Pathways to post-traumatic growth and post-traumatic stress following the Canterbury earthquakes in a cohort of 40-year-olds.

OBJECTIVE: To report on post-traumatic growth and post-traumatic stress following the Canterbury earthquakes and to quantify the relationships between exposure to the earthquakes, post-traumatic growth and post-traumatic stress. METHOD: The Christchurch Health and Development Study is a longitudinal birth cohort study of New Zealanders aged 40 years at the time of latest assessment in 2017. A total of 455 participants were exposed to the Canterbury earthquakes and assessed in 2012 and 2017. Post-traumatic growth was measured in 2017 using the Post-traumatic Growth Inventory. Earthquake-related post-traumatic stress was measured in 2012 using post-traumatic stress disorder items from the Diagnostic Interview Schedule. Post-traumatic growth and post-traumatic stress were modelled using measures of earthquake impact and subjective measures of earthquake consequences (peri-traumatic stress and disruption distress). RESULTS: There was an indirect relationship between earthquake impact and post-traumatic growth. This was mediated via disruption distress. There was also an indirect relationship between earthquake impact and post-traumatic stress. This was mediated via peri-traumatic stress and disruption distress. Post-traumatic growth and post-traumatic stress were not significantly related. CONCLUSIONS: Measurement of post-traumatic growth and post-traumatic stress is required for a holistic understanding of disaster consequences. Subjective assessment of distress following disasters is required to predict their psychological effects.

The long-term impacts of the Canterbury earthquakes on the mental health of the Christchurch Health and Development Study cohort.

OBJECTIVE: Long-term studies following disasters are rare. It is important to quantify long-term effects of disasters to determine impacts on populations over time. We therefore aim to report the long-term associations between exposure to the Canterbury earthquakes and common mental disorders, taking into account potential confounding factors. METHODS: The Christchurch Health and Development Study is a 40-year longitudinal study of a birth cohort of New Zealand children (635 males and 630 females). The Christchurch Health and Development Study includes 884 participants with data on earthquake exposure and mental health outcomes at ages 34 and 40 years. Rates of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) disorders were measured categorically and using an expanded definition that included sub-syndromal symptoms. The current impact of the earthquakes is reported using 12-month prevalence data 7 years after the earthquakes. The cumulative impact of the earthquakes over the 7 years since onset is also reported. RESULTS: There was a linear trend towards increasing rates of disorder with increasing exposure to the earthquakes. After adjusting for covariates, the 12-month prevalence of anxiety disorder symptoms was significantly increased (p = 0.003). The earthquakes were also associated with cumulative increases in symptoms of post-traumatic stress disorder (p < 0.001), anxiety disorder (p = 0.016), nicotine dependence (p = 0.012), and the total number of disorders (p = 0.039). CONCLUSION: The Canterbury earthquakes were associated with persistent increases in Anxiety Disorder symptoms 7 years after their onset. The earthquakes were also associated with cumulative increases in symptoms of common psychiatric disorders. The magnitude of these effects is small, may no longer be clinically significant and has decreased over time.

Psychological distress, loneliness, alcohol use and suicidality in New Zealanders with mental illness during a strict COVID-19 lockdown.

INTRODUCTION: People with pre-existing mental health conditions may have been disproportionally impacted by the COVID-19 pandemic and associated public health restrictions. In this study, we compared psychological outcomes, experiences and sources of stress over the pandemic lockdown in New Zealanders with and without a previous diagnosis of mental illness. METHODS: Two online surveys were conducted in New Zealand over the level 4 lockdown in April 2020 measuring psychological distress, anxiety, well-being, suicidality, alcohol use and subjective experiences. They included 3389 participants, of whom 18.4% reported having been previously diagnosed with a mental illness. RESULTS: During the lockdown, people previously diagnosed with a mental illness had about twice the risk of reporting moderate-high levels of psychological distress (K10 ⩾ 12), at least moderate levels of anxiety (GAD-7 ⩾ 10) and poor well-being (WHO-5 ⩽ 12). They reported increased alcohol use and were about four times as likely to have experienced suicidal thoughts with 3% reporting having made a suicide attempt over the lockdown period. They reported less satisfaction with, and poorer relationships with people in their 'bubble', reduced social contacts and greater loneliness. They also reported higher levels of health and financial concerns. CONCLUSION: During the COVID-19 lockdown in New Zealand, people with a previous diagnosis of a mental illness were at increased risk of detrimental psychological outcomes. This highlights the importance of recognising this and the challenges people face in pandemics.

Evaluation of the All Right? Campaign for tangata whaiora/mental health service users in Canterbury, New Zealand.

All Right? is a wellbeing campaign developed in response to the devastating Canterbury earthquakes of 2010 and 2011. Vulnerable groups post-disaster include people with a prior history of or unresolved mental illness. This research focussed on the reach and impact of All Right? specifically for tangata whaiora/mental health service users. Evaluation objectives were primarily focussed on assessing the extent which mental health service users engaged with All Right? and to determine the impact of this interaction. Both qualitative and quantitative methods were used to gather data. Findings indicated that mental health service users responded to All Right? to a greater extent than the general target population, e.g. about one-third (37%) of respondents to a population based Christchurch survey agreed that they had done activities as a result of what they had seen or heard of the All Right? campaign compared with approximately two-thirds (68%) of respondents to the mental health service users' survey. One of the key factors facilitating mental health service users' engagement with All Right? appears to be that the campaign was directed at whole-of-population level, therefore engagement was not defined by being a mental health service user. Engagement was also likely to be facilitated by the campaigns perceived impact of reducing mental illness-related stigma. This research concluded that population-wide wellbeing campaigns in the post-disaster context, when done well, can positively impact the wellbeing of the overall population, including mental health service users.

Learning from previous disasters: Potential pitfalls of epidemiological psychosocial research in the COVID-19 environment.

It is critical to understand the psychosocial impacts of the COVID-19 pandemic on populations around the world. In this article, we highlight the key challenges associated with epidemiological psychosocial research in a disaster context and reflect on lessons learned from firsthand experience over the last decade in Christchurch, New Zealand, following the 2010/2011 Canterbury earthquakes and 2019 Mosque attacks. We make recommendations for study design to improve the quality of research evaluating the impacts of the COVID-19 pandemic, the inclusion of positive outcome measures and the need to evaluate a range of cultural contexts. We hope that highlighting these areas will improve research and result in a better understanding of the psychosocial impacts of the pandemic.

Impact of the Canterbury earthquakes on dispensing of psychiatric medication for children and adolescents: longitudinal quantitative study.

BACKGROUND: Natural disasters are increasing in frequency and impact; they cause widespread disruption and adversity throughout the world. The Canterbury earthquakes of 2010-2011 were devastating for the people of Christchurch, New Zealand. It is important to understand the impact of this disaster on the mental health of children and adolescents. AIMS: To report psychiatric medication use for children and adolescents following the Canterbury earthquakes. METHOD: Dispensing data from community pharmacies for the medication classes antidepressants, antipsychotics, anxiolytics, sedatives/hypnotics and methylphenidate are routinely recorded in a national database. Longitudinal data are available for residents of the Canterbury District Health Board (DHB) and nationally. We compared dispensing data for children and adolescents residing in Canterbury DHB with national dispensing data to assess the impact of the Canterbury earthquakes on psychotropic prescribing for children and adolescents. RESULTS: After longer-term trends and population adjustments are considered, a subtle adverse effect of the Canterbury earthquakes on dispensing of antidepressants was detected. However, the Canterbury earthquakes were not associated with higher dispensing rates for antipsychotics, anxiolytics, sedatives/hypnotics or methylphenidate. CONCLUSIONS: Mental disorders or psychological distress of a sufficient severity to result in treatment of children and adolescents with psychiatric medication were not substantially affected by the Canterbury earthquakes.

Childhood abuse and psychotic experiences in adulthood: findings from a 35-year longitudinal study.

BACKGROUND: The extent to which exposure to childhood sexual and physical abuse increases the risk of psychotic experiences in adulthood is currently unclear.AimsTo examine the relationship between childhood sexual and physical abuse and psychotic experiences in adulthood taking into account potential confounding and time-dynamic covariate factors. METHOD: Data were from a cohort of 1265 participants studied from birth to 35 years. At ages 18 and 21, cohort members were questioned about childhood sexual and physical abuse. At ages 30 and 35, they were questioned about psychotic experiences (symptoms of abnormal thought and perception). Generalised estimating equation models investigated covariation of the association between abuse exposure and psychotic experiences including potential confounding factors in childhood (socioeconomic disadvantage, adverse family functioning) and time-dynamic covariate factors (mental health, substance use and life stress). RESULTS: Data were available for 962 participants; 6.3% had been exposed to severe sexual abuse and 6.4% to severe physical abuse in childhood. After adjustment for confounding and time-dynamic covariate factors, those exposed to severe sexual abuse had rates of abnormal thought and abnormal perception symptoms that were 2.25 and 4.08 times higher, respectively than the 'no exposure' group. There were no significant associations between exposure to severe physical abuse and psychotic experiences. CONCLUSIONS: Findings indicate that exposure to severe childhood sexual (but not physical) abuse is independently associated with an increased risk of psychotic experiences in adulthood (particularly symptoms of abnormal perception) and this association could not be fully accounted for by confounding or time-dynamic covariate factors.Declaration of interestNone.

The impact of the Canterbury earthquakes on dispensing for older person's mental health.

OBJECTIVE: To evaluate the impact of the Canterbury earthquakes on the mental health of older people by examining dispensing patterns of psychotropic medication. METHOD: Dispensing data from community pharmacies for antidepressants, antipsychotics, anxiolytics, and sedative/hypnotics are routinely recorded in a national database. Longitudinal data are available for residents of the Canterbury District Health Board (DHB) (n = 67 760 at study onset) and the rest of New Zealand (n = 469 055 at study onset). We compared older age dispensing data between 2008 and 2018 for Canterbury DHB with older age dispensing data nationally in order to assess the impact of the Canterbury earthquakes on the mental health of older persons. RESULTS: Older age residents of Canterbury are dispensed antidepressants, antipsychotics, and anxiolytics at higher rates than national comparators, but this finding predated the onset of the earthquakes. Short-term increases in anxiolytic and sedative/hypnotic dispensing occurred for the month following the February 2011 earthquake. No other short- or longer-term increases in dispensing of psychiatric medication were present. CONCLUSION: The February 2011 Canterbury earthquake caused a short-term increase in dispensing of anxiolytics and sedative/hypnotics. No longer-term effects on dispensing were observed. This suggests that older persons sought assistance for insomnia and anxiety in the aftermath of the most devastating earthquake, but longer-term rates of clinically significant anxiety and depression for older persons did not increase as a consequence of the earthquakes sequence.

Traumatic imagery following glucocorticoid administration in earthquake-related post-traumatic stress disorder: A preliminary functional magnetic resonance imaging study.

OBJECTIVE: Post-traumatic stress disorder involves excessive retrieval of traumatic memories. Glucocorticoids impair declarative memory retrieval. This preliminary study examined the effect of acute hydrocortisone administration on brain activation in individuals with earthquake-related post-traumatic stress disorder compared with earthquake-exposed healthy individuals, during retrieval of traumatic memories. METHOD: Participants exposed to earthquakes with (n = 11) and without post-traumatic stress disorder (n = 11) underwent two functional magnetic resonance imaging scans, 1-week apart, in a double-blind, placebo-controlled, counter-balanced design. On one occasion, they received oral hydrocortisone (20 mg), and on the other, placebo, 1 hour before scanning. Symptom provocation involved script-driven imagery (traumatic and neutral scripts) and measures of self-reported anxiety. RESULTS: Arterial spin labelling showed that both post-traumatic stress disorder and trauma-exposed controls had significantly reduced cerebral blood flow in response to retrieval of traumatic versus neutral memories in the right hippocampus, parahippocampal gyrus, calcarine sulcus, middle and superior temporal gyrus, posterior cingulate, Heschl's gyrus, inferior parietal lobule, angular gyrus, middle occipital gyrus, supramarginal gyrus, lingual gyrus and cuneus, and the left prefrontal cortex. Hydrocortisone resulted in non-significant trends of increasing subjective distress and reduced regional cerebral blood flow in the left inferior frontal gyrus, left anterior cingulate gyrus, middle temporal gyrus, cerebellum, postcentral gyrus and right frontal pole, during the trauma script. CONCLUSION: Findings do not fit with some aspects of the accepted neurocircuitry model of post-traumatic stress disorder, i.e., failure of the medial prefrontal cortex to quieten hyperresponsive amygdala activity, and the potential therapeutic benefits of hydrocortisone. They do, however, provide further evidence that exposure to earthquake trauma, regardless of whether post-traumatic stress disorder eventuates, impacts brain activity and highlights the importance of inclusion of trauma-exposed comparisons in studies of post-traumatic stress disorder.

Earthquake brain: Impairment of spatial memory following long-term earthquake-related stress.

OBJECTIVES: The primary aim of this study was to investigate neuropsychological function in patients with earthquake-related posttraumatic stress disorder, compared with earthquake-exposed but resilient controls. We hypothesised that individuals with posttraumatic stress disorder would have poorer neuropsychological performance on tests of verbal and visuospatial learning and memory compared with the earthquake-exposed control group. The availability of groups of healthy patients from previous studies who had been tested on similar neuropsychological tasks prior to the earthquakes allowed a further non-exposed comparison. METHOD: In all, 28 individuals with posttraumatic stress disorder and 89 earthquake-exposed controls completed tests of verbal and visuospatial learning and memory and psychomotor speed. Further comparisons were made with non-exposed controls who had been tested before the earthquakes. RESULTS: No significant difference in performance on tests of verbal or visuospatial memory was found between the earthquake-exposed groups (with and without posttraumatic stress disorder), but the posttraumatic stress disorder group was significantly slowed on tests of psychomotor speed. Supplementary comparison with historical, non-exposed control groups showed that both earthquake-exposed groups had poorer performance on a test of visuospatial learning. CONCLUSION: The key finding from this study is that there were no differences in verbal or visuospatial learning and memory in individuals with posttraumatic stress disorder compared with similarly earthquake-exposed controls. Compared with non-exposed controls, both earthquake-exposed groups had poorer performance on a test of visuospatial (but not verbal) learning and memory. This offers preliminary evidence suggesting that it is earthquake (trauma) exposure itself, rather than the presence of posttraumatic stress disorder that affects aspects of neuropsychological functioning. If replicated, this may have important implications for how information is communicated in a post-disaster context.

Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis.

BACKGROUND: Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.AimsOur aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters. METHOD: This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics. RESULTS: Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27-0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43-2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies. CONCLUSIONS: Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.Declaration of interestNone.

Flexible electronics-compatible non-enzymatic glucose sensing via transparent CuO nanowire networks on PET films.

Diabetic individuals need simple, accurate, and cost effective means by which to independently assess their glucose levels in a non-invasive way. In this work, a sensor based on randomly oriented CuO nanowire networks supported by a polyethylene terephthalate thin film is evaluated as a flexible, transparent, non-enzymatic glucose sensing system analogous to those envisioned for future wearable diagnostic devices. The amperometric sensing characteristics of this type of device architecture are evaluated both before and after bending, with the system's glucose response, sensitivity, lower limit of detection, and effect of applied bias being experimentally determined. The obtained data shows that the sensor is capable of measuring changes in glucose levels within a physiologically relevant range (0-12 mM glucose) and at lower limits of detection (0.05 mM glucose at +0.6 V bias) consistent with patient tears and saliva. Unlike existing studies utilizing a conductive backing layer or macroscopic electrode setup, this sensor demonstrates a percolation network-like trend of current versus glucose concentration. In this implementation, controlling the architectural details of the CuO nanowire network could conceivably allow the sensor's sensitivity and optimal sensing range to be tuned. Overall, this work shows that integrating CuO nanowires into a sensor architecture compatible with transparent, flexible electronics is a promising avenue to realizing next generation wearable non-enzymatic glucose diagnostic devices.

Is there an optimal length of psychological treatment for eating disorder pathology?

Treatment guidelines for eating disorders (ED) are unclear about the optimal length of psychological care. We aimed to investigate associations between treatment duration and changes in ED pathology. Data for 164 outpatients accessing psychological interventions for ED were analyzed using MANOVA. We tested associations between number of therapy sessions and pre-post treatment changes in clinical outcomes (EDE-Q global scores, binge eating, purging); adjusting for baseline measures, diagnoses, and treatment type. Secondary analyses included rapid response variables in the above outcomes by treatment session eight. Partial correlations between treatment duration and BMI changes (adjusting for intake BMI) were examined for anorexia nervosa cases. Treatment duration was not significantly associated with changes in ED outcomes after adjusting for rapid response. BMI change (weight regain) was not correlated with treatment duration in anorexia nervosa cases. Rapid response was associated with better EDE-Q outcomes, but not with changes in binge eating or purging behaviors. ED outcomes are unrelated to treatment duration; rapid response is a useful prognostic indicator for treatment planning.

The role of peri-traumatic stress and disruption distress in predicting symptoms of major depression following exposure to a natural disaster.

OBJECTIVE: Few studies have examined the contribution of specific disaster-related experiences to symptoms of depression. The aims of this study were to do this by examining the roles of peri-traumatic stress and distress due to lingering disaster-related disruption in explaining linkages between disaster exposure and major depressive disorder symptoms among a cohort exposed to the 2010-2011 Canterbury (New Zealand) earthquakes. METHODS: Structural equation models were fitted to data obtained from the Christchurch Health and Development Study at age 35 ( n = 495), 20-24 months following the onset of the disaster. Measures included earthquake exposure, peri-traumatic stress, disruption distress and symptoms of major depressive disorder. RESULTS: The associations between earthquake exposure and major depression were explained largely by the experience of peri-traumatic stress during the earthquakes (ß = 0.180, p < 0.01) and not by disruption distress following the earthquakes (ß = 0.048, p = 0.47). CONCLUSION: The results suggest that peri-traumatic stress has been under-recognised as a predictor of major depressive disorder.

An evaluation of Health of the Nation Outcome Scales data to inform psychiatric morbidity following the Canterbury earthquakes.

OBJECTIVE: Following the onset of the Canterbury, New Zealand earthquakes, there were widespread concerns that mental health services were under severe strain as a result of adverse consequences on mental health. We therefore examined Health of the Nation Outcome Scales data to see whether this could inform our understanding of the impact of the Canterbury earthquakes on patients attending local specialist mental health services. METHOD: Health of the Nation Outcome Scales admission data were analysed for Canterbury mental health services prior to and following the Canterbury earthquakes. These findings were compared to Health of the Nation Outcome Scales admission data from seven other large District Health Boards to delineate local from national trends. Percentage changes in admission numbers were also calculated before and after the earthquakes for Canterbury and the seven other large district health boards. RESULTS: Admission Health of the Nation Outcome Scales scores in Canterbury increased after the earthquakes for adult inpatient and community services, old age inpatient and community services, and Child and Adolescent inpatient services compared to the seven other large district health boards. Admission Health of the Nation Outcome Scales scores for Child and Adolescent community services did not change significantly, while admission Health of the Nation Outcome Scales scores for Alcohol and Drug services in Canterbury fell compared to other large district health boards. Subscale analysis showed that the majority of Health of the Nation Outcome Scales subscales contributed to the overall increases found. Percentage changes in admission numbers for the Canterbury District Health Board and the seven other large district health boards before and after the earthquakes were largely comparable with the exception of admissions to inpatient services for the group aged 4-17 years which showed a large increase. CONCLUSION: The Canterbury earthquakes were followed by an increase in Health of the Nation Outcome Scales scores for attendees of local mental health services compared to other large district health boards. This suggests that patients presented with greater degrees of psychiatric distress, social disruption, behavioural change and impairment as a result of the earthquakes.

Identifying medical students at risk of underperformance from significant stressors.

BACKGROUND: Stress is associated with poorer academic performance but identifying vulnerable students is less clear. A series of earthquakes and disrupted learning environments created an opportunity to explore the relationships among stress, student factors, support and academic performance within a medical course. METHODS: The outcomes were deviations from expected performances on end of year written and clinical examinations. The predictors were questionnaire-based measures of connectedness/support, impact of the earthquakes, safety, depression, anxiety, stress, resilience and personality. RESULTS: The response rate was 77%. Poorer than expected performance on all examinations was associated with greater disruptions to living arrangements and fewer years in the country; on the written examination with not having a place to study; and on the clinical examination with relationship status, not having the support of others, less extroversion, and feeling less safe. There was a suggestion of a beneficial association with some markers of stress. CONCLUSION: We show that academic performance is assisted by students having a secure physical and emotional base. The students who are most vulnerable are those with fewer social networks, and those who are recent immigrants.

The impact of the Canterbury earthquakes on prescribing for mental health.

OBJECTIVE: The aim of this study is to evaluate the impact of the Canterbury earthquakes on the mental health of the local population by examining prescribing patterns of psychotropic medication. METHOD: Dispensing data from community pharmacies for antidepressants, antipsychotics, anxiolytics and sedatives/hypnotics are routinely recorded in a national database. The close relationship between prescribing and dispensing provides the opportunity to assess prescribing trends for Canterbury compared to national data and therefore examines the longitudinal impact of the earthquakes on prescribing patterns. RESULTS: Short-term increases in the use of anxiolytics and sedatives/hypnotics were observed after the most devastating February 2011 earthquake, but this effect was not sustained. There were no observable effects of the earthquakes on antidepressant or antipsychotic dispensing. CONCLUSION: Short-term increases in dispensing were only observed for the classes of anxiolytics and sedatives/hypnotics. No sustained changes in dispensing occurred. These findings suggest that long-term detrimental effects on the mental health of the Canterbury population were either not present or have not resulted in increased prescribing of psychotropic medication.

Psychiatric admissions fall following the Christchurch earthquakes: an audit of inpatient data.

OBJECTIVE: Following the devastating earthquake in Christchurch, New Zealand, there was the widespread perception that the demand for inpatient mental health services would increase. However, our clinical observation was to the contrary, with substantial reductions in inpatient utilisation being noted. We therefore examined psychiatric bed occupancy and admission data to improve understanding of the impact of the disaster on mental health services. METHOD: We audited acute psychiatric bed occupancy and admission rates prior to and following a major earthquake. RESULTS: After the earthquake, total bed occupancy reduced from an average of 93% to 79%. Daily admissions also reduced by 20.2% for the 30 days following the earthquake. All diagnostic groups, with the exception of the 'Schizophrenia, schizotypal and delusional disorders' category, contributed to the reduction. No rebound to increased occupancy or admissions was seen over the study period. CONCLUSION: The study confirmed our clinical observation that demand for acute inpatient psychiatric services were markedly reduced after the February 2011 earthquake.

[Experimentation of care partners program in psychiatry: the model Montreal]. / L'expérimentation du Programme partenaires de soins en psychiatrie : le modèle de Montréal.

UNLABELLED: The approach of the partnership of care and services developed by the direction collaboration dans patient partnership (DCPP) of the Faculty of medicine of the University of Montreal, considers the patient as a full care actor, in the same way as healthcare professionals, his experientiel knowledges are recognized and the patient develops gradually his self-determination. Since 2010, in order to allow cultural changes involved with this approach, the 'Program Partners of Care' (PPC) facilitated resource patient' integration and involvement into Continuous Improvement Committees (CIC), within 29 general and specialized health care teams in 19 health and social services facilities in Quebec, among wich four teams specialized in mental health. The purpose of the article is to describe briefly this approach, to demonstrate that it is successfully applicable to mental health clienteles, under certain conditions. METHOD: The evaluation of this approach arises from quantitative data of self-adminitered questionnaires by the participants of continuous Improvement Commettes, as well as a reflexive approach of the participants and the members of the DCPP to understand the processes and the implemented services. The results reveal that the objectives of transformation selected through the specialized mental health CIC refer to welcoming process in the facilities, to the period of transition from a facilities service to another one, to the patient involvement in their own Interdisciplinary Plan (IIP). Among the faciliting factors for patients' participation in thse CIC: the caregivers and managers' adaptability to adjust to a patient's pace; the identification to the best communication mechanisms to get in touch with them; faciliting discussion in small working group; an existing trust relationship with the members of the CIC; the support of the resource patients between them as well as support by coach patient of the DCPP. The members of the CIC develop a sense of pride, an energy, a new motivation and a group cohesion. The patient develop a sens of belonging to the team, they experience a higher self-esteem as well as developping a sens of usefulness, by contributing to the improvement of specialized mental health facilities. Giving back, as well as participing in the better quality of services fot the benefit of other patients make a whole lot of sense for them, this process even sometimes allows their full revovrey. In conclusion, the report reveals the applicicability of this approach in the field of the mental health. It il all the more attainable when the winning conditions as the closeness of the managers specialized in the domain, the choice of significant targets of continuous improvement for the patients are taken into account.

Cardiorenal syndrome: understanding the connections between cardiac and renal disease.

Renal and cardiac diseases are nearly ubiquitous in hospitalized patients and common causes of morbidity in outpatients. Although the connection between the heart and kidneys is relatively well known in the medical community, a more formal classification for the clinical interplay of the two systems has been developed only recently. Cardiorenal syndrome was described by Italian nephrologist Claudio Ronco in 2008. This classification allows for justification of management strategies in these complex patients and will guide further research studies.