Clinical pharmacist interventions in the transition of care in a mental health hospital: case reports focused on the medication reconciliation process.

The transition of care represents a key point in the hospital admission and discharge process. A comprehensive transition could lead to fewer medication-related problems. The hospital clinical pharmacist could help in the transition of care process with a comprehensive medication reconciliation process, which has been poorly described in mental health hospitals. This study presents two clinical cases in which hospital clinical pharmacists identified omitted medications and other medication-related issues, including medication errors, during the transition of care in a mental health hospital. These positive experiences may encourage other countries to establish similar collaborations with hospital clinical pharmacists in mental health hospitals.

Treatment of Symptom Clusters in Schizophrenia, Bipolar Disorder and Major Depressive Disorder With the Dopamine D3/D2 Preferring Partial Agonist Cariprazine.

Cariprazine is currently approved for the treatment of patients with schizophrenia (USA and EU), and for manic, depressive, and episodes with mixed features in bipolar I disorder (USA): several randomized controlled studies have also explored its efficacy in patients with major depressive disorder. This review summarizes its current therapeutic uses and potential advantages for treating the main symptoms of schizophrenia, bipolar I and major depressive disorder, considering its pharmacodynamic properties, efficacy, and tolerability. Its predominantly D3 receptor preferring affinity, with functional selectivity according to the prevailing neuronal environment, contributes to its efficacy across a wide array of psychopathological symptoms (including reality distortion, disorganized thought, negative symptoms, mood disturbance, anhedonia, and cognitive impairment), and to a favorable side effect profile. Cariprazine may be a "drug of choice" in patients with predominant negative and cognitive symptoms of schizophrenia, as well as those with metabolic syndrome. Further investigation of its relative efficacy when compared to aripiprazole or other active comparators is warranted. Its effectiveness in the treatment of bipolar mania, bipolar I depression and bipolar I episodes with mixed features, with minimal accompanying metabolic changes is well-established. The longer half-life and delayed time to relapse in patients diagnosed with schizophrenia when compared to other second-generation antipsychotics represent other advantages, given the high rates of non-adherence and frequent relapses seen in clinical practice. Its efficacy in overlapping symptom domains in other major psychiatric disorders appears promising.

Assessment of Cognitive Function, Social Disability and Basic Life Skills in Euthymic Patients with Bipolar Disorder.

BACKGROUND: Data from the literature suggests the presence of cognitive impairments which persist in the euthymic phase of bipolar disorder (BD) and have significant consequences in regards to psychosocial functioning. THE AIMS OF OUR STUDY WERE: 1) to ascertain the cognitive function (CF), social disability (SD) and basic life skills (BLS) of euthymic patients diagnosed with BD, 2) their relationship and 3) to compare CF, SD and BLS in euthymic patients diagnosed with BD to euthymic patients with recurrent major depressive disorder (rMDD). SUBJECTS AND METHODS: Ninety eight euthymic patients diagnosed either with BD (N=48, mean age 48.79 years, SD = 8.587) or rMDD (N=50, mean age 50.02 years, SD = 9.826) underwent testing using the Brief Assessment of Cognition in Affective Disorders (BAC-A) test, the Sheehan Disability Scale (SDS) and the UCSD performance-based skills assessment (UPSA-brief). RESULTS: Euthymic patients with BD demonstrated significantly lower scores as compared to normal population values in verbal, learning and working memory, verbal fluency, attention and processing speed, affective memory for negative and positive words (p<0.01 each) and motor speed (p<0.05), but not for reasoning/problem solving (p=0.05). Furthermore, their mean total SDS score of 17.60 (SD = 6.450, Sk = -0.833) and its subscale scores were higher, while their UPSA-B total scores were lower (M = 76.01, SD = 17.148, Sk = -0.412). There was a correlation between CF, SD and BLS scores (p<0.01), as well as between BLS and SD scores (p<0.05). The analysis of variance did not however show significant differences between subgroups of patients. CONCLUSION: Patients with euthymic BD had lower cognitive function, greater social disability and lower basic life skills. There were similar decreases in cognitive and psychosocial function between patients in the euthymic phase of either BD or MDD.

Cognitive Models of Positive and Negative Symptoms of Schizophrenia and Implications for Treatment.

This article reviews cognitive models of positive and negative symptoms of schizophrenia, as well as basic principles of cognitive behavioural therapy (CBT) for hallucinations, delusions and negative symptoms. Cognitive models of schizophrenia posit that individuals' view of the self is influenced by a combination of genetic vulnerability, early childhood experience and environmental stressors later in the life, and that these factors determine how internal and external experiences are interpreted. Cognitive behavioural therapy for schizophrenia is based on the basic principles of CBT and establishes connection between thoughts, emotions and behaviour. Treatment focuses on the meaning the individual attributes to psychotic experience, his or her understanding of it and ways of coping with symptoms, and is intended to reduce the distress caused by psychotic experience and correct thoughts and assumptions that are incompatible with objective evidence. The latest contradictory data on the efficacy of CBT for schizophrenia point to the need to use protocols that are tailored to specific symptoms and subgroups of patients based on the stage of illness, level of neurocognitive impairment and severity of the disorder, and manual-based in order to ensure fidelity of implementation.

Subtypes of homicide offenders based on psychopathic traits.

The aim of the present study was to explore the subtypes of offenders based on psychopathic traits in a sample of 127 adult homicide offenders (n=40.3% convicted of murder, n=32.6% convicted of aggravated murder, n=27.1% convicted of attempted murder). A two-step cluster analysis of the four factors of psychopathy yielded three clusters, which were then compared on the general dimensions of personality defined by the HEXACO model, intelligence, sadism and psychopathology variables conceptualized by the MMPI-202. Cluster 1 was characterized by moderate scores on psychopathy factors, Agreeableness and aggressiveness. Cluster 2 was a psychopathic-like group with the highest scores on psychopathy factors, sadism, aggressiveness and paranoia, and with the lowest scores on Emotionality and Agreeableness. Cluster 3 was a non-psychopathic group with the lowest scores on psychopathy factors and aggressiveness, and with the highest scores on Agreeableness and Honesty-Humility. There were no significant differences between the clusters on intelligence, Openness to experience, Extraversion, Conscientiousness, and a number of psychopathological variables, including depression and anxiety. Present findings did not provide support for the distinction between primary and secondary psychopathy. The current study further contributes to the person-oriented research of psychopathy by emphasizing the differences between the individuals with high, moderate and low psychopathic traits.

Comorbidity and Suicidality in Patients Diagnosed with Panic Disorder/Agoraphobia and Major Depression.

BACKGROUND: Comorbidity of anxiety and depression (both current and lifetime) is associated with greater chronicity and an increased risk of suicidality. We wished to ascertain which symptom clusters had the strongest association with suicidality. Our aims were (1) to examine the presence of current comorbidity and suicidality in patients diagnosed with panic disorder/agoraphobia (PD/A) and major depression (MD), and their relationship with duration of psychiatric treatment and frequency of hospital admission; and (2) to examine which coexisting symptoms were most strongly predictive of suicidality in sub-groups and the overall group. SUBJECTS AND METHODS: The study sample comprised 100 patients with PD/A and MD. The following assessment instruments were applied: the Panic and Agoraphobia Scale, the Beck Anxiety Inventory, the Beck Depression Inventory-II, the Beck Scale for Suicide Ideation, the Obsessive-Compulsive Inventory-Revised, the Liebowitz Social Anxiety Scale and the Whiteley Index of Hypochondriasis. RESULTS: High rates of current comorbidity were seen in both groups. Patients with MD had significantly higher suicidality scores, but were also older, with a longer duration of psychiatric treatment and more frequent hospitalizations. In the overall group, psychiatric comorbidity was correlated with duration of psychiatric treatment and frequency of hospitalizations (with the exception of hypochondriasis which was not correlated with frequency of hospitalization). In both sub-groups and the overall group, suicidality was correlated with scores for all examined comorbidity (with the exception of hypochondriasis in the PD/A group): however, after multiple regression only obsessive-compulsive symptomatology predicted suicidality in all sub-groups and the overall group, as well as depression in the overall group. Depression supposed as dependent variable and obsessive-compulsive symptomatology as a mediator explained around 37% of the variance in suicidal ideation. CONCLUSION: Patients with PD/A or MD show high rates of current comorbidity. The effect of depression on suicidality was significant, but a non-trivial impact was also mediated by obsessive-compulsive symptomatology.

Risk factors and the prevalence of anorexia nervosa among female students in Serbia.

BACKGROUND/AIM: The widespread symptoms of anorexia netvosa (AN) in young women require to draw professional attention to this problem in Serbia. In previous research on AN, insecure attachment styles, perfectionism and concerns about body shape were identified as notable risk factors. The aim of this study was to identify the prevalence of AN among female students and assess the importance of these factors in its development. METHODS: The Eating Attitudes Test (EAT-40), the Experiences in Close Relationships Scale (ECR), the Frost Multidimensional Perfectionism Scale (FMPS) and the Body Shape Questionnaire (BSQ) were applied to a sample of 500 randomly selected female students of the University of Belgrade, the mean age of 22.44 years (min 18, max 35). In addition, Body Mass Index (BMI) was also calculated. RESULTS: Although 38 (7.6%) female students displayed symptoms of AN (EAT > 30) and 13 (2.6%) had BMI indicating anorexia nervosa syndrome (B4I < or = 17.50 kg/m2), only 1 (0.2%) student fulfilled both criteria. The majority of female students (60.4%) had some type of insecure attachment style. There is a significant influence of attachment styles on symptoms of AN: female students with insecure attachment styles have a significantly higher mean score on the EAT compared to those with secure attachment style (F = 7.873; p < 0.01). There was a positive correlation between scores on the EAT and FMPS (r = 0.217;p < 0.01), and scores on the EAT and BSQ (r = 0.388; p < 0.01). CONCLUSIONS: The obtained results show the prevalence of AN of 0.2% among female students and indicate the importance of insecure attachment styles, perfectionism and concern about body shape as risk factors. Activities for the prevention of AN in this subpopulation should include internet-based therapy and special counseling services with specific programs focusing on emotion-regulation skills through mindfulness, acceptance and commitment techniques, as well as specific cognitive-behavioral techniques.

Assessment of self-perception of transsexual persons: pilot study of 15 patients.

BACKGROUND AND AIMS: There have been few studies in the area of Self-Perception in transsexual persons, except for the population of transsexual adolescents. Bearing in mind its importance not only in the assessment of personality but also in predicting adaptive capacity, the goal of our research is based on the examination of Self-Perception of adult transsexual persons. METHOD: The study was conducted using a Rorschach test, which provides an insight into various aspects of Self-Perception. The sample consisted of 15 transsexual persons, who passed the standard diagnostic procedure. RESULTS: The results suggest that transsexual persons manage to maintain Adequate Self-Esteem. Hypervigilance Index and Obsessive Style Index are negative, while the values showing a negative quality of Self-Regard and the capacity for introspection tend to increase. In the process of Self-Introspection, negative and painful emotional states are often perceived. CONCLUSION: The estimation of Self-Perception in adult transsexual persons indicates a trend of subjective perception of a personal imperfection or inadequacy. This is probably the result of experiencing discomfort for a number of years due to gender incongruence and dysphoria, in particular in persons who enter the sex reassignment procedure later in their adulthood.

Personality disorders in persons with gender identity disorder.

BACKGROUND: Investigations in the field of gender identity disorder (GID) have been mostly related to psychiatric comorbidity and severe psychiatric disorders, but have focused less on personality and personality disorders (PDs). AIMS: The aim of the study was to assess the presence of PDs in persons with GID as compared to cisgendered (a cisgender person is a person who is content to remain the gender they were assigned at birth) heterosexuals, as well as to biological sex. METHODS: The study sample consisted of 30 persons with GID and 30 cisgendered heterosexuals from the general population. The assessment of PDs was conducted by application of the self-administered Structured Clinical Interview for DSM-IV Axis II PDs (SCID-II). RESULTS: Persons with GID compared to cisgender heterosexuals have higher presence of PDs, particularly Paranoid PD, avoidant PDs, and comorbid PDs. In addition, MtF (transwomen are people assigned male at birth who identify as women) persons are characterized by a more severe psychopathological profile. CONCLUSIONS: Assessment of PDs in persons with GID is of great importance as it comprises a key part of personalized treatment plan tailoring, as well as a prognostic factor for sex-reassignment surgery (SRS) outcome.

Obsessive versus delusional jealousy.

Although obsessive jealousy is a highly disturbing disorder, frequently it goes unrecognized, as most attention is paid to delusional jealousy, being the more prominent clinical phenomenon. In order to distinguish obsessive from delusional jealousy, the basic clinical characteristics of these two types of jealousy are presented, as well as the mechanism of their respective genesis, and the differences which we must be aware of in order to prevent misdiagnosis and consequent wrong treatment choices. The theoretical considerations are supported by case presentations providing a clear picture of the phenomena discussed. Unlike delusional jealousy, characterized by the presence of strong, false beliefs that the partner is unfaithful, individuals with obsessive jealousy suffer from unpleasant and irrational jealous ruminations that the partner could be unfaithful, accompanied by compulsive checking of partners' behaviour, which is recognised by the patient as ego-dystonic. This jealousy resembles obsessive-compulsive phenomenology more closely. Despite the differences, both forms of jealousy result in significant distress for patients and intimate relationships, and carry the risk of abuse, homicide and/or suicide. Delusional jealousy is a psychotic disorder and should be treated mainly with antipsychotics, while obsessive jealousy resembles obsessive-compulsive disorder and should be treated with SSRIs and cognitive-behavioural therapy. Regardless of the presence or absence of insight into the disorder, one of the key factors in the treatment of pathological jealousy is to motivate the sufferers for pharmacological and psychotherapeutic interventions.

Personality profiles of patients with dysthymic and panic disorder.

BACKGROUND: The research objective was to identify personality characteristics as well as similarities between, and differences in personality profiles of persons suffering from Dysthymic (DD) and Panic Disorder (with/without Agoraphobia) (PD/PDA). SUBJECTS AND METHODS: Three groups (N=120) were analysed: DD, PD/PDA, and a healthy control group, matched by socio-demographic characteristics and classified in sub-groups according to gender. Diagnoses were made using the Structured Clinical Interview for DSM-IV DD and PD/PDA, and the personality assessment was made using the Minnesota Multiphasic Personality Inventory 201 (MMPI-201). RESULTS: MMPI-201 profile of DD and PD/PDA groups has been characterised by a global increase of "neurotic triad" scales (Depression-Hypochondriasis-Hysteria) (D-Hs-Hy), more expressed in the DD group. Sub-groups of women and men with DD, when compared to the healthy control group, have a significant (p<0.01) increase on the F, Hs, D, Pd, Pa, Pt and Sc scales, and sub-groups with PD/PDA a significant (p<0.01) increase on the F, Hs, D, Hy, Pa, Pt and Sc scales. Scores on the F, D, Hy, Hs, Pt, and Sc scales were significantly higher (p<0.05), as well as on the scale Pa (p<0.01) in men suffering from DD than in the PD/PDA sub-group. Women suffering from DD, when compared to the PD/PDA women, showed a significant increase (p<0.05) on the F and Hy scales. CONCLUSION: Personality profiles of persons suffering from DD and PD/PDA are very similar, with differences being more dimensional than qualitative. Theoretical and practical implications of these findings have been discussed.

[Autogynephilia].

Gender identity disorder is a sexual disorder characterized by strong identification with the opposite gender, followed by unpleasant feeling dueto the birth given gender. Longstanding clinical experience with transgender population has brought new knowledge and better understanding of gender identity and gender identity disorders. Initial knowledge referred to sexual orientation of gender dysphoric persons such as homosexual, heterosexual, bisexual and asexual.The contemporary literature dealing with transgenderism and transsexualism brings out the concept of autogynephilia (from Greek "love oneself as a woman") which is the subject of numerous controversies among the experts in this field as well as in the transgender community. The concept of autogynephilia gained importance in Blanchard's work and his attempts to improve diagnostic categories of gender identity disorders and implement efficient strategies in the management of adult male patients. The main topic of this paper refers to the evolution of the autogynephilia concept, which most prominent authors within the field elaborate as a type of male paraphillic tendency of a person to be sexually by the idea of a phantasy or an image of oneself as a woman, naming these persons "nonhomosexual transsexuals" or "autogynephilic transsexuals".

Sociodemographic profile of transsexual patients.

BACKGROUND: Gender identity disorder is a rare entity in psychiatry which affects deep instincts and personal identity. A review of the recent literature has shown that research of socio-demographic characteristics of transsexual patients is sporadic. There are very few investigations which consider the socio-demographic characteristics in individuals with disharmonized sex and gender identity. This kind of research has not been done in Serbia until now. The objective of this research was to evaluate and analyze socio-demographic data of transsexual persons with a homosexual orientation. SUBJECT AND METHODS: The paper presents the mentioned characteristics on sample of 30 gender dysphoric persons. The patients were examined by The Belgrade team for gender identity. The transsexuals were in a stage of preparation for the sex-reassignment surgery (SRS), and transsexualism was diagnosed and guided within this program (used criteria were keeping with ICD X, DSM IV and Diagnostic schedule recommended by Standards of Care for Dysphoric Persons of the Harry Benjamin International Gender Dysphoria Association). We have examined the following socio-demographic characteristics: sex, age, place of residence, educational level, employment and religion. RESULTS: Results and analysis of obtained data have shown that the socio-demographic profile of transsexual patients included in the research is: predominantly males (male/female sex ratio 3:2); refer for psychiatric help in younger age (frequently before 26); most of them with high school education; live in urban communities; mostly Orthodox religion; equally employed and unemployed. CONCLUSION: Gathering and analysis of sociodemographic data is important for elucidating the transsexual patient's profile. It facilitates better understanding, timely recognition and choice of appropriate treatment for these patients.

Life events and social support in a 1-year preceding panic disorder.

BACKGROUND: The aim of the study was to examine the frequency and class of life events, as well as social support, in patients with panic disorder (with/without agoraphobia) (PD/PDA) in a 1-year period preceding the onset of panic attacks. SUBJECTS AND METHODS: The study sample included 40 patients (PD/PDA) (of an average age of 39.25, SD 6.96), and 40 matched healthy controls (M 37.50, SD 8.05). The following instruments were applied: DSM-IV criteria for PD/PDA, Stressful Life Events Scale, Social Support Index (SSI), Family Coping Coherence Index (FCCI), Relative and Friend Support (RFS) and Family Hardiness Index (FHI). The study was retrospective. RESULTS: Patients with PD/PDA compared to the healthy controls, had significantly increased frequency of negative life events (M 3.8, min 0, max 11) (p<0.05). With respect to the class of life events, PD/PDA patients reported significantly more frequently: mild somatic illness, serious somatic illness, conflict with a member of the extended family, separation from a significant person (p<0.05) and frequent marital conflicts (p<0.01). The patients compared to the healthy controls, had significantly lower level of social support by SSI, FHI, and FCCI (p<0.001). By RFS, there were no significant differences between the two groups. CONCLUSION: Increased frequency of negative life events (particularly somatic illness, interpersonal conflicts and separation), combined with absence of the most part of the supportive quality of the environment (particularly family support), precede the development of PD/PDA in vulnerable persons.