Psychiatry in the emergency room: one year period of clinical experience.

OBJECTIVE: We examined the psychiatric consultations carried out over one year at the Emergency Room (ER) of the hospital of Perugia, with the aim of describing the epidemiologic characteristics of patients with any psychiatric illness and their management. We also assessed the distribution of psychiatric emergencies over this year of observation. METHOD: We recruited patients admitted to the ER, between July 2011 and June 2012, for which a psychiatric consultation was required. We used the t-test for continuous variables. Categorical variables were analyzed with the chi-squared test and the Fisher exact test. We considered significant test results with p<0.05. The post-hoc analyses were carried out with Bonferroni or Sidak correction. Statistical analyses were performed using STATA 12.0. RESULTS: Neurotic, stress-related and somatoform disorders were the most represented. The most frequent approach to patients with psychiatric complaints did not imply the use of psychopharmacological treatments or coercive interventions. No particular seasonality of psychopathology was observed. CONCLUSIONS: One of the fundamental aspects of the psychiatric intervention is empathy along with the attempt to enter into a relationship with the patient, in order to share, where possible, the therapeutic project, particularly in the case the of patients with acute and severe psychiatric illnesses.

Psychiatry in the emergency room: clinical experience in Perugia.

BACKGROUND: We examined all psychiatric consultations carried out over 3 years at the Emergency Room (ER) of the hospital of Perugia, with the aim of describing the epidemiologic characteristics of patients with any psychiatric illness and their management. We also assessed the distribution of psychiatric emergencies over this period of observation. SUBJECTS AND METHODS: We recruited patients consecutively admitted to the ER, between June the 20th 2011 and June the 20th 2014, for which a psychiatric consultation was required. We analysed socio-demographic and clinical data as well as the type of long-range plan after discharge. Continuous variables were presented as means and standard deviations. Categorical variables were presented as number and percentages. For comparing the means we used the Student's t-test. For analyzing the association between categorical variables we performed Pearson's chi-squared test or the Fisher's exact test where appropriate. We considered significant test results with p<0.05. The post-hoc analyses were carried out by means of standardized Pearson residuals, in order to assess the significance of the cell-wise divergences from homogeneity. Spearman's correlations were computed for reasons for a psychiatric consultation request across months. Multinomial logistics regression model was used for analyzing the variability of the reasons for the admission to the ER for the 12 months. Statistical analyses were performed using the R software v 3.1. RESULTS: Neurotic, stress-related and somatoform disorders were the most represented. The most frequent approach to patients with psychiatric complaints did not imply the use of psychopharmacological treatments or coercive interventions. No particular seasonality of psychopathology was observed. CONCLUSIONS: ERs may represent the place where the first psychiatric visit occurs and a point of reference for the chronic patients. It can also represent an opportunity for further examination of organic comorbidity.

Resilience and depressive disorders.

INTRODUCTION: There is considerable variability in the response of individuals to adverse environmental conditions, while some develop psychiatric illnesses like depression, others seem very capable of dealing with it. It is in this observation that the concepts of vulnerability and resilience are rooted. METHODS: We conducted a review of the literature by inserting in PubMed the keywords resilience, vulnerability and depressive disorders. DISCUSSION AND CONCLUSIONS: Freud formerly used the so-called crystal-principle to describe the concept of vulnerability: according to this, the different psychopathologies would arise depending on the different psychological weaknesses, just like a crystal thrown to the ground shatters along its lines of cleavage intrinsic to it, albeit invisible. The term resilience has been borrowed from physics where it is used to describe the ability of a material to withstand impact without cracking. In psychology, the term resilience refers to a complex and dynamic multidimensional construct, which derives from the interaction of neurobiological, social and personal factors and indicates the ability to adaptively cope with stress and adversity, preserving a normal physical and psychological functioning. Resilience has proven to be a protective factor against the development of psychiatric disorders such as depression. Making a conceptual leap, the concepts of vulnerability and resilience can be related to the psychodynamic classification of depression postulated by Gaetano Benedetti, who distinguished four kinds of depression: the first due to the failure of the ego, the second to the perversion of the superego, the third to the inhibition of the Id and the fourth to the collapse of the ego ideal. It is possible to improve the resilience of depressed subjects through pharmacological and psychotherapeutic interventions.

Comparing a Community Mental Health team in Bedford (UK) with Community Mental Health Services in Perugia (Italy): description of teams and caseloads.

INTRODUCTION: The aim of our work is to evaluate and compare some of the key indicators that characterize one English Community Health team (Bedford), two Italian Mental Health Services, in Bastia and Magione, and one University Hospital Mental Health Service, in Perugia. Our work was conducted on the basis of a collaboration between Cambridge University (UK) and the University of Perugia (Italy). SUBJECTS AND METHODS: We analyzed and described the teams supplying information about the number of psychiatrists, types of staff and populations in the catchment areas. Furthermore, we analyzed their caseloads, referring to the epidemiologic features and the diagnostic aspects. We considered the population that were referred to the services in February 2013. RESULTS: There are some differences between the organization of the teams and the caseloads of the Community Mental Health Services in Italy and in England and between the community health services and the hospital service. As for the diagnostic aspects, Mood Disorders seem to be the most frequent diagnosis in each service (Bedford 53.8%, Perugia 48%, Magione 45%, Bastia 38%). CONCLUSIONS: The World Health Organisation identifies strong links between mental health status and development for individuals, communities and countries. In order to improve the mental health of the population, countries need effective and accessible treatment, prevention, and promotion programs. Achieving adequate support for mental health in any country requires a unified and shared approach. Little research has been done to describe the Mental Health Services in the different countries of the world, consequently more studies are needed to assess the improvements in the mental health system in relation to the services available for the population. In our study, according to the literature, we detected that mood disorders are the most frequent cause of referral to mental health services in all the populations studied.

Suicidal attempts among Emergency Department patients: one-year of clinical experience.

INTRODUCTION: Suicidal ideation and attempts account for a significant number of Emergency Department visits and represent a major public and mental health problem. Suicide and suicide attempts are a major cause of death and morbidity worldwide. SUBJECTS AND METHODS: 111 suicide attempters (81 F (73%), 30 M (27%)) were consequently recruited in the Emergency Department of the Santa Maria della Misericordia, Perugia, Italy between June 2011 and June 2012. Patients were assessed and demographic and clinical data were collected in clinical records. Data analysis was conducted using SPSS software. Chi-square test and logistic regression were used as appropriate. A p-value <0.05 was considered statistically significant. RESULTS: Females attempt suicide 3 times more frequently than males and generally use a non-violent suicide attempt method. In our sample unmarried status is the most represented and the most common diagnosis is major depressive disorder, followed by borderline personality disorder. Suicide attempts are more frequent in January. CONCLUSION: It is of crucial importance to conduct a suicide risk assessment when subjects are admitted to an ED given that the strongest known predictor for future suicide is attempted suicide.

The continuum between Bipolar Disorder and Borderline Personality Disorder.

INTRODUCTION: Several studies have been carried out regarding the possible overlap between Bipolar Disorder and borderline personality disorder. Up to now, it is not possible to provide a definitive picture. In fact, there is currently significant debate about the relationship between Borderline Personality Disorder and Bipolar Disorder. METHODS: MEDLINE searches were performed to identify the latest studies of these disorders, considering psychodynamic aspects. DISCUSSION: Bipolar disorder and borderline personality disorder share common clinical features, namely affective instability and impulsivity which however differ in quality. Consequently, to better understand these aspects, it is necessary to trace the stages of childhood psychological development. CONCLUSIONS: It has been claimed that Bipolar Disorder Type II can be divided into two subtypes: one stable and functional between episodes and one unstable between episodes which is related to Borderline Personality Disorder. However, better diagnostic theories, psychiatrist's empathy and patience remain the essential tool to understand and to face human suffering.

Differences in the personality profile of medication-overuse headache sufferers and drug addict patients: a comparative study using MMPI-2.

BACKGROUND: Medication-overuse headache (MOH) refers to headache attributed to excessive use of acute medications. The role of personality needs studies to explain the shifting from drug use to drug abuse. The main aim of this study is to study personality, according to Minnesota Multiphasic Personality Inventory, comparing MOH, episodic headache, substance addicts (SA) vs healthy controls. METHODS: Eighty-two MOH patients (mean age 44.5; 20 M, 62 F) and 35 episodic headache (mean age 40.2; 8 M, 27 F), were compared to 37 SA (mean age 32.5; 29 M, 8 F) and 37 healthy controls (mean age: 32.49; 20 M, 17 F). International Classification of Headache Disorders 2nd Edition criteria were employed. Chi-square test, Kruskal-Wallis test, and post hoc comparisons were used for statistics. RESULTS: MOH patients scored higher on Hypochondriasis, Depression (only females), Hysteria (only females) (P < .000). MOH did not show higher scores than episodic headache or healthy controls in dependency scales, while SA did. CONCLUSION: The data obtained show that MOH and SA do not share common personality characteristics linked to dependence. Although further studies are needed to understand if such a difference is related to instrumental characteristics or to yet undiscovered psychobiological characteristics of MOH patients; however, we hypothesize that the detected difference may rely on the fact that drug dependence in the 2 groups is promoted by entirely different needs: pleasure seeking in the SA group, pain avoidance in the MOH group.

Medication-overuse headache and personality: a controlled study by means of the MMPI-2.

OBJECTIVE: The main aim of this study involves comparing the personality profiles of patients with medication-overuse headache (MOH) and episodic headaches, in order to elucidate the role of personality characteristics, according to one of the most widely used and validated personality assessment tool: Minnesota Multiphasic Personality Inventory (MMPI-2). BACKGROUND: Many studies have assessed the personality of headache patients by means of MMPI-2 only using clinical and content scales. In this study the supplementary scales were also used as they evaluate different aspects of personality, particularly broad personality characteristics, generalized emotional distress and behavioral dyscontrol. METHODS: We recruited 219 subjects (151 women and 68 men) who were grouped in the following categories: MOH group (n = 82); episodic headache group (n = 82; 58 migraine aura; 6 migraine with aura; 6 frequent episodic tension-type headache; 12 migraine+infrequent episodic tension-type headache) and 1 group of 55 healthy controls. MMPI-2 was employed. Data were computed with one-way anova and post hoc analyses. RESULTS: Medication-overuse headache and episodic headache patients (EH) showed a very similar pattern, differentiating each other only in the Hypochondriasis (Hs) (P = .007; MOH: mean 14.18 [SD 5.53]; EH: mean 11.93 [SD 5.88] and Health Concerns [HEA]) (P = .005; MOH: mean 14.06 [SD 5.38]; EH: mean 11.81 [SD 5.59]) scales. Surprisingly, no differences were found between the 3 groups in the scales measuring dependence-related behavior such as Addiction Potential Scale (Aps) and Addiction Admission Scale (Aas). MOH and episodic headache patients scored significantly higher in the so-called neurotic scales Hs (P < .0001; MOH: mean 14.18 [SD 5.53]; EH: mean 11.93 [SD 5.88]; CONTROLS: mean 5.91 [SD 3.57]), Depression (D) (P < .0001; MOH: mean 26.44 [SD 7.01]; EH: mean 26.09 [SD 5.85]; CONTROLS: mean 21.47 [SD 4.90]), and Hysteria (Hy) (P < .0001; MOH: mean 27.33 [SD 5.51]; EH: mean 26.81 [SD 5.68]; CONTROLS: mean 21.95 [3.85]) and in many other scales such as Paranoia (Pa), Psychasthenia (Pt), Schizophrenia (Sc) while they scored significantly lower on Ego Strength (Es) and Dominance (Do) scales when compared with controls. CONCLUSIONS: Patients with MOH and episodic headache showed very similar patterns, differentiating only in the Hypochondriasis and Health Concerns scales. Surprisingly, there were no significant differences in the scores of the scales measuring dependence-related behavior. The clinical role of MMPI-2 in discriminating MOH patients with dependency from drugs is discussed, in order to implement a complete tests' battery for headache patients' assessment.