectiveness of typical and atypical neuroleptics in the control of behavioral and psychopathological symptoms of dementia. Results of a retrospective study]. / Effectividad de los neurolépticos típicos y atípicos en el control de los síntomas conductuales y psicopatológicos de la demencia. Resultados de un estudio retrospectivo.

INTRODUCTION: Presence of disruptive behavioural and psychological symptoms in dementia (BPSD) is highly prevalent and, as a consequence, neuroleptics are frequently used in these patients to control BPSD. Several reviews have shown the clinical equivalence of different classes of neuroleptics in BPSD control, although that equivalence has been only indirectly assessed by comparing the combined results of different types of active drugs versus placebo. Thus, little is known on the comparative effectiveness, head to head, of different neuroleptics on BPSD. The aim of this study was to gather preliminary information on the effectiveness of typical (haloperidol, thioridazine) and atypical (olanzapine, risperidone) neuroleptics on BPSD. METHODS: Multicenter, observational and retrospective study using chart reviews of patients with dementia to assess neuroleptic prescriptions and clinical outcomes at 12 weeks on treatment. RESULTS: No significant differences on BPSD improvement were found by type of neuroleptic (n=78; Kruskal- Wallis exact test; p=0.47). There also were no differences by neuroleptics when the analysis was stratified by levels of cognitive decline (Kruskal-Wallis exact test; p=0.86 and 0.87 for moderate and severe levels of deterioration, respectively). Recorded side effects were worse in the haloperidol group (n=19) regarding rigidity (Fisher's exact; p=0.01), tremor (Fisher's exact p=0.03) and akathisia (Fisher's exact; p=0.03). CONCLUSIONS: Our findings support the equivalence in effectiveness of several classes of neuroleptics commonly used to treat BPSD. Nevertheless these results need to be confirmed by adequately powered randomized trials and further pharmacoepidemiological studies to assess their safety.

[Utility of quetiapine in tardive dyskinesia]. / Utilidad de la quetiapina en la discinesia tardía.

INTRODUCTION: Neuroleptic induced tardive dyskinesia is a late appearing extrapyramidal disorder of involuntary, choreoatetoid movements. It may appear during chronic treatment with classical neuroleptics or a short time after its prolonged administration is interrupted. At present, there is no agreement on what would be the best way to treat dyskinesias. Clozapine is an alternative treatment to take into account, although the risk of agranulocytosis may be excessive to use it when there is a mild or moderate form of dyskinesia. Cases of improvement of dyskinesias both with olanzapine as well as with risperidone, although in a lower number, have been reported. Due to its receptor profile, quetiapine is the atypical antipsychotic that is most similar to clozapine, which leads us to consider it for the treatment of dyskinesias. METHODS: The first patient is a 66 year old woman with schizoaffective disorder of 16 years of evolution who has received many classical neuroleptics and who presents a picture or orolingual dyskinesias with a score of 28 on the AIMS scale. Treatment was substituted with Quetiapine until reaching a dose of 400 mg/day over 4 months, obtaining a decrease in the AIMS score up to 9. The second patient is a 60 year old woman diagnosed of bipolar disorder under treatment since 26 years of age with delusional jealousy ideation. Different atypical antipsychotics were used, all of them causing dyskinetic symptoms in the orolingual region, that disappeared with low doses of quetiapine, with good stabilization of her psychopathology. The third patient is a 33 old male diagnosed of paranoid schizophrenia when he was 18 years old. He was under maintenance treatment with haloperidol, biperiden and lorazepam, until 27 years of age, when the treatment was changed to risperidone, after presenting an orofacial tardive dyskinesia with masticatory type movements and lingual protrusion, with a 19 score on the AIMS scale. The change to quetiapine 600 mg/day reduced the score on the AIMS scale to 3. DISCUSSION: Our experience, based on 3 cases, shows an early and lasting improvement of the tardive dyskinesia with quetiapine. This experience is reinforced by other investigators with similar cases. In all, we have 12 cases that support the efficacy of quetiapine in the treatment of tardive dyskinesias.

[Alzheimer's caregiver burden and psychological distress. A neglected association in the assessment of dementias]. / Sobrecarga del cuidador de pacientes con enfermedad de Alzheimer y distrés psíquico. Una asociación relegada en la valoración de las demencias.

INTRODUCTION: Caregivers of dementia patients have a high risk of developing mental disorders. Nevertheless, their burden is not routinely assessed during the clinical assessment of the Alzheimer's type dementia patients. This study was designed to evaluate the association between caregiver's burden and psychological distress and to estimate the prevalence of mental disorders among the caregivers. METHODS: Cross-sectional study of Alzheimer patients' caregivers (n = 40). The caregiver burden was assessed by the Zarit scale whereas the GHQ-28 was used to evaluate psychological distress. RESULTS: The Zarit caregiver burden scale was able to discriminate the psychic distress levels (area under the curve: 0.87; 95% CI: 0.77 0.98). Its sensitivity (93%; 95% CI: 68.0 99.8) and specificity (80%; 95% CI: 59.3 93.2) were good for a cut-off point of 62/63. The estimated prevalence of psychiatric disorders in the caregivers was 20.7% (95% CI: 0.0 60.0%). CONCLUSION: The Zarit caregiver burden scale is useful for assessing psychological distress and should be included in any clinical protocol devised to evaluate the needs of patients with dementia.

[Assessment of the Life Skills Profile and the Brief Psychiatric Rating Scale as predictors of the length of psychiatric hospitalization]. / Valoración del Perfil de Habilidades de la Vida Cotidiana y de la Escala Breve de Valoración Psiquiátrica como instrumentos predictores del tiempo de ingreso hospitalario.

INTRODUCTION: Length of hospital stay is generally used as an indirect indicator of effectiveness and efficiency of treatment programs, but it is uncommon that other factors related with hospital stay are also contemplated. The aims of this study are to analyse the relationship between illness severity and adaptative behavior and to assess the predictive power of both constructs on the length of hospital stay. METHODS: Multicenter prospective study (n = 132). The outcome variable is the length of hospital stay cut off at 90 days. The illness severity (BPRS) and the adaptative behavior (LSP) of psychiatric patients are explanatory variables. RESULTS: After adjusting for age, gender and psychiatric diagnosis, negative symptoms (OR = 2.3; 95%CI = 1.3 4.1), self-competence (OR = 0.85; 95% CI = 0.78 0.93), and the total LSP score (OR = 0.96; 95% CI = 0.93 0.98), were significantly associated to the length of hospital stay. These three variables shared a similar predictive power (chi2 = 1.9 on 2 d.f.; P = 0.4). CONCLUSION: Deficits in adaptative behaviour are as relevant as negative symptoms to explain the length of hospital stay. Both assessment domains should be included in the administrative information at discharge.

[The cost of care of elderly patients with psychogeriatric pathology in the community]. / El coste del paciente anciano con patología psicogeriátrica en la comunidad.

OBJECTIVE: To estimate the cost and cost variability of psychogeriatric care in the community. METHODS: 69 patients and their respective family caregivers were studied, 34 attending a psychogeriatric Day Centre (DC) and 35 receiving the usual Community Care (CC) based mainly on outpatient healthcare. The following costs were recorded: general expenses, medication, transportation, resource utilisation, informal care and indirect costs due to health impairment and loss of work productivity of the caregiver. RESULTS: The mean cost of the care of a psychogeriatric outpatient was of 205,989 Spanish pta per month (1,648 US $), with an additional cost of DC of 85,941 Spanish pta/month (688 US $). In the CC group, 71% of the cost was due to informal care but in the case of DC, the largest cost item corresponded to resource utilisation (42%). Cost increased with age of the patient, cognitive and functional impairment and caregiver burden. CONCLUSIONS: The cost of psychogeriatric patients' care in the community is higher for those who attend a DC, those who are in a more advanced state of their disease and those whose caregivers are overburdened.