Dermatological Manifestations in the Intensive Care Unit: A Practical Approach.

Dermatological problems are not usually related to intensive medicine because they are considered to have a low impact on the evolution of critical patients. Despite this, dermatological manifestations (DMs) are relatively frequent in critically ill patients. In rare cases, DMs will be the main diagnosis and will require intensive treatment due to acute skin failure. In contrast, DMs can be a reflection of underlying systemic diseases, and their identification may be key to their diagnosis. On other occasions, DMs are lesions that appear in the evolution of critical patients and are due to factors derived from the stay or intensive treatment. Lastly, DMs can accompany patients and must be taken into account in the comprehensive pathology management. Several factors must be considered when addressing DMs: on the one hand, the moment of appearance, morphology, location, and associated treatment and, on the other hand, aetiopathogenesis and classification of the cutaneous lesion. DMs can be classified into 4 groups: life-threatening DMs (uncommon but compromise the patient's life); DMs associated with systemic diseases where skin lesions accompany the pathology that requires admission to the intensive care unit (ICU); DMs secondary to the management of the critical patient that considers the cutaneous manifestations that appear in the evolution mainly of infectious or allergic origin; and DMs previously present in the patient and unrelated to the critical process. This review provides a characterization of DMs in ICU patients to establish a better identification and classification and to understand their interrelation with critical illnesses.

One-year follow-up of a randomized trial with a dilemma-focused intervention for depression: Exploring an alternative to problem-oriented strategies.

BACKGROUND: Cognitive behavioural therapy (CBT) is aimed to counteract cognitions and behaviours that are considered as dysfunctional. The aim of the study is to test whether the inclusion of a non-counteractive approach (dilemma-focused intervention, DFI) in combination with CBT group therapy will yield better short- and long-term outcomes than an intervention conducted entirely using CBT. METHOD: A total of 128 patients with depression and at least one cognitive conflict, of six health community centres in Barcelona, participated from November of 2011 to December of 2014 in seven weekly group CBT sessions and were then randomly allocated to either DFI or CBT (eight individual sessions each) by an independent researcher. Depressive symptoms were assessed with the Beck Depression Inventory-II at baseline, at the end of therapy and three- and twelve-month follow-ups. Therapists did not participate in any of the assessments nor in the randomisation of patients and evaluators were masked to group assignment. Both intention to treat and complete case analyses were performed using linear mixed models with random effects. FINDINGS: According to intention-to-treat analysis (F2, 179 = 0.69) and complete case analysis (F2, 146 = 0.88), both conditions similarly reduced the severity of symptoms across posttreatment assessments. For the 77 participants (CBTgroup +CBTindividual = 40; CBTgroup+DFIindividual = 37) that completed allocated treatment and one-year follow-up assessment, response and remission rates were relative higher for the DFI condition, however no significant differences were found between treatment conditions. The relapse rates were similar between treatment conditions (CBTgroup +CBTindividual = 7/20; CBTgroup+DFIindividual = 8/22). INTERPRETATION: Although using a counteractive approach across all the treatment sessions is quite effective, it does not seem to be necessary to produce significant improvement. DFI may be considered as an alternative, which could be included in a wider treatment for depression. TRIAL REGISTRATION: ClinicalTrials.gov; ID: NCT01542957.

Rationale and state of the art in early detection and intervention in psychosis / Justificación y estado de la cuestión en la detección e intervención temprana en psicosis

Schizophrenia-spectrum disorders have a chronic and episodic course that results in impairment of all life domains. Pharmacological and psychosocial treatments provide symptom relief, but there is not a cure for schizophrenia and many patients suffer chronic impairment. In addition, it is expensive both in economical terms and also in terms of personal costs for both patients and their families. International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and first-episode phases of psychotic illness. This focus is associated with increasing optimism about the benefits of implementing treatment as early as possible in the course of psychosis at least to help improve the course of illness, reducing its long-term impact. The most recent epidemiological studies have shown that patients with longer duration of untreated psychosis (DUP) have worse short-term outcomes in terms of treatment response, positive symptoms, negative symptoms, and global functioning. Neuroimaging studies have also indicated that prolonged untreated illness is associated with more pronounced structural brain abnormalities, while this is less prominent earlier in the course of the disorder. Therefore, early detection aims to reduce treatment delay in the hope of improving prognosis and reducing illness severity. Early intervention in psychotic disorders has gained momentum in the last decades, and there is now an estimated 200 centers worldwide offering specialized services for young people experiencing their first episode of psychosis. Each of these programs has unique characteristics and distinctive features in terms of treatment modalities and assessment tools, but most have a number of common elements and goals: a) early detection of new cases, b) reducing DUP, and c) providing better and continued treatment during the «critical period¼ of the early years of the disease. Moreover, the role of family work in early psychosis can be crucial given that relatives are the main informal caretakers of persons with mental health problems. Family interventions in early psychosis usually offer psychoeducation and/or individual and group family therapy, communication and problem solving training, which can help to develop coping strategies and reduce distress and burden. Intervention programs in early psychosis are usually composed by interdisciplinary teams, providing a wide range of integrated services that typically include psychoeducation, clinical case management, and group interventions. Specific interventions generally include pharmacotherapy, stress management, relapse prevention, social and employment rehabilitation support, and cognitive and family therapy. Given the complex etiology and clinical manifestation of psychosis, treatment packages for people experiencing early psychosis need to be individually tailored to specific needs rather than applied homogenously across early psychosis patients. The current challenge in the implementation of psychological interventions in the early stages of psychosis are: 1. to adapt treatment modalities that have been proven effective in stable and residual stages of the disease to its early stages; 2. to develop new forms of therapy tailored to the specific characteristics of these early stages of psychosis (prodromal and ultra high-risk phase, onset and first episode psychosis, and «critical period¼ or post-crisis psychosis); and 3. treatment packages need to be individually tailored to their specific needs rather than applied homogenously across a group of patients. The aims of this paper are: 1. to present the basic concepts, rationale and state of the art of the early detection and intervention paradigm; 2. to review and present the main detection and intervention programs in early psychosis and 3. to provide an overview of the current psychotherapeutic approaches in early psychosis.

Los trastornos del espectro psicótico presentan un curso crónico y episódico que provoca alteraciones en todas las áreas de la vida, generando importantes grados de discapacidad, pérdida de funciones psicosociales, grandes costos económicos, una comorbilidad considerable y sufrimiento tanto para los pacientes como para sus familias. A pesar de que los tratamientos farmacológicos y psicosociales han ayudado a aliviar los síntomas y mejorar la calidad de vida, en muy pocas ocasiones se logra una recuperación satisfactoria a nivel psicológico y funcional. Durante los últimos 15 años, el optimismo creciente sobre la posibilidad de mejorar el pronóstico de la psicosis y alterar con ello el tradicional curso negativo de la enfermedad ha producido una reforma sustancial en la práctica clínica y en el desarrollo de estrategias de intervención temprana en muchos países. De esta manera, el desplazamiento del foco de atención desde las fases estables o residuales de la psicosis hacia los inicios de la misma está suponiendo una serie de innovaciones y avances, tanto en la evaluación y diagnóstico como en las modalidades terapéuticas y en la consiguiente reordenación de los servicios asistenciales. Los estudios epidemiológicos más recientes han mostrado que los pacientes con mayor duración de la psicosis no tratada tienen peor respuesta al tratamiento farmacológico, mayor gravedad de síntomas positivos, síntomas negativos y peor funcionamiento global. Por otra parte, los estudios de neuroimagen también indican que un periodo prolongado de enfermedad no tratada produce anormalidades estructurales cerebrales más pronunciadas. Es por esto que la detección temprana en psicosis tiene como objetivo reducir la demora del tratamiento para mejorar el pronóstico y reducir la gravedad del trastorno. La detección temprana y la aplicación del tratamiento específico más eficaz para cada fase inicial del trastorno son dos elementos que diferencian la intervención temprana de las formas habituales de asistencia actuales. Cada vez existen más grupos en todo el mundo dedicados a establecer programas clínicos e iniciativas de investigación centradas en la psicosis temprana. Cada uno de estos programas tiene características particulares y rasgos propios en cuanto a las modalidades de tratamiento o los instrumentos de evaluación, pero la mayoría tiene una serie de elementos y objetivos en común: a) detectar de forma precoz nuevos casos; b) reducir el periodo de tiempo desde que el paciente presenta una sintomatología claramente psicótica hasta que recibe un tratamiento adecuado y c) proporcionar un mejor y continuo tratamiento en el «periodo crítico¼ de los primeros años de la enfermedad. En el contexto de la prevención e intervención temprana, el trabajo con la familia puede ser crucial, ya que los familiares son los principales cuidadores informales y son una parte fundamental para la recuperación del paciente. La mayoría de las intervenciones familiares ofrecen psicoeducación y/o terapia familiar que ayudan a desarrollar estrategias de adaptación y afrontamiento, disminuir el estrés y la carga a largo plazo, así como mejorar la comunicación y la resolución de problemas. Los programas de intervención en la psicosis temprana están habitualmente formados por equipos interdisciplinarios que proporcionan una amplia serie de servicios integrados que suelen incluir psicoeducación, manejo clínico de casos e intervenciones grupales. Las intervenciones específicas incluyen generalmente farmacoterapia, manejo de estrés, prevención de recaídas, apoyo y rehabilitación social y laboral, así como terapia cognitiva y familiar. Dada la compleja etiología y manifestación clínica de la psicosis, los tratamientos para personas con psicosis incipiente deben ser adaptados individualmente a las necesidades específicas en lugar de aplicarlos homogéneamente a todos los pacientes por igual. El desafío actual en la aplicación de intervenciones en la psicosis temprana consiste en: 1. conseguir adaptar aquellas modalidades de tratamiento que ya han demostrado su eficacia en las fases estables y residuales de la enfermedad a los inicios de la misma; 2. integrar y desarrollar nuevas formas de terapia que se adapten a las características específicas de cada una de las fases iniciales de la psicosis (fase prodrómica o de alto riesgo, inicio de la psicosis o primer episodio de psicosis y «fase crítica¼ o poscrisis) y 3. adecuar los tratamientos de manera individual en vez de aplicarlos de forma homogénea. Los objetivos del presente artículo son: 1. presentar los conceptos básicos, la justificación y el estado de la cuestión del paradigma de detección e intervención temprana en psicosis; 2. hacer una revisión y presentar los principales programas de detección e intervención temprana en psicosis y 3. proporcionar una visión general de los enfoques psicoterapéuticos actuales en psicosis incipiente.