RESUMO
Psychiatric diagnostic categories are neither valid nor stable. They tell us little about the causes of the problems, the prognosis or what treatment might be beneficial. A psychiatric diagnosis must not therefore be a prerequisite for providing proper health care.
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Transtornos Mentais , Humanos , Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologiaRESUMO
[This corrects the article DOI: 10.1186/s13033-016-0064-8.].
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BACKGROUND: Most studies of services for people with severe mental illness have been performed in cities. Our 7-year follow-up study aimed to investigate clinical course and satisfaction with services among individuals with severe mental illness who received community mental health services in a rural area. The services were provided by primary care and a community mental health center (CMHC), which worked in close collaboration and emphasized individually tailored case management, relationship-building and continuity of care. METHODS: All 57 patients with severe mental illness who were seen by the CMHC in 1992-1993 and were still alive in 1999 were asked to participate. Retrospective ratings were performed for the first month of contact in 1992-1993 based on patient records and detailed notes. A semi-structured interview was conducted in 1999-2000 with the 40 patients (70.2 %) who gave written consent to participate in the study. DSM-IV diagnoses were made using OPCRIT. The retrospective baseline ratings and the follow-up interview included assessments of symptoms and functioning using the following instruments: the Brief Psychiatric Rating Scale Expanded version 4 (BPRS-E), the Health of the Nation Outcome Scales (HoNOS), the Global Assessment of Functioning Scale (split version), and the Practical and Social Functioning Scale (PSF). RESULTS: The ratings revealed improvements in psychiatric problems and functioning. Patients with schizophrenia spectrum disorders improved primarily in psychotic symptoms, while patients with severe affective disorders improved primarily in affective symptoms. Large variations in the use of primary care and mental health services were observed, with more intensive specialized mental health services for individuals with schizophrenia spectrum disorders than severe affective disorders. Overall, the patients were satisfied with the provided services. They were most satisfied with GPs and more satisfied with local outpatient and inpatient services than with hospital inpatient services and medication. CONCLUSIONS: Patients with severe mental illness in a rural area value local services that emphasize relationships and close collaborations among the CMHC, GPs and primary health and social care. Even in an area with a fairly well-staffed CMHC, the highest patient satisfaction was reported for GPs, indicating the potential key role of GPs for this patient group.
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BACKGROUND: Music therapy (MT) has been shown to be efficacious for mental health care clients with various disorders such as schizophrenia, depression and substance abuse. Referral to MT in clinical practice is often based on other factors than diagnosis. We aimed to examine the effectiveness of resource-oriented MT for mental health care clients with low motivation for other therapies. METHOD: This was a pragmatic parallel trial. In specialised centres in Norway, Austria and Australia, 144 adults with non-organic mental disorders and low therapy motivation were randomised to 3 months of biweekly individual, resource-oriented MT plus treatment as usual (TAU) or TAU alone. TAU was typically intensive (71% were inpatients) and included the best combination of therapies available for each participant, excluding MT. Blinded assessments of the Scale for the Assessment of Negative Symptoms (SANS) and 15 secondary outcomes were collected before randomisation and after 1, 3 and 9 months. Changes were analysed on an intention-to-treat basis using generalised estimating equations in longitudinal linear models, controlling for diagnosis, site and time point. RESULTS: MT was superior to TAU for total negative symptoms (SANS, d = 0.54, p < 0.001) as well as functioning, clinical global impressions, social avoidance through music, and vitality (all p < 0.01). CONCLUSION: Individual MT as conducted in routine practice is an effective addition to usual care for mental health care clients with low motivation.
Assuntos
Transtornos Mentais/terapia , Motivação , Musicoterapia/métodos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Cooperação do Paciente/psicologia , Adulto , Feminino , Humanos , Análise de Intenção de Tratamento , Relações Interpessoais , Modelos Lineares , Masculino , Transtornos Mentais/psicologia , Escalas de Graduação Psiquiátrica , Autorrelato , Método Simples-Cego , Resultado do TratamentoRESUMO
OBJECTIVE: Antidepressants are supposed to be withdrawn during a manic episode. The aim of this study was to analyze the characteristics of manic patients who received antidepressants during a manic phase in a large, naturalistic study. METHOD: The European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year prospective observational study of inpatients and outpatients with acute mania/mixed mania (DSM-IV or ICD-10 criteria) conducted in 14 European countries. Of 2,416 manic patients who continued into the maintenance phase of the study, 345 (14%) were taking an antidepressant and 2,071 (86%) were not taking an antidepressant at baseline, week 1, and/or week 2 postbaseline. Demographic and clinical variables were collected at baseline and each study visit up to 24 months. Outcome measures included the Clinical Global Impressions-Bipolar Disorder scale (CGI-BP overall, mania, and depression scores) at 12 weeks and 24 months, the 5-item Hamilton Depression Rating Scale (HDRS-5), and the Young Mania Rating Scale (YMRS) at 12 weeks only. The present study was conducted from December 2002 to June 2004. RESULTS: More antidepressant maintenance use was seen in patients with mixed episodes (P < .001), rapid cyclers (P < .02), patients with more previous depressive episodes (P < .001), and patients with higher mean HDRS-5 score at baseline (P < .001)-specifically patients with anxiety (P = .013). Patients in the antidepressant group had significantly higher CGI-BP depression scores (P < .001) and a significantly higher rate of depression relapse (P < .001) at both 12 weeks and 24 months. CONCLUSIONS: Patients with mania receiving antidepressants are more likely to be outpatients with mixed episodes, anxiety, or rapid cycling and have a higher risk of depression relapse during follow-up.
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Antidepressivos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Doença Aguda , Adolescente , Adulto , Idoso , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/psicologia , Estudos Transversais , Europa (Continente) , Feminino , Seguimentos , Humanos , Classificação Internacional de Doenças , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Recidiva , Fatores de Risco , Resultado do TratamentoRESUMO
In bipolar disorder, mood stabilizers and second-generation antipsychotics have a central role in pharmacotherapy. There are, however, substantial differences in how the treatment is realized in different countries. The aim of this paper was to compare the treatment of acute mania in the Nordic countries with other European countries during the first 12 weeks of the EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) study. Adult patients with bipolar disorder were enrolled within standard course of care as in/outpatients if they initiated/changed oral medication with antipsychotics, anticonvulsants or lithium for treatment of acute mania. Five hundred and thirty European psychiatrists including 23 Nordic psychiatrists enrolled 3459 patients including 79 Nordic patients eligible for analysis using the same study methods assessing demographics, psychiatric history, clinical status, functional status and pharmacological treatment. Psychiatric status at inclusion measured by the Young Mania Rating Scale (YMRS) and the Clinical Global Impression-Bipolar Disorder (CGI-BP) were similar in the Nordic and European patient groups, which is surprising as 73% of the Nordic patients compared with 38% of the European patients were inpatients. In the Nordic group of patients, more patients were living independently. Before inclusion in the study more patients in the Nordic group had combination therapy, but after inclusion in the study the prescription pattern of psychopharmacy was similar in the Nordic and the European patient groups. This study indicated differences in admission patterns, patient social functioning and medical treatment in the Nordic patients compared with the European patients.
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Antimaníacos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Comparação Transcultural , Doença Aguda , Adulto , Anticonvulsivantes/uso terapêutico , Antidepressivos/uso terapêutico , Antipsicóticos/uso terapêutico , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/epidemiologia , Estudos Transversais , Dinamarca , Quimioterapia Combinada , Uso de Medicamentos , Europa (Continente) , Feminino , Finlândia , Humanos , Carbonato de Lítio/uso terapêutico , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Noruega , Admissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Ajustamento Social , Fatores SocioeconômicosRESUMO
Despite significant advances in pharmacologic therapy of depression over the past two decades, a substantial proportion of patients fail to respond or experience only partial response to serotonin re-uptake inhibitor antidepressants, resulting in chronic functional impairment. There appears to be a pattern of symptoms that are inadequately addressed by serotonergic antidepressants - loss of pleasure, loss of interest, fatigue and loss of energy. These symptoms are key to the maintenance of drive and motivation. Although these symptoms are variously defined, they are consistent with the concept of ;decreased positive affect'. Positive affect subsumes a broad range of positive mood states, including feelings of happiness (joy), interest, energy, enthusiasm, alertness and self-confidence. Although preliminary, there is evidence to suggest that antidepressants that enhance noradrenergic and dopaminergic activity may afford a therapeutic advantage over serotonergic antidepressants in the treatment of symptoms associated with a reduction in positive affect. Dopaminergic and noradrenergic agents, including the dual acting norepinephrine and dopamine re-uptake inhibitors, have demonstrated antidepressant activity in the absence of serotonergic function, showing similar efficacy to both tricyclic and serotonin re-uptake inhibitor antidepressants. Moreover, the norepinephrine and dopamine re-uptake inhibitor bupropion has been shown to significantly improve symptoms of energy, pleasure and interest in patients with depression with predominant baseline symptoms of decreased pleasure, interest and energy. Focusing treatment on the predominant or driving symptomatology for an individual patient with major depression could potentially improve rates of response and remission.
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Afeto/efeitos dos fármacos , Antidepressivos/uso terapêutico , Catecolaminas/metabolismo , Transtorno Depressivo Maior/tratamento farmacológico , Inibidores da Captação de Neurotransmissores/uso terapêutico , Inibidores da Captação Adrenérgica/uso terapêutico , Antidepressivos/farmacologia , Transtorno Depressivo Maior/metabolismo , Transtorno Depressivo Maior/psicologia , Dopamina/metabolismo , Inibidores da Captação de Dopamina/uso terapêutico , Humanos , Inibidores da Captação de Neurotransmissores/farmacologia , Norepinefrina/metabolismo , Seleção de Pacientes , Indução de Remissão , Serotonina/metabolismo , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Previous research has shown positive effects of music therapy for people with schizophrenia and other mental disorders. In clinical practice, music therapy is often offered to psychiatric patients with low therapy motivation, but little research exists about this population. The aim of this study is to examine whether resource-oriented music therapy helps psychiatric patients with low therapy motivation to improve negative symptoms and other health-related outcomes. An additional aim of the study is to examine the mechanisms of change through music therapy. METHODS: 144 adults with a non-organic mental disorder (ICD-10: F1 to F6) who have low therapy motivation and a willingness to work with music will be randomly assigned to an experimental or a control condition. All participants will receive standard care, and the experimental group will in addition be offered biweekly sessions of music therapy over a period of three months. Outcomes will be measured by a blind assessor before and 1, 3, and 9 months after randomisation. DISCUSSION: The findings to be expected from this study will fill an important gap in the knowledge of treatment effects for a patient group that does not easily benefit from treatment. The study's close link to clinical practice, as well as its size and comprehensiveness, will make its results well generalisable to clinical practice.
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Protocolos Clínicos , Transtornos Mentais/psicologia , Transtornos Mentais/terapia , Motivação , Musicoterapia/métodos , Adulto , Atitude Frente a Saúde , Protocolos Clínicos/normas , Terapia Combinada , Seguimentos , Humanos , Classificação Internacional de Doenças , Transtornos Mentais/diagnóstico , Noruega , Processos Psicoterapêuticos , Projetos de Pesquisa/normas , Resultado do TratamentoRESUMO
Several effective treatments for social phobia are now available, notably cognitive behavioural therapy and some antidepressant medications. Controlled trials indicate that 25-45% of patients fail to respond to the initial treatment. To my knowledge, nothing has yet been published on the treatment of refractory cases. Phenelzine is effective in social phobia, and no treatment has been shown to be superior to phenelzine. Hence, phenelzine is a reasonable option for patients unresponsive to other treatments. This report presents the results of naturalistic, open-label phenelzine treatment of a series of seven consecutive, previously unresponsive patients treated with a mean dose of phenelzine 66 mg. Six patients were classified as responders according to Clinical Global Impression (CGI) ratings. Some experienced dramatic improvement and regained ability to function in school or work. Two patients experienced re-emergence of social phobia while on maintenance therapy. The majority of patients had a sustained response and elected to stay on the medication. There were no serious adverse events. Two patients discontinued due to side-effects. The drawbacks of phenelzine therapy may be more than outweighed by its potential utility in relieving social anxiety disorder. Phenelzine appears to be effective in treating social phobia that has been unresponsive to other treatments. No patient should be considered treatment resistant without being offered a trial of phenelzine.
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Inibidores da Monoaminoxidase/uso terapêutico , Fenelzina/uso terapêutico , Transtornos Fóbicos/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Transtornos Fóbicos/diagnóstico , Escalas de Graduação Psiquiátrica , Resultado do TratamentoRESUMO
Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment in psychiatry. We reviewed all published evidence on the efficacy of this treatment option in depressive disorders. An extensive electronic and manual search for eligible research reports identified only 12 studies that met the predetermined criteria for inclusion. rTMS was administered differently in most studies, and patient characteristics varied widely. A formal meta-analysis of the studies was thus not possible. Instead, we conducted a qualitative evaluation of the included studies. The antidepressive efficacy was not consistent, and where efficacy was demonstrated, it was modest in most studies. Some patients had good but transient responses to rTMS. Treatment gains were not maintained beyond the treatment period. Comparisons with electroconvulsive therapy (ECT) indicated the superiority of ECT. More, larger and more carefully designed studies are needed to demonstrate convincingly a clinically relevant effect of rTMS. We conclude that there is insufficient evidence for rTMS as a valid treatment for depression at present.