Medium and long-term efficacy of psychoeducational family intervention for bipolar I disorder: Results from a real-world, multicentric study.

OBJECTIVES: This study aims to explore the long-term efficacy of a psychoeducational family intervention (PFI) in bipolar I disorder at one and five years post-intervention in terms of improvement of: (1) patients' symptoms and global functioning and (2) relatives' objective and subjective burden and coping strategies. METHODS: This is a multicentre, real-world, controlled, outpatient trial. Recruited patients and key-relatives were consecutively allocated to the experimental intervention or treatment as usual. Patients were assessed at baseline, and after one and five years. RESULTS: One hundred and thirty-seventh number families have been recruited; 70 have been allocated to the experimental intervention, and 67 have been allocated to the control group. We observed an increasing positive effect of the PFI on patients' clinical status, global functioning and objective and subjective burden after one year. We also found a reduction in the levels of relatives' objective and subjective burden and a significant improvement in the levels of perceived professional support and of coping strategies. The efficacy of PFI on patients' clinical status was maintained at five years from the end of the intervention, in terms of relapses, hospitalizations and suicide attempts. CONCLUSIONS: The study showed that the provision of PFI in real-world settings is associated with a significant improvement of patients' and relatives' mental health and psychosocial functioning in the long term. We found that the clinical efficacy of the intervention, in terms of reduction of patients' relapses, hospitalization and suicide attempts, persists after 5 years. It is advisable that PFI is provided to patients with BD I in routine practice.

The State of the Art of the DSM-5 "with Mixed Features" Specifier.

The new DSM-5 "with mixed features" specifier (MFS) has renewed the interest of the scientific community in mixed states, leading not only to new clinical studies but also to new criticisms of the current nosology. Consequently, in our paper we have reviewed the latest literature, trying to understand the reactions of psychiatrists to the new nosology and its epidemiological, prognostic, and clinical consequences. It seems that the most widespread major criticism is the exclusion from the DSM-5 MFS of overlapping symptoms (such as psychomotor agitation, irritability, and distractibility), with a consequent reduction in diagnostic power. On the other hand, undoubtedly the new DSM-5 classification has helped to identify more patients suffering from a mixed state by broadening the narrow DSM-IV-TR criteria. As for the clinical presentation, the epidemiological data, and the therapeutic outcomes, the latest literature does not point out a univocal point of view and further research is needed to fully assess the implications of the new DSM-5 MFS. It is our view that a diagnostic category should be preferred to a specifier and mixed states should be better considered as a spectrum of states, according to what was stated many years ago by Kraepelin.

The psychosomatic spectrum: a clinical-analytic survey of the relationship between eating disorders and migraine.

OBJECTIVE: To evaluate if somatic symptoms of Eating Disorders and Migraine reflect similar aspects of personality and temperament. METHODS: The clinical notes of 27 migraineurs and of 26 ED outpatients were reviewed; 40 medical students of the University of Perugia were recruited as healthy controls. TCI, DMI, SCID-II and TAS-20 were used. STATISTICAL ANALYSIS: performed by logistic regression, a cluster analysis that gave the weight for the three groups, and a logistic regression of the cluster analysis. RESULTS: Patients showed medium scores in almost all the scales of the different tests. High scores in HA and low scores in NS characterized both migraine and ED patients. Logistic regression of the cluster analysis underscored that ED patients, migraineurs, and controls differed for HA (435.424, p≤0.0001), TAS-20 F2 (difficulty in describing feelings to others; 7.087, p=0.029), and the defense mechanism turning against object (6.702, p=0.035). DISCUSSION: The temperamental aspects of low NS and high HA represent the core symptoms of a spectrum composed of somatizing patients who use affective and behavioral strategies that are not functional enough in affective regulation.

Psychosocial functioning in consultation-liaison psychiatry patients: influence of psychosomatic syndromes, psychopathology and somatization.

BACKGROUND: This study investigated whether the Diagnostic Criteria for Psychosomatic Research (DCPR) were able to predict psychosocial functioning in addition to psychiatric diagnoses and somatization in consultation-liaison psychiatry (CLP) patients. METHOD: A consecutive sample of 208 CLP patients were recruited and assessed for sociodemographic and medical data, psychopathology (SCID), psychosomatic syndromes (DCPR structured interview) and somatization (SCL-90-R SOM scale and multisomatoform disorder, MSD). The main endpoints were the mental and physical components of psychosocial functioning (SF-36). RESULTS: A total of 185 (89%) patients had any psychiatric diagnosis, 51 (25%) had MSD positive criteria, 176 (85%) had any DCPR syndrome, and 105 (51%) had multiple DCPR syndromes. Although psychiatric and psychosomatic syndromes were variously associated with psychosocial functioning, hierarchical regression and effect size analyses showed that only DCPR syndromes, particularly demoralization and health anxiety, with somatization but not DSM-IV psychopathology independently predicted poor psychosocial functioning. CONCLUSIONS: The presence of psychosomatic syndromes, assessed with DCPR criteria, and high levels of somatization had larger effect size and were independent predictors of the mental and physical components of psychosocial dysfunction, over and above psychopathology. The DCPR classification can provide CLP professionals with a set of sensitive diagnostic criteria for a comprehensive clinical evaluation of psychosomatic syndromes that might play a significant mediating role in the course and the outcome of medical patients referred for psychiatric consultation.

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study.

Background: Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients' personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives' coping strategies in BD. Methods: A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania "Luigi Vanvitelli" has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group. Results: The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as "maintenance of social interests" (odds ratio [OR]=0.309, CI=0.04-0.57; p=0.023), "positive communication with the patient" (OR=0.295, CI=0.13-0.46; p=0.001), and "searching for information" (OR=0.443, CI=0.12-0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt "resignation" (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and "coercion" (OR=-0.268, CI=-0.46 to -0.08; p=0.006) strategies, compared to TAU relatives. Conclusion: PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.

Symptoms of depression in late luteal phase dysphoric disorder: a variant of mood disorder?

BACKGROUND: In premenstrual syndrome, depressed mood in the luteal phase of the menstrual cycle is acknowledged, whereas the presence of symptoms of depression during the follicular phase remains in debate. METHODS: On the basis of prospective daily recording of the presence and severity of symptoms for at least two menstrual cycles, 43 women were diagnosed with Late Luteal Phase Dysphoric Disorder (LLPD) according to the criteria of the third edition revision of the Diagnostic and Statistical Manual of Mental Disorders. They were compared to a group of 85 women who showed no evidence of LLPD for two menstrual cycles. Structured psychiatric interviews were administered during the follicular phase. Only those subjects without Axis I disorders were subsequently included in the study. RESULTS: Those women with minor/moderate symptoms of depression had an odds of suffering from LLPD of 1.9 (95% CI=1.5-2.4, p<0.001) in relation to increasing severity of symptoms of depression at the total MADRS scale (1-point increase). The ORs of LLPD in relation to each dimension (1-point increase) of the emotional/affective, cognitive, and neurovegetative symptoms were 1.6 (95% CI=1.2-2.3, p=0.003), 2.8 (95% CI=0.9-8.5, p=0.077) and 3.3 (95% CI=1.9-5.9, p<0.001), respectively. LIMITATIONS: No hormonal changes that may be associated with symptoms of LLPD were determined in this study. CONCLUSIONS: LLPD is likely to represent a variant of a depressive disorder, where premenstrual psychobiological changes seem to exacerbate mild depressive symptoms and signs to which LLPD women are otherwise predisposed. This hypothesis opens new perspectives for prevention and of even treatment for LLPD. Further longitudinal studies with larger populations and evaluation of hormonal changes are needed to confirm these data.

Consultation-Liaison Psychiatry-from theory to clinical practice: an observational study in a general hospital.

BACKGROUND: To investigate significant association between various clinical and extra-clinical factors brought out the activities of Consultation-Liaison Service. METHODS: Data from all psychiatric consultations for patients admitted to the Perugia General Hospital and carried out over a 1-year period (from July the 1st 2009 to June the 30th 2010) were collected by a structured clinical report including: socio-demographic features, features of referrals, features of back-referrals. T-test, Mann-Whitney U-test, χ(2)-test and Fischer's were statistically used. RESULTS: 1098 consultations were performed. The consultations carried out the Emergency Unit were excluded from the study. The type and the reasons for the referrals were discussed such as the ICD-10 diagnosis and the liaison interventions too. Significant associations emerged between gender and: social status and occupation (p < 0.05 and p < 0.01 respectively). Clinical sector related with reason for referral (p < 0.01), type of consultation (p < 0.01), liaison investigations (p < 0.01) and long-term treatment plan after hospital discharge (p < 0.01). The ICD-10 psychiatric diagnosis (Schizophrenia, Affective Syndrome and Neurotic-StressSomatoform Syndrome) was associated with social status (p < 0.01), social condition (p < 0.01), consultation type (p < 0.01), advice (p < 0.01) and reason for consultation (p < 0.01). CONCLUSIONS: The need for better physical and psychological investigation is confirmed in order to promote not only disease remission but overall wellbeing.

Psychiatric needs of male prison inmates in Italy.

This paper presents data on the mental health needs of men in an Italian prison and examines if mental health needs of inmates differ across key correctional subpopulations. Interviewers conducted semi-structured clinical interviews with 526 convicted males incarcerated in the Spoleto Prison from October 2010 through September 2011. Nearly two thirds (65.0%) of inmates had an Axis I or Axis II disorder. About half (52.7%) had an Axis I disorder. Personality disorders were the most common disorders (51.9%), followed by anxiety (25.3%) and substance use disorders (24.9%). Over one third of inmates (36.6%) had comorbid types of disorder. The most common comorbid types of disorders were substance use disorders plus personality disorders (20.1%) and anxiety disorders plus personality disorders (18.0%). Findings underscore a significant need for specialized mental health services for men in Italian prisons. Moreover, as inmates return to the community, their care becomes the responsibility of the community health system. Service systems must be equipped to provide integrated services for those with both psychiatric and substance use disorders and be prepared for challenges posed by patients with personality disorders.

Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled, multicentric, real-world study.

BACKGROUND: This study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to bipolar I disorder. The efficacy of the intervention was evaluated in terms of improvement of patients׳ social functioning and reduction of family burden. METHODS: This was a multicentre, real-world, controlled, outpatient trial carried out in 11 randomly recruited Italian mental health centres. Enroled patients and key-relatives were consecutively allocated either to receive PFI and Treatment As Usual (TAU) or to a waiting list receiving TAU alone. The efficacy of the intervention was evaluated in terms of improvement in patients׳ social functioning (primary outcome) and reduction of family burden (secondary outcome). RESULTS: Of the 137 recruited families, 70 were allocated to the experimental group and 67 to the control group. At the end of the intervention, significant improvements in patients׳ social functioning and in relatives׳ burden were found in the treated group compared to TAU. This effect of the intervention remained also after controlling for several confounding patient׳s socio-demographic and clinical factors. The experimental intervention had an impact also on other outcome measures, such as patients׳ clinical status and personal burden. LIMITATIONS: Lack of an active control group. CONCLUSIONS: The results of this study clearly show that the psychoeducational family intervention according to the Falloon model is effective in improving the social outcome of patients with bipolar I disorder.

Pathways to mental health care in Italy: results from a multicenter study.

BACKGROUND AND AIMS: In Italy, the reform of the mental health system in 1978 should have drastically changed the provision of care and pathways of patients seeking to obtain it. The aim of this article is to examine the current pathways to psychiatric care in Italy. METHODS: We used a method developed in the World Health Organization international collaborative studies to investigate pathways to care in 15 Italian mental health centers. We recruited 420 patients with a psychiatric illness and explored the care pathways they took to reach to psychiatric services and the delays from the onset of illness to reaching psychiatric care. RESULTS: The majority of patients (33.8%) had direct access to mental health care, whereas the others arrived to a specialist in psychiatry through general hospitals (20.3%), general practitioners (33.0%) or private practitioners (9.8%). The main diagnosis for referral was neurotic disorder (36.6%), followed by affective disorder (35.4%) and psychotic disorder (11.5%). The delay from onset of illness to psychiatric care was greater for patients with psychotic disorders than for those with affective and neurotic disorders. The most frequently prescribed treatments were pharmacotherapy (56%), psychological support (8%), and psychotherapy (7.0%); 15% of the patients received no treatment. CONCLUSIONS: Our multicenter study shows that although general practitioners and hospital doctors are still the main referral point for mental health care, a greater proportion of patients are first seen in private settings or directly reach mental health centers, compared to previous surveys conducted in Italy. However, a stronger collaboration of psychiatrists with general practitioners and psychologists is still needed.

[Comorbility between anxiety and depression in patients with carcinoid tumors]. / Comorbilità di ansia e depressione nei pazienti con tumori carcinoidi.

BACKGROUND: People who have malignant cancer are plagued with a variety of symptoms that often severely limit their lives. In the case of carcinoid tumors, symptoms of anxiety and depression are two manifestations often associated with disturbances produced by the tumor itself and the chemicals that the tumor secretes. The aim of this study was to compare the incidence of these symptoms for gastro-entero-pancreatic (GEP) tumors and non-gastro-entero-pancreatic (non-GEP). METHODS: Patients with GEP and patients with non-GEP completed the Hospital Anxiety and Depression Scale (HADS). HADS and all of its subscales were analyzed. RESULTS: Patients with GEP tended to have higher average total scores on the HADS-D than those with non-GEP (p<0.08), and items in which the difference between GEP and non-GEP were statistically significant were anhedonia (p<0.05), a reduced ability to laugh and have fun (p<0.05), and the feeling of hopelessness (p<0.05). No significant differences emerged, however, in HADS-T and HADS-A scores. CONCLUSIONS: On the basis of these findings, patients with GEP are affected more than patients with non-GEP with increased levels of depressive and anxiety symptoms. What is difficult to determine, however, is whether these symptoms are related to hormone overproduction, or whether they are related to tumor-related emotional distress.

[Urban insecurity and fear of crime in people suffering from mental disorders: a study in 24 Mental Health Centers in Italy]. / Insicurezza percepita e paura del crimine in persone affette da disturbi mentali: uno studio in 24 Centri di Salute Mentale.

AIMS: To assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes. METHODS: Twenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists' Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools. RESULTS: The final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (± 13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%). DISCUSSION AND CONCLUSIONS: Our results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients' psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders.

Botulinum A toxin intravesical injections for painful bladder syndrome: impact upon pain, psychological functioning and Quality of Life.

INTRODUCTION: To assess the impact of intravesically injected botulinum A toxin (BoNT/A) upon bladder pain, urological complaints, symptoms of anxiety and depression, and Quality of Life (QoL) in patients with painful bladder symptoms (PBS) refractory to conventional treatment. PATIENTS AND METHODS: In this prospective study 14 patients received one injection of BoNT/A (200 U diluted in 20 ml 0.9% NaCl), under cystoscopic guidance. At pre- and 3 months post- treatment all patients underwent an urological assessment (voiding diary, urodynamics), a pain quantification on a visual analog scale (VAS), an evaluation with the 14-item Hamilton Anxiety Rating Scale (HAM-A) to assess symptoms of psychic and somatic anxiety, an evaluation with the Hamilton Depression Rating Scale (HAM-D) to assess depression, and the 36-item Medical Outcomes Study Short Form (SF-36) to assess QoL. Results. At pre-treatment all 14 patients had increased daytime and nighttime urinary frequency and high VAS scores. Nine patients had pathological HAM-A scores and all had pathological HAM-D scores. At the 3-month follow-up 10/14 patients reported a subjective improvement in pain. Mean VAS score, mean daytime and nighttime urinary frequency decreased significantly (p <0.01, <0.01 and <0.01, respectively). All domains in SF-36 and HAM-A significantly improved (p<0.01). All domains, except weight and sleep disorders, significantly improved in HAM-D, particularly somatoform symptoms (p<0.01), cognitive performance (p<0.01), and circadian variations (p<0.01). CONCLUSION: In patients with refractory PBS with symptoms of anxiety, depression and poor QoL, BoNT/A intravesical treatment reduced bladder pain, improved psychological functioning, and well-being.

Co-occurring psychiatric and substance use disorders among male detainees in Italy.

This paper presents data on the prevalence of co-occurring substance use and psychiatric disorders among newly imprisoned males in Italy. Interviewers conducted semi-structured clinical interviews with n=302 male detainees seven days after their admission to the prison of Perugia from August 2005 through July 2006. Over half of male detainees (54.3%) had either a substance use disorder or another psychiatric disorder. One of every five detainees (20.9%) had comorbid substance use and psychiatric disorders. Compared to detainees with psychiatric disorder only, substance use disorder only, or no disorder, detainees with comorbid substance use and psychiatric disorders were significantly more likely to have severe impairment in the areas of employment, substance abuse, family and social functioning, and psychiatric symptoms. Findings underscore the need for careful diagnostic screening at intake, access to treatment during detention, and an effective transition to services at the time of release.