Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study.

BACKGROUND: Implementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources. METHODS: Thirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants' accounts. RESULTS: Six major themes were identified. Three themes (Intervention characteristics; Carers' involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention's implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists' time constrains. CONCLUSIONS: This study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe - a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Attempted suicide in Podgorica, Montenegro: higher rates in females and unemployed males.

BACKGROUND: A change in suicide attempts is associated with comprehensive changes in mental and physical health and social environment. Attempted suicide and suicide are one of the biggest problems nowadays worldwide, not only in the field of mental health but also in the field of public health. The aim of the research was to determine the number of attempted suicides as well as the influence of clinical and demographic variables on the attempted suicide rate. METHODS: The data on the attempted suicide were analysed in the period 2012-2016 based on the data from the Emergency Ward of the Clinical Centre of Montenegro in Podgorica. The rate of attempted suicides as well as the unemployment rate was calculated. The statistical analysis included descriptive statistics of the raw data and relative numbers, Chi-squared test, Fisher's test and Spearman coefficient. RESULTS: The average age of males who attempted suicide was 38.35 ± 14.11, min 15 and max 88 years of age, and the age of women was 38.97 ± 16.81, min 16 and max 93 years of age. Women attempted suicide more frequently (p < 0.05). Female/male ratio during the investigation period slightly declined (1.93 in 2012 vs. 1.29 in 2016). The attempted suicide rates ranged from 103 per 100,000 residents in 2016 to 142 per 100,000 residents in 2015. Crude attempt rate was the highest in women in 2012 (102.42 per 100,000 residents) and for men in 2014 and 2015 (84.48 vs. 83.06 per 100,000 residents). Poisoning with psychotropic drugs was the dominant manner of attempt (93.2%), while the largest number of attempts was in the late spring and summer (May, June and July). Attempted suicide rate in man was associated with higher unemployment rate. CONCLUSIONS: Although women make the majority of attempted suicide cases, there has been a decline in the value of the rate for women and a rise for men. The attempted suicide rates in Podgorica belong to lower rates compared to the WHO European multicentre study on parasuicide. Poisoning with psychotropic drugs was the predominant manner, while the highest number of attempted suicides was in the late spring and summer (May, June and July). Unemployment influences men to attempt suicide much more frequently.

Relationship of suicide rates with climate and economic variables in Europe during 2000-2012.

BACKGROUND: It is well known that suicidal rates vary considerably among European countries and the reasons for this are unknown, although several theories have been proposed. The effect of economic variables has been extensively studied but not that of climate. METHODS: Data from 29 European countries covering the years 2000-2012 and concerning male and female standardized suicidal rates (according to WHO), economic variables (according World Bank) and climate variables were gathered. The statistical analysis included cluster and principal component analysis and categorical regression. RESULTS: The derived models explained 62.4 % of the variability of male suicidal rates. Economic variables alone explained 26.9 % and climate variables 37.6 %. For females, the respective figures were 41.7, 11.5 and 28.1 %. Male suicides correlated with high unemployment rate in the frame of high growth rate and high inflation and low GDP per capita, while female suicides correlated negatively with inflation. Both male and female suicides correlated with low temperature. DISCUSSION: The current study reports that the climatic effect (cold climate) is stronger than the economic one, but both are present. It seems that in Europe suicidality follows the climate/temperature cline which interestingly is not from south to north but from south to north-east. This raises concerns that climate change could lead to an increase in suicide rates. The current study is essentially the first successful attempt to explain the differences across countries in Europe; however, it is an observational analysis based on aggregate data and thus there is a lack of control for confounders.

Relationship of suicide rates to economic variables in Europe: 2000-2011.

BACKGROUND: It is unclear whether there is a direct link between economic crises and changes in suicide rates. AIMS: The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates. METHOD: Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation. RESULTS: There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged. CONCLUSIONS: Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Factor structure of the brief psychiatric rating scale-expanded among outpatients with psychotic disorders in five Southeast European countries: evidence for five factors.

The Brief Psychiatric Rating Scale (BPRS) is a useful tool for measuring the severity of psychopathological symptoms among patients with psychosis. Many studies, predominantly in Western countries, have investigated its factor structure. This study has the following aims: (a) to further explore the factor structure of the BPRS-Expanded version (BPRS-E, 24 items) among outpatients with psychotic disorders in Southeast European countries; (b) to confirm the identified model; and (c) to investigate the goodness-of-fit of the three competing BPRS-E factor models derived from previous studies. The exploratory factor analysis (EFA) produced a solution with 21 items grouped into five factors, thus supporting the existence of a fifth factor, i.e., Disorganization. A follow-up confirmatory factor analysis (CFA) revealed a 19-item model (with two items removed) that fit the data well. In addition, the stability of two out of three competing factor models was confirmed. Finally, the BPRS-E model with 5 factors developed in this cross-national study was found to include a greater number of items compared to competing models.

Non-pharmacological interventions for schizophrenia-analysis of treatment guidelines and implementation in 12 Southeast European countries.

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries-Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia-included non-pharmacological interventions. The remaining three countries-Kosovo (UN Resolution), Romania, and Slovenia-have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5-11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey.

BACKGROUND: Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE). OBJECTIVE: To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE. METHODS: An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers. RESULTS: In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia. CONCLUSION: Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Gender differences in relation to suicides committed in the capital of Montenegro (Podgorica) in the period 2000-2006.

BACKGROUND: The purpose of the study was to research gender differences in suicides committed in Podgorica between 2000 and 2006, including sociodemographic variables (e.g. age, marital status, education etc.), methods of and motives for committing suicide. Data were taken from the Police Directorate of Montenegro. SUBJECTS AND METHODS: We used data on 220 males and 83 females who committed suicide. Statistical analysis was done by using the crude specific rate. Significance between two independent crude rates is constructed around their 95% confidence intervals and it utilizes the difference between the two rates (D) to determine significance. RESULTS: The incidence of suicide in males was found to be higher than in females (the male to female suicide ratio is 2.6 to 1). Females were older than males. Females had completed elementary education more frequently , and they were single or divorced or widows. Males had completed secondary education more frequently and they were married. The most frequent employment status of both gender groups implied pensioner and unemployment statuses. There was a significant difference in suicide rates between the genders during the reporting period. Suicide rates increase with age in both genders. Males chose firearms, hanging, strangulation and suffocation and jumping. Females chose hanging, strangulation and suffocation, jumping and drowning as the most frequent methods of suicide. The most frequent motive for suicide in both gender groups was physical illness. The second most frequent motive was mental illness. Emotional and financial difficulties were motives which were more common in males, whereas family problems appeared to be motives two times more frequent in females. CONCLUSIONS: The complex multifactorial etiology of suicide suggests the need to consider gender differences when developing effective strategies for the therapy and the prevention of suicide.

Mental health law in Montenegro.

This paper discusses the services and treatments that are offered in Montenegro to persons who are mentally ill. A short history is given. The law on the protection of the rights of patients who are mentally ill is described, along with the regulations governing voluntary and forced treatment. An action plan for promoting mental health has been partly already realised but some of its aims still need to be accomplished.