An Observational Pilot Study using a Digital Phenotyping Approach in Patients with Major Depressive Disorder Treated with Trazodone.

This 8-week study was designed to explore any correlation between a passive data collection approach using a wearable device (i.e., digital phenotyping), active data collection (patient's questionnaires), and a traditional clinical evaluation [Montgomery-Åsberg Depression Rating Scale (MADRS)] in patients with major depressive disorder (MDD) treated with trazodone once a day (OAD). Overall, 11 out of 30 planned patients were enrolled. Passive parameters measured by the wearable device included number of steps, distance walked, calories burned, and sleep quality. A relationship between the sleep score (derived from passively measured data) and MADRS score was observed, as was a relationship between data collected actively (assessing depression, sleep, anxiety, and warning signs) and MADRS score. Despite the limited sample size, the efficacy and safety results were consistent with those previously reported for trazodone. The small population in this study limits the conclusions that can be drawn about the correlation between the digital phenotyping approach and traditional clinical evaluation; however, the positive trends observed suggest the need to increase synergies among clinicians, patients, and researchers to overcome the cultural barriers toward implementation of digital tools in the clinical setting. This study is a step toward the use of digital data in monitoring symptoms of depression, and the preliminary data obtained encourage further investigations of a larger population of patients monitored over a longer period of time.

Depression and suicidality among psychiatric residents - results from a multi-country study.

BACKGROUND: Previous studies have highlighted risks for depression and suicide in medical cohorts, but evidence regarding psychiatric residents is missing. This study aimed to determine rates of depression, suicide ideation and suicide attempt among psychiatric residents and to identify associated individual, educational and work-related risk factors. METHODS: A total of 1980 residents from 22 countries completed the online survey which collected data on depression (PHQ-9), suicidality (SIBQ), socio-demographic profiles, training, and education. Generalized linear modeling and logistic regression analysis were used to predict depression and suicide ideation, respectively. RESULTS: The vast majority of residents did not report depression, suicide ideation or attempting suicide during psychiatric training. Approximately 15% (n = 280) of residents met criteria for depression, 12.3% (n = 225) reported active suicide ideation, and 0.7% (n = 12) attempted suicide during the training. Long working hours and no clinical supervision were associated with depression, while more completed years of training and lack of other postgraduate education (e.g. PhD or psychotherapy training) were associated with increased risk for suicide ideation during psychiatric training. Being single and female was associated with worse mental health during training. LIMITATIONS: Due to the cross-sectional nature of the study, results should be confirmed by longitudinal studies. Response rate was variable but the outcome variables did not statistically significantly differ between countries with response rates of more or less than 50%. CONCLUSION: Depression rates among psychiatric residents in this study were lower than previously reported data, while suicide ideation rates were similar to previous reports. Poor working and training conditions were associated with worse outcomes. Training programmes should include effective help for residents experiencing mental health problems so that they could progress through their career to the benefit of their patients and wider society.

Violence in persons with and without psychosis in the Czech Republic: risk and protective factors.

PURPOSE: To prevent violence among persons with psychosis, further knowledge of the correlates and risk factors is needed. These risk factors may vary by nation. PATIENTS AND METHODS: This study examined factors associated with violent assaults in 158 patients with psychosis and in a matched control sample of 158 adults without psychosis in the Czech Republic. Participants completed interviews and questionnaires to confirm diagnoses, report on aggressive behavior, current and past victimization, and substance use. Additional information was collected from collateral informants and clinical files. Multiple regression analyses were conducted to identify factors that were independently associated with committing an assault in past 6 months. RESULTS: The presence of a psychotic disorder was associated with an increased risk of assaults (OR =3.80; 95% CI 2.060-7.014). Additional risk factors in persons with and without psychosis included recent physical victimization (OR =7.09; 95% CI 3.922-12.819), childhood maltreatment (OR =3.15; 95% CI 1.877-5.271), the level of drug use (OR =1.13; 95% CI 1.063-1.197), and the level of alcohol use (OR =1.04; 95% CI 1.000-1.084). Increasing age (OR =0.96; 95% CI 0.942-0.978) and employment (OR =0.30; 95% CI 0.166-0.540) were protective factors. Except for drug use, which appeared to have greater effect on violence in the group without psychosis, there were no major differences between patients and controls in these risk and protective factors. To our knowledge, this is the first published comparison of assault predictors between schizophrenia patients and matched controls. CONCLUSION: Recent physical victimization was the strongest predictor of assaults. Our findings are consistent with the emerging empirical evidence pointing to the very important role of victimization in eliciting violent behavior by the victims. Some current prediction instruments may underestimate the risk of violent behavior as they take little account of current victimization. Although psychosis per se elevates the risk of violence, other risk and protective factors for violence in persons with psychosis and comparison group are largely similar.

The PsyLOG mobile application: development of a tool for the assessment and monitoring of side effects of psychotropic medication.

Mobile health interventions are regarded as affordable and accessible tools that can enhance standard psychiatric care. As part of the mHealth Psycho-Educational Intervention Versus Antipsychotic-Induced Side Effects (mPIVAS) project (www.psylog.eu), we developed the mobile application "PsyLOG" based on mobile "smartphone" technology to monitor antipsychotic-induced side effects. The aim of this paper is to describe the rationale and development of the PsyLOG and its clinical use. The PsyLOG application runs on smartphones with Android operating system. The application is currently available in seven languages (Croatian, Czech, English, French, German, Japanese and Serbian). It consists of several categories: "My Drug Effects", "My Life Styles", "My Charts", "My Medication", "My Strategies", "My Supporters", "Settings" and "About". The main category "My Drug Effects" includes a list of 30 side effects with the possibility to add three additional side effects. Side effects are each accompanied by an appropriate description and the possibility to rate its severity on a visual analogue scale from 0-100%. The PsyLOG application is intended to enhance the link between patients and mental health professionals, serving as a tool that more objectively monitors side-effects over certain periods of time. To the best of our knowledge, no such applications have so far been developed for patients taking antipsychotic medication or for their therapists.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries.

PURPOSE: There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes. METHODS: This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models. RESULTS: A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio. CONCLUSION: Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Equal access for all? Access to medical information for European psychiatric trainees.

Access to medical information is important as lifelong scientific learning is in close relation with a better career satisfaction in psychiatry. This survey aimed to investigate how medical information sources are being used among members of the European Federation of Psychiatric Trainees. Eighty-three psychiatric trainees completed our questionnaire. A significant variation was found, and information availability levels were associated with training duration and average income. The most available sources were books and websites, but the most preferred ones were scientific journals. Our findings suggest that further steps should be taken to provide an equal access to medical information across Europe.

Numbers of early career psychiatrists vary markedly among European countries.

In the field of psychiatry the decline of recruitment and brain-drain are currently one of the most discussed topics among stakeholders on national and European level. Even though comprehensive data on psychiatric training in Europe have been already reported, no data are available on even the approximate number of early career psychiatrists (ECPs). With this objective in mind, the Early Career Psychiatrists Committee of the European Psychiatric Association (EPAECPC) and the European Federation of Psychiatric Trainees (EFPT) have undertaken a survey. Based on the methodology used, the total number of ECPs in all European countries was 46 144 with the average number of ECPs being 5.5/100 000 country inhabitants. The actual numbers in this respect varied greatly among countries from 0.4 and 0.6 ECPs/100 000 in Azerbaijan resp. Russia; to 20.4 and 28.4 ECPs/100 000 in Norway resp. Switzerland. An obvious East-West gradient with increasing numbers of ECPs when moving from East to West, and from South to North were found, mirroring the economic strength of European countries. This is the first study to specifically explore the number of ECPs across Europe which might have key implications for planning and establishing recruitment activities and for developing strategies for prevention of brain-drain, such as improvement of educational system and enlargement of professional opportunities.

Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study.

PURPOSE: This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries. METHODS: Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect. RESULTS: The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model. CONCLUSIONS: The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

Gender differences in coerced patients with schizophrenia.

BACKGROUND: Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. METHODS: 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. RESULTS: When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. CONCLUSIONS: Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the "excitement/hostile" cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Challenges for trainees in psychiatry and early career psychiatrists.

Psychiatry as a discipline will undergo major changes in the coming years. Although changes can be particularly stimulating and challenging from an intellectual, scientific and social viewpoint, the new generations of psychiatrists must be prepared to face these changes and deal with them appropriately. Paradigms which have represented the foundations of psychiatry in the last century now need a major revision. In particular, both trainees in psychiatry and early career psychiatrists need to (1) (re)discover psychopathology, (2) improve mental healthcare through integrated treatments, (3) identify and treat new syndromes, (4) promote an image of psychiatry with patients at the heart of care and as advocates for each other by fighting stigma and promoting the recruitment in psychiatry by medical students. These can be achieved by increasing involvement in institutions and organizations to influence the agenda. In this paper the possible contribution of trainees and early career psychiatrists is discussed and recommendations are made in order to set a new agenda for early career psychiatrists who will still be practising 2-3 decades from now.

Recruitment to psychiatry in the Czech Republic: 'waiting for resuscitation'?

Recruitment to psychiatry is becoming a serious obstacle in providing first-class mental health treatment in many countries worldwide. We attempt to address this burning issue by examining medical student's attitudes towards psychiatry and factors influencing their career choice in the Czech Republic. In 2010, 71 students in their last year of medical school at the First Faculty of Medicine, Charles University, Prague were recruited in this quantitative cross-sectional online study. From the sample, 16% (n = 11) of students were considering psychiatry as a career path. An important factor in choosing psychiatry as a career path was personal/family presence of mental illness. Longer experience with psychiatry placement also contributed to the choice of psychiatry, as well as participation in elective courses or psychiatric research projects. Students considering psychiatry were less systematic compared to the group not considering psychiatry. Low reported levels of recruitment to psychiatry present a problematic issue in the Czech Republic. To make psychiatry more appealing to medical students, proactive steps by the relevant stakeholders need to be implemented. These strategies should include steps such as allocating more time for psychiatry in the medical curriculum, better quality of lectures, and the inclusion of additional elective courses.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study.

BACKGROUND: Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment. AIMS: To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment. METHOD: A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission. RESULTS: A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement. CONCLUSIONS: Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

Psychiatry training in Europe: views from the trenches.

BACKGROUND: In the majority of European countries, postgraduate psychiatry training schemes are developed and evaluated by national bodies in accordance with national legislation. In order to harmonise training in psychiatry across Europe, the European Union of Medical Specialists (UEMS) issued a number of recommendations for effective implementation of training programs in psychiatry. AIMS: To describe the structure and quality assurance mechanisms of postgraduate psychiatric training in Europe. METHOD: The European Federation of Psychiatry Trainees (EFPT) conducted a survey, which was completed by the representatives of 29 member national psychiatric associations. RESULTS: In most countries (N = 19), the duration of the training programme is 5 years or more. Twenty-six countries have adapted a basic training programme that includes the 'common trunk' (according to UEMS definition) or a modified version of it. In 25 countries, trainees are evaluated several times during their training with a final exam at the end. In 25 countries, official quality assurance mechanisms exist. However, results demonstrate great variations in their implementation. CONCLUSIONS: Overall, psychiatric training programmes and assessment methods are largely compatible with one another across Europe. Quality assurance mechanisms, however, vary significantly. These should receive adequate attention by national and international educational policy makers.

Choice of antipsychotic treatment by European psychiatry trainees: are decisions based on evidence?

BACKGROUND: Little is known about the factors influencing treatment choice in psychosis, the majority of this work being conducted with specialists (consultant) in psychiatry. We sought to examine trainees' choices of treatment for psychosis if they had to prescribe it for themselves, their patients, and factors influencing decision-making. METHODS: Cross-sectional, semi-structured questionnaire-based study. RESULTS: Of the 726 respondents (response rate = 66%), the majority chose second-generation antipsychotics (SGAs) if they had to prescribe it for themselves (n = 530, 93%) or for their patients (n = 546, 94%). The main factor influencing choice was perceived efficacy, 84.8% (n = 475) of trainees stating this was the most important factor for the patient, and 77.8% (n = 404) stating this was the most important factor for their own treatment. Trainees with knowledge of trials questioning use of SGAs (CATIE, CUtLASS, TEOSS) were more likely to choose second-generation antipsychotics than those without knowledge of these trials (χ2 = 3.943; p = 0.047; O.R. = 2.11; 95% C.I. = 1.0-4.48). Regarding psychotherapy, cognitive behavioural therapy (CBT) was the most popular choice for self (33.1%; n = 240) and patient (30.9%; n = 224). Trainees were significantly more likely to prefer some form of psychotherapy for themselves rather than patients (χ2 = 9.98; p < 0,002; O.R. = 1.54; 95% CIs = 1.18-2.0). CONCLUSIONS: Trainees are more likely to choose second-generation antipsychotic medication for patients and themselves. Despite being aware of evidence that suggests otherwise, they predominantly base these choices on perceived efficacy.

Psychiatric disorders and aggression in the printed media: is there a link? A central European perspective.

BACKGROUND: A content analysis was used to describe the association between psychiatric disorders and aggression in the printed media in the Czech Republic and Slovakia. METHODS: Articles were chosen from the most widely read daily newspapers and magazines in both countries during five one-week periods in 2007. A coding manual was developed and a content analysis was performed. Aggressive behavior was assessed by two separate categories - the role of the mentally ill person in the violent act (perpetrator/victim) and the type of aggressive act (homicide, suicide). RESULTS: A total of 375 articles were analyzed. MAIN FINDINGS: 1) The proportion of articles depicting psychiatric disorders together with either self- or other-directed aggressive behavior is 31.2%; 2) Homicide was most frequently mentioned in the context of psychotic disorders and schizophrenia, while affective disorders were most frequently associated with both completed suicides and homicides; 3) Eating disorders and anxiety disorders were seldom associated with any kind of aggressive behavior, including self-harm; 4) The vast majority of articles presented mentally ill people as perpetrators, and these articles were more often coded as stigmatizing. 5) Articles with aggressive behavior mentioned on the cover are roughly as frequent as those with aggressive behavior in the later sections of the media (36.7% vs. 30.7%). CONCLUSIONS: The results are similar to the findings in countries with longer histories of consistent advocacy for improved depiction of mental illness in the media. However, we have shown that persons with mental illness are still over-portrayed as perpetrators of violent crimes, especially homicides.

The picture of mental health/illness in the printed media in three Central European countries.

Even in the era of the Internet, printed media are still among the most frequently identified sources of mental health information. Many studies have shown that this information is frequently negative and contributes to stigmatization of people with mental illness. This international comparative study describes the content of media messages about mental health/illness in terms of stigma in three Central European countries. The study sample comprised all articles pertaining to the topic of mental health/illness (N = 450) identified during five week-long periods in 2007 chosen from the six most widely read newspapers and magazines in each country. The authors used content analysis methods to achieve quantitative and qualitative objectives. More than half of all articles contained negative statements reflecting stigma toward persons with mental illness. Substance abuse disorders are the most frequent mental conditions covered in all three countries (22%), and psychotic disorders are the most stigmatized. Countries significantly differ in length of articles, in the association of aggressive behavior with persons with mental illness, and in the use of a sensationalized style of writing. Coverage of mental health/illness issues differs to some extent across countries but is generally of poor quality. On the basis of the authors' findings, practical recommendations for journalists can be tailored specifically for each country.

Development of the PICMIN (picture of mental illness in newspapers): instrument to assess mental illness stigma in print media.

PURPOSE: The aim of this paper is to report on the development and applicability of a standardised and objective measure of stigma of mental illness in print media. Picture of mental illness in newspapers (PICMIN) instrument consists of eleven descriptive and five analytical categories. It is intended to allow comparison among countries and different studies over time. METHODS: The research team conducted a three-phase study to develop the instrument based on the principles of content analysis and test its inter-coder reliability (ICR). In the first phase, keyword search and ICR assessment was performed on articles from Croatia (75), Czech Republic (203), and Slovakia (172). The second phase consisted of instrument revision and training, along with ICR reassessment on 40 articles from USA and UK. In the third, main phase articles from Croatia (238), Czech Republic (226), and Slovakia (158) were analysed with the final version of the PICMIN instrument. RESULTS: Across three countries, ICR was found acceptable to assess mental illness representations related to stigma in print media. Print media representations of the mental illness in Croatia, Czech Republic, and Slovakia significantly differed in the type of media distribution, whether headline of the article was positioned on the media cover, in the use of a sensationalistic style of writing, in the association of aggressive behaviour with persons with mental illness and in the distribution of the global impression of the headline. CONCLUSIONS: PICMIN instrument allows comparison among countries and different studies over time.