Spanish validation of the Premorbid Adjustment Scale (PAS-S).

BACKGROUND: The Premorbid Adjustment Scale (PAS) has been the most widely used scale to quantify premorbid status in schizophrenia, coming to be regarded as the gold standard of retrospective assessment instruments. AIMS: To examine the psychometric properties of the Spanish version of the PAS (PAS-S). METHOD: Retrospective study of 140 individuals experiencing a first episode of psychosis (n=77) and individuals who have schizophrenia (n=63), both adult and adolescent patients. Data were collected through a socio-demographic questionnaire and a battery of instruments which includes the following scales: PAS-S, PANSS, LSP, GAF and DAS-sv. The Cronbach's alpha was performed to assess the internal consistency of PAS-S. Pearson's correlations were performed to assess the convergent and discriminant validity. RESULTS: The Cronbach's alpha of the PAS-S scale was 0.85. The correlation between social PAS-S and total PAS-S was 0.85 (p<0.001); while for academic PAS-S and total PAS-S it was 0.53 (p<0.001). Significant correlations were observed between all the scores of each age period evaluated across the PAS-S scale, with a significance value less than 0.001. There was a relationship between negative symptoms and social PAS-S (0.20, p<0.05) and total PAS-S (0.22, p<0.05), but not with academic PAS-S. However, there was a correlation between academic PAS-S and general subscale of the PANSS (0.19, p<0.05). Social PAS-S was related to disability measures (DAS-sv); and academic PAS-S showed discriminant validity with most of the variables of social functioning. PAS-S did not show association with the total LSP scale (discriminant validity). CONCLUSION: The Spanish version of the Premorbid Adjustment Scale showed appropriate psychometric properties in patients experiencing a first episode of psychosis and who have a chronic evolution of the illness. Moreover, each domain of the PAS-S (social and academic premorbid functioning) showed a differential relationship to other characteristics such as psychotic symptoms, disability or social functioning after onset of illness.

Burden of chronic physical conditions and mental disorders in primary care.

BACKGROUND: The World Health Organization (WHO) has stated that the three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depression and ischaemic heart disease. AIMS: To estimate health-related quality of life (HRQoL) and quality-adjusted life-year (QALY) losses associated with mental disorders and chronic physical conditions in primary healthcare using data from the diagnosis and treatment of mental disorders in primary care (DASMAP) study, an epidemiological survey carried out with primary care patients in Catalonia (Spain). METHOD: A cross-sectional survey of a representative sample of 3815 primary care patients. A preference-based measure of health was derived from the 12-item Short Form Health Survey (SF-12): the Short Form-6D (SF-6D) multi-attribute health-status classification. Each profile generated by this questionnaire has a utility (or weight) assigned. We used non-parametric quantile regressions to model the association between both mental disorders and chronic physical condition and SF-6D scores. RESULTS: Conditions associated with SF-6D were: mood disorders, beta = -0.20 (95% CI -0.18 to -0.21); pain, beta = -0.08 (95%CI -0.06 to -0.09) and anxiety, beta = -0.04 (95% CI -0.03 to -0.06). The top three causes of QALY losses annually per 100 000 participants were pain (5064), mood disorders (2634) and anxiety (805). CONCLUSIONS: Estimation of QALY losses showed that mood disorders ranked second behind pain-related chronic medical conditions.

What is the relative importance of self reported psychotic symptoms in epidemiological studies? Results from the ESEMeD--Catalonia Study.

Different prevalence of non-affective psychosis has been reported in general population surveys. The objectives of this study were to describe lifetime prevalence of non-affective psychosis in Catalonia, Spain; and to analyze the use of the CIDI psychosis module as a screening instrument for psychotic disorders. As part of the ESEMeD project in Catalonia, 1645 respondents were assessed with the CIDI. Respondents who scored positively to any of the CIDI psychosis screen questions, who had been hospitalised for a psychiatric reason or had received antipsychotic medication were re-assessed with the SCID-I by a clinician. The results showed that 11.18% people of the sample had lifetime self reported psychotic symptoms using the CIDI. After a clinical interview with the SCID-I, between 0.85 and 2.37% of the sample had a psychotic disorder, and 0.48%-1.58% had schizophrenia. The most frequent reported psychotic symptoms in individuals without a psychotic disorder were those related with hearing or seeing something missing during a bereavement period. Experiencing mind control, feeling that your mind was being controlled by strange forces, experiencing attempts of communications (CIDI questions) and taking medication were the items that discriminate between non-affective psychosis cases and negatives. Only experiencing mind control was associated with psychotic disorders in a logistic regression analysis. The main conclusions are that the use of lay-administered interviews should only be used as a screening instrument in the detection of psychosis in general population surveys because the majority of self reported psychotic symptoms have not been found to be associated with a psychotic disorder.

Do needs, symptoms or disability of outpatients with schizophrenia influence family burden?

BACKGROUND: Most needs of outpatients with schizophrenia are met by the family. This could cause high levels of family burden. The objective of this study is to assess the relationship between the patients' needs and other clinical and disability variables and the level of family burden. METHOD: A total sample of 231 randomly selected outpatients with schizophrenia was evaluated with the Camberwell Assessment of Needs, Positive and Negative Syndrome Scale, Global Assessment of Functioning and Disability Assessment Scale. A total of 147 caregivers also answered the objective and subjective family burden questionnaire (ECFOS-II). Correlations between total number of needs and family burden, t tests between presence or absence of need for each domain of family burden and regression models between family burden and needs, symptoms, disability and sociodemographic variables were computed. RESULTS: The number of patients' needs was correlated with higher levels of family burden in daily life activities, disrupted behaviour and impact on caregiver's daily routine. The patients' needs most associated with family burden were daytime activities, drugs, benefits, self-care, alcohol, psychotic symptoms, money and looking after home. In a regression model, a higher number of needs, higher levels of psychopathology and disability, being male and older accounted for higher levels of family burden. CONCLUSION: Patients with schizophrenia with more needs cause greater family burden but not more subjective concerns in family members. The presence of patients' needs (daytime activities, alcohol and drug), severity of psychotic symptoms and disability are related to higher levels of family burden.

A descriptive case-register study of delusional disorder.

OBJECTIVE: A few empirically based studies' data on delusional disorder (DD) exist. We aim to describe sociodemographic and clinical correlates of DD and to identify clinical profiles associated to DD and its subtypes. METHODS: This is a case-register study based on all those subjects attending community mental health services within a geographically well-defined area. Four hundred and sixty-seven patients had been diagnosed as DD cases at psychiatric services serving a catchment area of some 607,494 inhabitants living in South Barcelona (Spain) during a three-year period (2001-2003). A thorough systematic review of computerised medical records was used to establish DSM-IV diagnosis, rendering a valid sample of 370 patients who fulfilled DSM-IV criteria for DD. Independent variables gathered include sociodemographic data, family and personal psychiatric history, and comorbid diagnoses on all DSM-IV axes (including GAF). We used descriptive and univariate statistical methods to explore sample frequencies and correlates across DD types. RESULTS: The mean age of the patients was 55 years and the sample had a mean GAF score of 51 suggesting a poor functionality; 56.5% of the patients were female. The most frequent DD types were persecutory (48%), jealous (11%), mixed (11%) and somatic (5%), whilst 23% qualified for the NOS type. Most frequent symptoms identified were self-reference (40%), irritability (30%), depressive mood (20%) and aggressiveness (15%). Hallucinations were present in 16% of the patients (6% tactile; 4% olfactory). Nearly 9% had a family history of schizophrenia (higher among those with the jealous subtype) and 42% had a comorbid axis II diagnosis (mostly paranoid personality disorder). Depression was significantly more frequent among the persecutory and jealous types. Finally, global functioning was significantly better among jealous and mixed types and worse amongst erotomanic and grandiose cases (p=0.008). CONCLUSIONS: In the absence of other similar empirical data, this modest study provides unique empirical evidence of some clinical and risk correlates of DD and its subtypes.

Treatment adequacy of anxiety and depressive disorders: primary versus specialised care in Spain.

BACKGROUND: Literature suggests that a high proportion of the population with mental disorders remains either untreated or poorly treated. This study aimed to describe the adequacy of treatment for Anxiety and Depressive disorders in Spain, how this differs between providers (primary versus specialised care) and which factors are associated with appropriate care. METHOD: Data were derived from the Spanish sample (N=5473) of the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross sectional study in a representative sample of adults. The subsample analyzed was composed by the 133 subjects with a mental disorder in the year prior to the interview who received treatment. Treatment adequacy was evaluated in two different ways: (1) considering definitions of minimally adequate treatment evidence based guidelines and criteria used in other epidemiological studies; (2) considering experts rating of treatment appropriateness based on the information contained in the case vignettes created from the CIDI answers. Generalised Estimating Equation (GEE) models and simple logistic regression were conducted to assess the correlates of adequate treatment. RESULTS: Similar proportions of patients in specialty and general medical treatment received a minimally adequate treatment (31.8% and 30.5%, respectively). Associated factors to appropriateness were living in a large city, having a high educational level, and having a good self rated health state. LIMITATIONS: Treatment adequacy was based on simple information and criteria. CONCLUSIONS: Only one third of the mental health treatment in Spain met minimal adequacy criteria. More research is needed in order to find out reasons for these low rates.

Cognitive correlates of verbal memory and verbal fluency in schizophrenia, and differential effects of various clinical symptoms between male and female patients.

BACKGROUND: Impairment of higher cognitive functions in patients with schizophrenia might stem from perturbation of more basic functions, such as processing speed. Various clinical symptoms might affect cognitive efficiency as well. Notably, previous research has revealed the role of affective symptoms on memory performance in this population, and suggested sex-specific effects. METHOD: We conducted a post-hoc analysis of an extensive neuropsychological study of 88 patients with schizophrenia. Regression analyses were conducted on verbal memory and verbal fluency data to investigate the contribution of semantic organisation and processing speed to performance. The role of negative and affective symptoms and of attention disorders in verbal memory and verbal fluency was investigated separately in male and female patients. RESULTS: Semantic clustering contributed to verbal recall, and a measure of reading speed contributed to verbal recall as well as to phonological and semantic fluency. Negative symptoms affected verbal recall and verbal fluency in the male patients, whereas attention disorders affected these abilities in the female patients. Furthermore, depression affected verbal recall in women, whereas anxiety affected it in men. CONCLUSIONS: These results confirm the association of processing speed with cognitive efficiency in patients with schizophrenia. They also confirm the previously observed sex-specific associations of depression and anxiety with memory performance in these patients, and suggest that negative symptoms and attention disorders likewise are related to cognitive efficiency differently in men and women.

Three-factor model of premorbid adjustment in a sample with chronic schizophrenia and first-episode psychosis.

BACKGROUND: The dimensionality of premorbid adjustment (PA) has been a debated issue, with attempts to determine whether PA is a unitary construct or composed of several independent domains characterized by a differential deterioration pattern and specific outcome correlates. AIMS: This study examines the factorial structure of PA, as well as, the course and correlates of its domains. METHOD: Retrospective study of 84 adult patients experiencing first-episode psychosis (FEP) (n=33) and individuals with schizophrenia (SCH) (n=51). All patients were evaluated with a comprehensive battery of instruments including clinical, functioning and neuropsychological variables. A principal component analysis accompanied by a varimax rotation method was used to examine the factor structure of the PAS-S scale. Paired t tests and Wilcoxon rank tests were used to assess the changes in PAS domains over time. Bivariate correlation analyses were performed to analyse the relationship between PAS factors and clinical, social and cognitive variables. RESULTS: PA was better explained by three factors (71.65% of the variance): Academic PA, Social PA and Socio-sexual PA. The academic domain showed higher scores of PA from childhood. Social and clinical variables were more strongly related to Social PA and Socio-sexual PA domains, and the Academic PA domain was exclusively associated with cognitive variables. CONCLUSION: This study supports previous evidence, emphasizing the validity of dividing PA into its sub-components. A differential deterioration pattern and specific correlates were observed in each PA domains, suggesting that impairments in each PA domain might predispose individuals to develop different expressions of psychotic dimensions.

Depressive comorbidity in personality disorders.

INTRODUCTION: We aimed to investigate the nature of the associations between PD clusters and MDs, functionality and mental health services use. METHODS: This is a case register study of all cases with a diagnosis of PD detected clinically in a well-defined area in the province of Barcelona covered by 7 Community Mental Health Teams. DSM-IV diagnoses were established by fully trained psychiatrists. Data was also gathered on socio-demographic variables; functional status (GAF) and data on use of health resources, using a systematic computerized method. We performed a non-parametric univariate statistical analysis. RESULTS: We found a higher percentage of major depressive disorder (MDD) among cluster C patients (17%), followed by cluster A (10%) and cluster B (9, 8%). As for the comorbidity between PD clusters and dysthymic disorder, we found that the prevalence was higher among cluster B patients (23,7%) than cluster C (20,2%) or cluster A (7,1%). When considering both MDs together, we found the highest prevalence among cluster C patients (36,87%), followed by cluster B (33,5%) and cluster A (17,1%). Cluster A patients showed worse functioning and visited hospitals most. CONCLUSIONS: A high comorbidity between all MDs analyzed and personality disorders was found, being particularly prominent among cluster C PDs.

Is major depression adequately diagnosed and treated by general practitioners? Results from an epidemiological study.

OBJECTIVES: The aim of this study was to (1) to explore the validity of the depression diagnosis made by the general practitioner (GP) and factors associated with it, (2) to estimate rates of treatment adequacy for depression and factors associated with it and (3) to study how rates of treatment adequacy vary when using different assessment methods and criteria. METHODS: Epidemiological survey carried out in 77 primary care centres representative of Catalonia. A total of 3815 patients were assessed. RESULTS: GPs identified 69 out of the 339 individuals who were diagnosed with a major depressive episode according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (sensitivity 0.22; kappa value: 0.16). The presence of emotional problems as the patients' primary complaint was associated with an increased probability of recognition. Rates of adequacy differed according to criteria: in the cases detected with the SCID-I interview, adequacy was 39.35% when using only patient self-reported data and 54.91% when taking into account data from the clinical chart. Rates of adequacy were higher when assessing adequacy among those considered depressed by the GP. CONCLUSION: GPs adequately treat most of those whom they consider to be depressed. However, they fail to recognise depressed patients when compared to a psychiatric gold standard. Rates of treatment adequacy varied widely depending on the method used to assess them.