Gender differences and risk of readmission in hospitalizations with a diagnosis of psychotic spectrum disorders.

BACKGROUND: Gender differences in psychosis are a topic that has been studied considering different aspects. Although some available evidence would point to a possible better prognosis in women, this claim is far from conclusively established. METHODS: We propose an analysis of gender differences in the risk of readmission to an acute hospitalization unit, an indicator related to prognosis. RESULTS AND CONCLUSIONS: We found that although the risk of readmission at 1 year is lower in women, this seems to be explained by other confounding factors.

The Impact of Stressful Life Events on Suicidal Ideation in Gender Dysphoria: A Moderator Effect of Perceived Social Support.

Factors associated with suicidal ideation in the gender dysphoria population are not completely understood. This high-risk population is more likely to suffer stressful events such as assault or employment discrimination. This study aimed to determine the association of stressful events and social support on suicidal ideation in gender dysphoria and to analyze the moderator effect of social support in relation to stressful events and suicidal ideation. A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain that consisted of 204 individuals (51.7% birth-assigned males and 48.3% birth-assigned females), aged between 13 and 59 (M = 27.95 years, SD = 9.58). A Structured Clinical Interview, a list of 16 stressful events, and a functional social support questionnaire (Duke-UNC-11) were used during the initial visits to the unit. The data were collected between 2011 and 2012. A total of 50.1% of the sample have had suicidal ideation. The following stressful events were associated with suicidal ideation: homelessness, eviction from home, and having suffered from physical or verbal aggression. Also, there was an inverse relation between perceived social support and suicidal ideation. There was a statistically significant interaction between a specific stressful event (eviction) and perceived social support. The study suggests that the promotion of safer environments could be related to lower suicidal ideation and that networks that provide social support could buffer the association between specific stressful events and suicidal ideation.

Bipolar multiplex families have an increased burden of common risk variants for psychiatric disorders.

Multiplex families with a high prevalence of a psychiatric disorder are often examined to identify rare genetic variants with large effect sizes. In the present study, we analysed whether the risk for bipolar disorder (BD) in BD multiplex families is influenced by common genetic variants. Furthermore, we investigated whether this risk is conferred mainly by BD-specific risk variants or by variants also associated with the susceptibility to schizophrenia or major depression. In total, 395 individuals from 33 Andalusian BD multiplex families (166 BD, 78 major depressive disorder, 151 unaffected) as well as 438 subjects from an independent, BD case/control cohort (161 unrelated BD, 277 unrelated controls) were analysed. Polygenic risk scores (PRS) for BD, schizophrenia (SCZ), and major depression were calculated and compared between the cohorts. Both the familial BD cases and unaffected family members had higher PRS for all three psychiatric disorders than the independent controls, with BD and SCZ being significant after correction for multiple testing, suggesting a high baseline risk for several psychiatric disorders in the families. Moreover, familial BD cases showed significantly higher BD PRS than unaffected family members and unrelated BD cases. A plausible hypothesis is that, in multiplex families with a general increase in risk for psychiatric disease, BD development is attributable to a high burden of common variants that confer a specific risk for BD. The present analyses demonstrated that common genetic risk variants for psychiatric disorders are likely to contribute to the high incidence of affective psychiatric disorders in the multiplex families. However, the PRS explained only part of the observed phenotypic variance, and rare variants might have also contributed to disease development.

EEG abnormalities and clinical phenotypes in pre-school children with autism spectrum disorder.

BACKGROUND: Abnormalities on electroencephalography (EEG) results have been reported in a high percentage of children with Autism Spectrum Disorder (ASD). The purpose of this study was to explore the prevalence of EEG abnormalities in a clinical population of pre-school children with Autism Spectrum Disorder and the differences in terms of the following phenotypic characteristics: adaptive behavior, executive functioning, severity of Autism Spectrum Disorder core symptoms, and comorbidity symptoms. METHODS: A cross-sectional analysis of 69 children who attended the Autism Spectrum Disorder early diagnosis program with electroencephalography and clinical diagnosis was performed. A battery of questionnaires was also made to parents to evaluate emotions, behavior, and functional skills for daily living. RESULTS: Out of 69 pre-school children with Autism Spectrum Disorder, twenty nine (42%) had abnormalities in electroencephalography results. The group with abnormal epileptiform electroencephalography exhibited more impairment in executive functioning and social-relationship coexisting symptoms. CONCLUSIONS: The presence of an abnormal epileptiform electroencephalography in pre-school children with ASD already suggests a worse development in clinical features.

Iconic Therapy for the reduction of borderline personality disorder symptoms among suicidal youth: a preliminary study.

BACKGROUND: Iconic therapy (IT) is a new therapy that uses images to teach skills with the aim of improving the symptoms of borderline personality disorder. Preliminary results are promising, and there is indication that IT may be effective. The purpose of this preliminary study was to test the effectiveness of IT compared to a psychological supportive intervention (SI). METHODS: The study was carried out at the University Regional Hospital of Malaga. Young patients (N = 40; 15-30 years) with suicidal or parasuicidal behavior and borderline personality traits were randomized into IT (N = 20) or SI (N = 20). The main outcome variable was a change in the symptoms of borderline personality disorder (BSL-23) at the end of treatment. The secondary outcome variables were suicidal ideation and behavior, self-harm, the need for medication, the number of visits to mental health professionals, maladaptive behavior, satisfaction with therapy and perceived improvement, both at the end of the intensive treatment and at the 12-month follow-up. RESULTS: As expected, the two therapies produced a reduction in BPD symptoms at 10 weeks post-treatment and at the 12-month follow-up. Contrary to expectation, there were no statistically significant differences in the effectiveness of the two therapies (p > 0.05). However, at the 12-month follow-up, the effect sizes for the difference between the effectiveness of the two therapy groups on BSL-23 scores (d = 0.33) and on maladjustment to daily life (d = 0.39) was found to exceed the commonly used convention for a small effect (d = 0.20). Besides, participants in the IT group showed greater satisfaction with therapy than those who received SI. The mean difference between groups was statistically significant after the 10-week treatment period (p < .01), with a large effect size (d = 1.11). Nevertheless, this difference was not maintained at the 12-month follow-up (p > .05), although the effect size for this analysis (d = 0.34) was found to exceed a small effect. CONCLUSIONS: This preliminary study did not find a statistically significant difference in the effectiveness of the two therapies, probably due to the small sample of participants, but there are some indicators (effect sizes) suggesting that perhaps IT may be superior for reducing BPD symptoms and maladjustment in daily life. Future studies with larger samples and comparisons with established treatments for borderline personality disorder are necessary to confirm that IT effects are significant and persistent in the long term. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03011190 . First posted 05/01/2017. Last update posted 15/05/2018.

The Impact of COVID-19 Confinement on Cognition and Mental Health and Technology Use Among Socially Vulnerable Older People: Retrospective Cohort Study.

BACKGROUND: COVID-19 forced the implementation of restrictive measures in Spain, such as lockdown, home confinement, social distancing, and isolation. It is necessary to study whether limited access to basic services and decreased family and social support could have deleterious effects on cognition, quality of life, and mental health in vulnerable older people. OBJECTIVE: This study aims to explore the impact of the COVID-19 outbreak on cognition in older adults with mild cognitive impairment or dementia as the main outcome and the quality of life, perceived health status, and depression as secondary outcomes and to analyze the association of living alone and a change in living arrangements with those outcomes and other variables related with the use of technology and health services. Likewise, this study aims to analyze the association of high and low technophilia with those variables, to explore the access and use of health care and social support services, and, finally, to explore the informative-, cognitive-, entertainment-, and socialization-related uses of information and communications technologies (ICTs) during the COVID-19 outbreak. METHODS: This cohort study was conducted in Málaga (Spain). In total, 151 participants with mild cognitive impairment or mild dementia, from the SMART4MD (n=75, 49.7%) and TV-AssistDem (n=76, 50.3%) randomized clinical trials, were interviewed by telephone between May 11 and June 26, 2020. All participants had undergone 1-3 assessments (in 6-month intervals) on cognition, quality of life, and mood prior to the COVID-19 breakout. RESULTS: The outbreak did not significantly impact the cognition, quality of life, and mood of our study population when making comparisons with baseline assessments prior to the outbreak. Perceived stress was reported as moderate during the outbreak. After correction for multiple comparisons, living alone, a change in living arrangements, and technophilia were not associated with negative mental health outcomes. However, being alone was nominally associated with self-perceived fear and depression, and higher technophilia with better quality of life, less boredom, perceived stress and depression, and also less calmness. Overall, health care and social support service access and utilization were high. The most used ICTs during the COVID-19 outbreak were the television for informative, cognitive, and entertainment-related uses and the smartphone for socialization. CONCLUSIONS: Our findings show that the first months of the outbreak did not significantly impact the cognition, quality of life, perceived health status, and depression of our study population when making comparisons with baseline assessments prior to the outbreak. Living alone and low technophilia require further research to establish whether they are risk factors of mental health problems during lockdowns in vulnerable populations. Moreover, although ICTs have proven to be useful for informative-, cognitive-, entertainment-, and socialization-related uses during the pandemic, more evidence is needed to support these interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04385797; https://clinicaltrials.gov/ct2/show/NCT04385797. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/26431.

Trends in Psychiatric Hospitalizations of Patients With Dual Diagnosis in Spain.

OBJECTIVE: Substance use disorders are highly prevalent in people living with a mental health disorder. Co-occurring substance use disorders have been associated with a worse prognosis and poorer adherence to treatment. The aim of this study was to analyze the temporal trends in the prevalence of substance use disorders in patients admitted to a psychiatric inpatient unit between 1998 and 2020. METHODS: This is a retrospective study based on the registry of 18,367 hospitalizations and 7,124 patients with a mental health disorder admitted during the period 1998 to 2020 in Malaga, Spain. Time trend analysis by gender and substance used was calculated using a segmented regression model. The permutation test was used to determine inflection points. A sensitivity analysis was performed based on the assumptions of autocorrelation and homoscedasticity. RESULTS: A total of 22.2% of admissions had a diagnosis of mental health disorder and co-occurring substance use disorders. Prevalence was higher among males (30.0%) than females (9.4%; p < .001). Patients with both disorders had a shorter length of stay by 2 days (p < .001) and a younger age at first admission (by 6.5 years; p < .001) compared to patients without substance use disorders. There was no difference in the total number of hospitalizations between the two groups. Psychotic disorders and multiple drug use disorders were the most prevalent diagnoses in men compared to women, whereas personality disorders and alcohol use were the most common diagnoses in women. We observed an increase in the prevalence of dual diagnosis between 2005 and 2020. There was a 3.0% increase in cannabis-related admissions per year during the whole study period (p < .001). Cannabis and cocaine use disorders have become the most prevalent in the last 10 years, while opioid and alcohol use disorders have decreased. CONCLUSIONS: Co-occurring substance use disorders are highly prevalent among hospitalized patients. In recent years, the pattern of substance use has shifted, with cannabis being the most prevalent, while opiates and alcohol substance use have decreased. We need to devise a specialized approach and integrative treatment for patients with co-occurring disorders.

Effectiveness and implementation of an online intervention (MINDxYOU) for reducing stress and promote mental health among healthcare workers in Spain: a study protocol for a stepped-wedge cluster randomized trial.

BACKGROUND: The World Health Organization has formally recognized that healthcare professionals are at risk of developing mental health problems; finding ways to reduce their stress is mandatory to improve both their quality of life and, indirectly, their job performance. In recent years, particularly since the COVID-19 pandemic outbreak, there has been a proliferation of online interventions with promising results. The purpose of the present study is twofold: to test the effectiveness of an online, self-guided intervention, MINDxYOU, to reduce the stress levels of healthcare workers; and to conduct an implementation study of this intervention. Additionally, an economic evaluation of the intervention will be conducted. METHODS: The current study has a hybrid effectiveness-implementation type 2 design. A stepped wedge cluster randomized trial design will be used, with a cohort of 180 healthcare workers recruited in two Spanish provinces (Malaga and Zaragoza). The recruitment stage will commence in October 2022. Frontline health workers who provide direct care to people in a hospital, primary care center, or nursing home setting in both regions will participate. The effectiveness of the intervention will be studied, with perceived stress as the main outcome (Perceived Stress Scale), while other psychopathological symptoms and process variables (e.g., mindfulness, compassion, resilience, and psychological flexibility) will be also assessed as secondary outcomes. The implementation study will include analysis of feasibility, acceptability, adoption, appropriateness, fidelity, penetration, and sustainability. The incremental costs and benefits, in terms of quality-adjusted life years, will be examined by means of cost-utility and cost-effectiveness analyses. DISCUSSION: MINDxYOU is designed to reduce healthcare workers' stress levels through the practice of mindfulness, acceptance, and compassion, with a special focus on how to apply these skills to healthy habits and considering the particular stressors that these professionals face on a daily basis. The present study will show how implementation studies are useful for establishing the framework in which to address barriers to and promote facilitators for acceptability, appropriateness, adoption, feasibility, fidelity, penetration, and sustainability of online interventions. The ultimate goal is to reduce the research-to-practice gap. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov on 29/06/2022; registration number: NCT05436717.

Impulsivity, decision-making and risk-taking behaviour in bipolar disorder: a systematic review and meta-analysis.

Despite the robust body of work on cognitive aspects of bipolar disorder (BD), a clear profile of associated impairments in impulsivity, decision-making and risk-taking from studies that use behavioural measures has yet to be established. A systematic review, across four electronic databases (PsycINFO, MEDLINE/PubMed, ScienceDirect and Scopus), of literature published between January 1999 and December 2018 was carried out in accordance with the PRISMA statement. The protocol was registered on PROSPERO (CRD42018114684). A fixed-effect and random-effects meta-analysis using the Hedges' g (ES) estimate was performed. The analysis revealed significant impairment in BD individuals with medium effect sizes in various aspects of impulsivity - response inhibition (ES = 0.49; p < 0.0001), delay of gratification (ES = 0.54; p < 0.0001) and inattention (ES = 0.49; p < 0.0001) - and in decision-making (ES = 0.61, p = 0.0002), but no significant impairment in risk-taking behaviour (ES = 0.41; p = 0.0598). Furthermore, we found significant heterogeneity between studies for decision-making and risk-taking behaviour but not for impulsivity. Impaired risk-taking behaviour was significant in a subgroup of BD-I and euthymic individuals (ES = 0.92; p < 0.0001) with no significant heterogeneity. A stratification analysis revealed comparable results in euthymic and non-euthymic individuals for impulsivity. Our findings suggest that behaviour impulsivity is elevated in all phases of BD, representing a core and clinically relevant feature that persists beyond mood symptoms. More studies about decision-making and risk-taking are necessary to establish if they are impaired in BD and to analyze the role of mood state.

Factors Associated With High Use of Hospital Psychiatric Services in Málaga, Spain: Analysis of First Admissions.

The early prediction of patients at risk may facilitate the efficient use of interventions that have been demonstrated to reduce readmissions. The aim of the study was to analyze variables during first admissions associated with further high use of an inpatient hospitalization psychiatric unit in Málaga, Spain. The risk of having three or more psychiatric admissions was analyzed in a sample of 1535 first-time admissions with multivariate Cox regression. In the multivariate model, the variables associated with the risk of high use were age at admission (p < 0.001), length of stay (p < 0.001), place of residence (p < 0.001), and previous history with mental health services (p < 0.001). The results suggest that there are several easily accessible characteristics at first admission that are potentially useful in detecting patients at risk.

Telehealth Home Support During COVID-19 Confinement for Community-Dwelling Older Adults With Mild Cognitive Impairment or Mild Dementia: Survey Study.

BACKGROUND: The public health emergency of coronavirus disease (COVID-19) is rapidly evolving worldwide; some countries, including Spain, have implemented restrictive measures. Populations that are vulnerable to this outbreak and its physical and mental health effects include community-dwelling older adults with mild cognitive impairment or mild dementia. Telehealth is a potential tool to deliver health care and decrease exposure risk. OBJECTIVE: The aims of this study were to explore the impact of confinement on the health and well-being of community-dwelling older adults with mild cognitive impairment or mild dementia, to provide television-based and telephone-based health and social support, and to study the effects of a television-based assistive integrated technology, TV-AssistDem (TeleVision-based ASSistive Integrated Service to supporT European adults living with mild DEMentia or mild cognitive impairment). METHODS: A telephone-based survey was administered in Spain to 93 participants in the TV-AssistDem clinical trial from March 25 to April 6, 2020. RESULTS: Of the respondents, 60/93 (65%) were women. The mean age was 73.34 (SD 6.07), and 69/93 (74%) lived accompanied. Lockdown measures forced 17/93 respondents (18%) to change their living arrangements. Health status was found to be optimal in 89/93 respondents (96%), with no COVID-19 symptoms. Grocery and pharmacy outings were performed by family members of 68/93 participants (73%); 57 (61%) reported overall well-being, and 65 (70%) maintained their sleep quality. However, participants living alone reported greater negative feelings and more sleeping problems. Regarding leisure activities, 53/93 respondents (57%) took walks, 32 (35%) played memory games, 55 (60%) watched television, and 91 (98%) telephoned relatives. 58/93 (64%) respondents reported accessing moderate or too much COVID-19 information, 89 (97%) received it from television, and 56 (62%) stated that their understanding of the information was extreme. 39/93 (39%) respondents had contacted health and social services, while 29 (31%) requested information regarding these services during the telephone call. There were no significant differences in health and well-being between the intervention and control groups. Respondents with TV-AssistDem performed more memory exercises (24/93, 52% vs 8/93, 17.4%; P<.001) than control respondents. CONCLUSIONS: Our findings suggest that during COVID-19 confinement, the physical and mental health and well-being was optimal for the majority of our vulnerable population. However, those living alone reported greater negative psychological effects and sleeping problems. Measures adopted to address the negative experiences of confinement included keeping informed about the situation, accessing health and social services, having a support network that prevents risk of exposure to COVID-19 and guarantees food and medical supplies, a daily routine with maintained sleeping habits and leisure activities, staying physically and mentally active with cognitive stimulation exercises, and ensuring social connectedness using technology. Television sets were preferred technological devices to access COVID-19 information, watch television as a recreational activity, and perform memory exercises as an intellectual activity. Television-based telehealth support using TV-AssistDem demonstrated potential for cognitive stimulation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03653234; https://clinicaltrials.gov/ct2/show/NCT03653234.

Attitudes and Use of Information and Communication Technologies in Older Adults With Mild Cognitive Impairment or Early Stages of Dementia and Their Caregivers: Cross-Sectional Study.

BACKGROUND: Information and communication technologies are promising tools to increase the quality of life of people with dementia or mild cognitive impairment and that of their caregivers. However, there are barriers to their use associated with sociodemographic factors and negative attitudes, as well as inadequate knowledge about technologies. OBJECTIVE: The aim of this study was to analyze technophilia (attitudes toward new technologies) and the use of smartphones and tablets along with associated factors in people with dementia/mild cognitive impairment and their caregivers. METHODS: Data from the first visit of the Support Monitoring and Reminder for Mild Dementia (SMART4MD) randomized multicenter clinical trial were used for this analysis. Data were obtained from two European countries, Spain and Sweden, and from three centers: Consorci Sanitari de Terrassa (Catalonia, Spain), Servicio Andaluz de Salud (Andalusia, Spain), and the Blekinge Institute of Technology (Sweden). Participants with a score between 20 and 28 in the Mini Mental State Examination, with memory problems (for more than 6 months), and who were over the age of 55 years were included in the study, along with their caregivers. The bivariate Chi square and Mann-Whitney tests, and multivariate linear and logistic regression models were used for statistical analysis. RESULTS: A total of 1086 dyads were included (N=2172). Overall, 299 (27.53%) of people with dementia/mild cognitive impairment had a diagnosis of dementia. In addition, 588 (54.14%) of people with dementia/mild cognitive impairment reported using a smartphone almost every day, and 106 (9.76%) used specific apps or software to support their memory. Among the caregivers, 839 (77.26%) used smartphones and tablets almost every day, and 181 (16.67%) used specific apps or software to support their memory. The people with dementia/mild cognitive impairment showed a lower level of technophilia in comparison to that of their caregivers after adjusting for confounders (B=0.074, P=.02) with differences in technology enthusiasm (B=0.360, P<.001), but not in technology anxiety (B=-0.042, P=.37). Technophilia was associated with lower age (B=-0.009, P=.004), male gender (B=-0.160, P<.001), higher education level (P=.01), living arrangement (living with children vs single; B=-2.538, P=.01), country of residence (Sweden vs Spain; B=0.256, P<.001), lower depression (B=-0.046, P<.001), and better health status (B=0.004, P<.001) in people with dementia/mild cognitive impairment. Among caregivers, technophilia was associated with comparable sociodemographic factors (except for living arrangement), along with a lower caregiver burden (B=-0.005, P=.04) and better quality of life (B=0.348, P<.001). CONCLUSIONS: Technophilia was associated with a better quality of life and sociodemographic variables in people with dementia/mild cognitive impairment and caregivers, suggesting potential barriers for technological interventions. People with dementia/mild cognitive impairment frequently use smartphones and tablets, but the use of specific apps or software to support memory is limited. Interventions using these technologies are needed to overcome barriers in this population related to sociodemographic characteristics and the lack of enthusiasm for new technologies. TRIAL REGISTRATION: ClinicalTrials.gov NCT03325699; https://clinicaltrials.gov/ct2/show/NCT03325699.

TV-based assistive integrated service to support European adults living with mild dementia or mild cognitive impairment (TV-AssistDem): study protocol for a multicentre randomized controlled trial.

BACKGROUND: Mild cognitive impairment and mild dementia progressively compromise the ability of people to live independently and can have a negative impact on their quality of life. Within the current European Active and Assisted Living programme (AAL), project TV-AssistDem has been developed to deliver a TV-based platform service to support patients with mild cognitive impairment or mild dementia and provide relief to their caregivers. The application is intended to be used daily at home, mainly by the participants themselves, with the help of their informal caregivers. The aim of this study is to evaluate the effectiveness of TV-AssistDem to improve quality of life in people with mild cognitive impairment or mild dementia. METHODS: This is a 12-month European multicentre randomized controlled trial which will be performed in two countries: Spain and Romania. Two hundred and forty older adults will be recruited using identical inclusion/exclusion criteria. The primary outcome will be the change from baseline of TV-AssistDem on patient quality of life at 12 months. The secondary outcomes will be the changes from baseline of: 1) informal caregiver quality of life, 2) informal caregiver burden, 3) patient treatment adherence, 4) patient treatment compliance, 5) patient functional status, and 6) healthcare cost-effectiveness at 12 months. Patients in the intervention group will have access to an interactive platform which offers remote assistive services through a device connected to the television. The core services of the platform are: 1) Calendar and reminders, 2) Health monitoring and data transmission to a health server and 3) Videoconference; service-oriented applications are: 4) Cognitive stimulation; 5) Reminiscences; and 6) Patient and caregiver healthcare education. The analysis will be made following an intention-to-treat procedure. Linear and Generalized Mixed Model analysis will be performed. DISCUSSION: We hypothesize that the regular use of TV-AssistDem will result in an improvement in patient quality of life. The uniqueness of this home TV-based intervention lies on its widespread accessibility and its integrative approach to quality of life in people with mild cognitive impairment or mild dementia and their informal caregivers. However, several anticipated challenges will need to be faced: poor engagement and connectivity problems. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03653234 , Date of registration: 31 August 2018.

Effectiveness of iconic therapy for the reduction of borderline personality disorder symptoms among suicidal youth: study protocol for a randomised controlled trial.

BACKGROUND: Borderline personality disorder (BPD) is associated with an intensive use of mental health services, even in the absence of a full diagnosis. Early symptom detection and intervention may help alleviate adverse long-term outcomes. Iconic Therapy is an innovative manual-driven psychotherapy that treats BPD symptoms in a specific and intensive manner. Preliminary results are promising and the indication is that Iconic Therapy may be effective in reducing BPD symptoms. The aim of this study is to assess how effective Iconic Therapy is compared to Structured Support Therapy in a real clinical setting. METHODS/DESIGN: Our study will be a controlled 12-month pragmatic, two-armed RCT. A total of 72 young people (15 to 25 years old) with suicidal ideation/self-injuring behaviour and BPD traits and symptoms will participate in the study. The subjects will be randomised into two groups: Iconic Therapy or Structured Support Therapy. The participants will be assigned to either group on a 1:1 basis. Both the Iconic Therapy and the Structured Support Therapy programmes consist of 11 weekly sessions delivered by two trained psychologists in a group format of between 8 to 12 outpatients. The primary outcome will be measured by the change in symptom severity. Secondary outcomes include changes in suicidal ideation/ behaviour, non-suicidal self-injury, maladjustment to daily life and cost-effective analysis. The primary outcome will be a decrease in the severity of BPD symptoms as assessed by the Borderline Symptom List (BSL-23). For the clinical evaluation, three study assessments will take place: at baseline, after treatment and at 12-month follow-up. We hypothesise that patients attending the Iconic Therapy group will show a significantly higher reduction in symptoms than those in the Structured Support Therapy group. Data will be analysed using generalised estimating equation (GEE) models. DISCUSSION: By responding to the need for briefer and more comprehensive therapies for BPD, we foresee that Iconic Therapy may provide an alternative treatment whose specific therapeutic principles, visually represented on icons, will overcome classical Structured Support Therapy at reducing BPD symptoms. TRIAL REGISTRATION: NCT03011190.

Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A Systematic Review.

OBJECTIVE: This systematic review presents evidence regarding factors that may influence the patient's subjective experience of an episode of mechanical restraint, seclusion, or forced administration of medication. METHOD: Two authors searched CINAHL, PubMed, SCOPUS, Web of Science, and Psych-Info, considering published studies between 1 January 1992 and 1 February 2016. Based on the inclusion criteria and methodological quality, 34 studies were selected, reporting a total sample of 1,869 participants. RESULTS: The results showed that the provision of information, contact and interaction with staff, and adequate communication with professionals are factors that influence the subjective experience of these measures. Humane treatment, respect, and staff support are also associated with a better experience, and debriefing is an important procedure/technique to reduce the emotional impact of these measures. Likewise, the quality of the working and physical environment and some individual and treatment variables were related to the experience of these measures. There are different results in relation to the most frequently associated experiences and, despite some data that indicate positive experiences, the evidence shows such experiences to be predominantly negative and frequently with adverse consequences. It seems that patients find forced medication and seclusion to be more tolerable than mechanical restraint and combined measures. CONCLUSIONS: It appears that the role of the staff and the environmental conditions, which are potentially modifiable, affect the subjective experience of these measures. There was considerable heterogeneity among studies in terms of coercive measures experienced by participants and study designs.

Needs, Perceived Support, and Hospital Readmissions in Patients with Severe Mental Illness.

People with severe mental illness have multiple and complex needs that often are not addressed. The purpose of this study was to analyse needs and support perceived and the relationship with hospital readmission. We assessed 100 patients with severe mental illness at discharge from an acute inpatient unit in terms of needs (Camberwell Assessment of Needs), clinical status (The Brief Psychiatric Rating Scale), and social functioning (Personal and Social Performance); we also followed up these patients for 1 year. The group of patients who were readmitted had more total needs than did the non-readmitted, in addition to more unmet needs, although the differences were not significant. The highest risk factor for rehospitalisation was the number of previous admissions. In addition, the help of informal carers in alleviating psychological distress was associated with the risk of readmission. The main conclusion concerns the role of the psychological support provided by informal networks in preventing readmission.

Gender Dysphoria and Social Anxiety: An Exploratory Study in Spain.

INTRODUCTION: Social anxiety in gender dysphoria is still under investigation. AIM: To determine the prevalence and associated factors of social anxiety in a sample of individuals with gender dysphoria. METHODS: A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain. The sample consisted of 210 individuals (48% trans female and 52% trans male). MAIN OUTCOME MEASURES: Mini-International Neuropsychiatric Interview (MINI) for diagnosis of social anxiety disorder, Structured Clinical Interview, Exposure to Violence Questionnaire (EVQ), Beck Depression Inventory (BDI-II), and Functional Social Support Questionnaire (Duke-UNC-11). RESULTS: Of the total sample, 31.4% had social anxiety disorder. Social anxiety disorder was highly correlated with age (r = -0.181; CI = 0.061-0.264; P = .009) and depression (r = 0.345; CI = 0.213-0.468; P < .001); it is strongly associated to current cannabis use (relative risk [RR] = 1.251; CI = 1.070-1.463; P = .001) and lifetime suicidal ideation (RR = 1.902; CI 1.286-2.814; P < .001). Moreover, it is significantly associated to lifetime nonsuicidal self-injury (RR = 1.188; CI 1.018-1.386; P = .011), nationality (RR = 7.792; CI 1.059-57.392; P = .013), perceived violence at school during childhood and adolescence (r = 0.169; CI = 0.036-0.303; P = .014), unemployment (RR = 1.333; CI 1.02-1.742; P = .021), and hospitalization of parents in childhood (RR = 1.146; CI = 1.003-4.419; P = .046). Using multivariable analysis, the highly significant variables within the model were depression score (odds ratio [OR] = 1.083; CI = 1.045-1.123; P < .001) and current cannabis use (OR = 3.873; CI = 1.534-9.779, P = .004), also age (OR = 0.948; CI = 0.909-0.989; P = .012), hospitalization of parents during childhood (OR = 2.618; CI = 1.107-6.189; P = .028), and nationality (OR = 9.427; CI = 1.065-83.457; P = .044) were associated with social anxiety disorder. CONCLUSION: This study highlights the necessity of implementing actions to prevent and treat social anxiety in this high-risk population.

Sociodemographic Characteristics and Psychological Adjustment Among Transsexuals in Spain.

This study examined the sociodemographic characteristics and the psychological adjustment of transsexuals in Andalusia (Spain), and also analyzed the differences between female-to-male (FtM) and male-to-female (MtF) transsexuals. The sample included 197 transsexuals (101 MtF and 96 FtM) selected from those who visited the Transsexual and Gender Identity Unit at the Carlos Haya Hospital in Malaga between 2011 and 2012. Our analyses indicated that MtF transsexuals were more likely to have lower educational levels, live alone, have worked less frequently throughout their lifetime, and have engaged in prostitution. For FtM transsexuals, there were more frequent references to the mother's psychiatric history and more social avoidance and distress. Multivariate analysis showed that the number of personality dysfunctional traits and unemployment status were associated with depression in the entire sample. The following three conclusions can be made: there are significant differences between MtF and FtM transsexuals (mainly related to sociodemographic variables), depression was high in both groups, and a remarkable percentage of transsexuals have attempted suicide (22.8 %) or have had suicidal thoughts (52.3 %).

Effectiveness of a Multimodal Intervention Program for Restraint Prevention in an Acute Spanish Psychiatric Ward.

BACKGROUND: International recommendations have called to implement strategies to reduce the use of coercion in psychiatric settings. However, in Spain there is a lack of research about intervention programs to reduce mechanical restraint in acute psychiatric units. OBJECTIVE: The aim of this study was to evaluate the effectiveness of a multimodal intervention program based on the principles of six core strategies to reduce the frequency of use of mechanical restraint in an acute psychiatric ward. DESIGN: The design was a retrospective analysis of the frequency and duration of episodes of mechanical restraint prior to the intervention program (2012) and during the intervention program (2013) in one acute psychiatric ward. The intervention was governed by four strategies: (1) leadership and organizational changes, (2) registration and monitoring of risk patients, (3) staff training, and (4) involving patients in the treatment program. RESULTS: There was a significant difference between the mean number of monthly episodes of mechanical restraint per 1,000 patient days, pre-intervention (18.54 ± 8.78) compared with postintervention (8.53 ± 7.00; p = .005). We found the probability that mechanical restraint would occur in a hospital admission decreased after performing the intervention (odds ratio = .587; confidence interval = 0.411-0.838; p = .003) after adjusting for confounding variables. The total percentage of restrained patients fell from 15.07% to 9.74%. CONCLUSIONS: The main implication of the study is to support the effectiveness of specific intervention programs based on different measures to reduce mechanical restraint and without contemplating all the strategies that are considered effective.

Substance use and social anxiety in transsexual individuals.

OBJECTIVE: This study examined social anxiety and use of cannabis and cocaine among transsexuals. METHODS: A total of 379 transsexuals seeking treatment or consultation participated in this study, providing data on sociodemographics, substance use, and anxiety. Analyses were based on (a) lifetime but not current use versus never used and (b) current use only versus no current use (lifetime only or never used). RESULTS: Lifetime only cannabis users (n = 72, 19%) and lifetime only cocaine users (n = 36, 9.8%) were older, had more victimization, and received more mental health treatment that those who never used. Current cannabis users (n = 47, 12.4%) had higher scores on fear of negative evaluation and social avoidance than those not currently using (p <.01). Multivariate analysis showed that social avoidance and fear of negative evaluation were associated with current cannabis use (p <.05), but not cocaine. Further, being single was associated with current cannabis use, after controlling for social avoidance and fear of negative evaluation (p <.05). CONCLUSIONS: Transsexuals' levels of anxiety and cannabis/cocaine use are comparable to those in the general population. Cannabis may be used to control anxiety and can have detrimental clinical implications for transsexuals.