Development and validation of the mental health professional culture inventory.

AIMS: No instrument has been developed to explicitly assess the professional culture of mental health workers interacting with severely mentally ill people in publicly or privately run mental health care services. Because of theoretical and methodological concerns, we designed a self-administered questionnaire to assess the professional culture of mental health services workers. The study aims to validate this tool, named the Mental Health Professional Culture Inventory (MHPCI). The MHPCI adopts the notion of 'professional culture' as a hybrid construct between the individual and the organisational level that could be directly associated with the professional practices of mental health workers. METHODS: The MHPCI takes into consideration a multidimensional definition of professional culture and a discrete number of psychometrically derived dimensions related to meaningful professional behaviour. The questionnaire was created and developed by a conjoint Italian-Canadian research team with the purpose of obtaining a fully cross-cultural questionnaire and was pretested in a pilot study. Subsequently, a validation survey was conducted in northern Italy and in Canada (Montreal area, Quebec). Data analysis was conducted in different steps designed to maximise the cross-cultural adaptation of the questionnaire through a recursive procedure consisting of performing a principal component analysis (PCA) on the Italian sample (N = 221) and then testing the resulting factorial model on the Canadian sample (N = 237). Reliability was also assessed with a test-retest design. RESULTS: Four dimensions emerged in the PCA and were verified in the confirmatory factor analysis: family involvement, users' sexuality, therapeutic framework and management of aggression risk. All the scales displayed good internal consistency and reliability. CONCLUSIONS: This study suggests the MHPCI could be a valid and reliable instrument to measure the professional behaviour of mental health services workers. The content of the four scales is consistent with the literature on psychosocial rehabilitation, suggesting that the instrument could be used to evaluate staff behaviour regarding four crucial dimensions of mental health care.

Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men.

OBJECTIVE: Major depression is a major risk factor for suicide. However, not all individuals with major depression commit suicide. Impulsive and aggressive behaviors have been proposed as risk factors for suicide, but it remains unclear whether their effect on the risk of suicide is at least partly explained by axis I disorders commonly associated with suicide, such as major depression. With a case-control design, a comparison of the level of impulsive and aggressive behaviors and the prevalence of associated psychopathology was carried out with control for the presence of primary psychopathology. METHOD: One hundred and four male suicide completers who died during an episode of major depression and 74 living depressed male comparison subjects were investigated with proxy-based interviews by using structured diagnostic instruments and personality trait assessments. RESULTS: The authors found that current (6-month prevalence) alcohol abuse/dependence, current drug abuse/dependence, and cluster B personality disorders increased the risk of suicide in individuals with major depression. Also, higher levels of impulsivity and aggression were associated with suicide. An analysis by age showed that these risk factors were more specific to younger suicide victims (ages 18-40). A multivariate analysis indicated that current alcohol abuse/dependence and cluster B personality disorder were two independent predictors of suicide. CONCLUSIONS: Impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors. A developmental hypothesis of suicidal behavior, with impulsive and aggressive behaviors as the starting point, is discussed.

Suicide and mental disorders: a case-control study of young men.

OBJECTIVE: By means of the psychological autopsy method and a case-control design, the authors examined the association of specific mental disorders and comorbidity with suicide among young men. METHOD: Seventy-five men aged 18-35 years whose deaths were adjudicated as completed suicides by coroners of greater Montreal and Quebec City were matched to 75 living young men for age, neighborhood, marital status, and occupation. For each subject in both groups a key respondent best acquainted with the subject was interviewed by clinicians using standardized schedules. Information from the coroner and medical records was also collected. Two experienced psychiatrists, blind to outcome, established best-estimate DSM-III-R diagnoses. RESULTS: Six-month prevalence rates for all axis I diagnoses for the suicide and comparison groups were 88.0% and 37.3%, respectively; major depression was present in 38.7% and 5.3%, alcohol dependence in 24.0% and 5.3%, psychoactive substance dependence in 22.7% and 2.7%. Borderline personality disorder was identified in 28.0% and 4.0%, respectively. Of the suicide subjects, 28.0% had at least two of the following disorders: major depression, borderline personality disorder, and alcohol or drug dependence; the rate was 0.0% among the comparison subjects. CONCLUSIONS: In young men, completed suicide is linked to specific mental disorders, namely, major depression, borderline personality disorder, and substance abuse. Comorbidity involving any of these disorders is frequently associated with completed suicide.

Major depression in individuals with a history of childhood physical or sexual abuse: relationship to neurovegetative features, mania, and gender.

OBJECTIVE: Numerous studies have linked childhood trauma with depressive symptoms over the life span. However, it is not known whether particular neurovegetative symptom clusters or affective disorders are more closely linked with early abuse than are others. In a large community sample from Ontario, the authors examined whether a history of physical or sexual abuse in childhood was associated with particular neurovegetative symptom clusters of depression, with mania, or with both. METHOD: The World Health Organization Composite International Diagnostic Interview was used to assess 8,116 individuals aged 15-64 years. Each subject was asked about early physical and sexual abuse experiences on a structured supplement to the interview. Six hundred fifty-three cases of major depression were identified. Rates of physical and sexual abuse in depressive subgroups defined by typical and reversed neurovegetative symptom clusters (i.e., decreased appetite, weight loss, and insomnia versus increased appetite, weight gain, and hypersomnia, respectively) and by the presence or absence of lifetime mania were compared by gender. RESULTS: A history of physical or sexual abuse in childhood was associated with major depression with reversed neurovegetative features, whether or not manic subjects were included in the analysis. A strong relationship between mania and childhood physical abuse was found. Across analyses there was a significant main effect of female gender on risk of early sexual abuse; however, none of the group-by-gender interactions predicted early abuse. CONCLUSIONS: These results suggest an association between early traumatic experiences and particular symptom clusters of depression, mania, or both in adults.

Prediction of level of serotonin 2A receptor binding by serotonin receptor 2A genetic variation in postmortem brain samples from subjects who did or did not commit suicide.

OBJECTIVE: Postmortem studies have indicated that suicide victims have greater serotonin receptor 2A (5-HTR2A) binding in prefrontal brain regions. However, there remains some controversy regarding the biological specificity of these findings. The authors hypothesized that the variance observed in brain 5-HTR2A binding is genetically mediated, at least in part. METHOD: Postmortem data from 56 subjects who had committed suicide and 126 normal comparison subjects were studied; brain tissue was available from 11 subjects who committed suicide and 11 comparison subjects. Homogenate binding assays were carried out with [3H]ketanserin. Variation at the 5-HTR2A gene (HTR2A) was investigated by means of two polymorphisms: T102C and A-1438G. RESULTS: 5-HTR2A binding was greater in the prefrontal cortex of the subjects who committed suicide. In addition, the findings suggest that HTR2A variation significantly affects 5-HTR2A binding. However, no interaction between suicidal behavior and this locus was observed. CONCLUSIONS: These results confirm previous reports of greater 5-HTR2A binding in subjects who committed suicide; they also provide preliminary evidence suggesting that the number of 5-HTR2A receptors is genetically mediated.

Depression in Ontario: under-treatment and factors related to antidepressant use.

Our study examines how depression is treated in Ontario, with particular examination of the correlates of antidepressant utilization using a broad model of individual (clinical), demographic, and health system determinants of treatment. From a community epidemiologic survey, a sample of 333 individuals with major depression in the past year was identified. More than half received no treatment (untreated n = 170, 51.1%), while 74 (22.2%) received treatment without medication, 29 (8.7%) received treatment mainly with anxiolytics, and only 60 (18.0%) were treated with antidepressants. All four groups had similar rates of alcohol and substance abuse. Disability and comorbid anxiety were common, with the least in the untreated group and the most in the antidepressant group. Increased use of antidepressants was associated with psychiatrist contact, while family physicians treated a substantial minority primarily with anxiolytics. Under a universal health care system, no differential access to antidepressants was found in terms of demographic characteristics. Clinical severity and contact with a psychiatrist correlate with antidepressant treatment of depression.

Assessment of a new rehabilitative coping skills module for persons with schizophrenia.

A rehabilitative coping skills module employing problem solving and cognitive behavioral therapy and an experimental repeated-measure design was tested on 55 randomly selected persons severely handicapped by schizophrenia, most of whom had lived almost half of their lives in psychiatric wards. Unlike the control group of 44 comparable schizophrenics, the experimental group exhibited a significant decrease in delusions and increase in self-esteem, and maintained hygiene levels.

Social factors affecting clinical caseload in Italian good practice areas.

Italian statistics indicate that fewer people are living alone than in Great Britain. Psychiatric Case Register figures show that the treated prevalences are nearly half those found in British Case Register areas. The level of staffing in good practice areas like South-Verona or Trieste is at least similar and at times higher than British or American counterparts. The clinical caseload of Italian clinical teams is therefore lower. The Italian patients may have a greater social network's availability by the mere fact of living in the same household of relatives. It is hypothesized that these elements affect a clinical team's availability to offer alternatives to hospitalisation. A ratio caseload/staff should be taken into account in assessing the Italian psychiatric reform and alternatives to hospitalisation.

[Suicide among young male adults in Quebec: psychopathology and utilization of medical services]. / Le suicide chez les jeunes adultes de sexe masculin au Québec: psychopathologie et utilisation des services médicaux.

Seventy five young male adults between the age of 18 and 35 who had committed suicide were compared with 75 male adults still alive matched for age, residence, marital and employment status. For each group a principal respondent was interviewed in order to reconstitute the psychological profile of each individual, as well as their utilisation of health services. This was completed by the study of the coroner's reports and the medical records when available. At six months the prevalence for all axis I diagnosis was 88.8% for the suicide group and 37.3% for the control group. Among the subjects who had committed suicide 38.7% were afflicted by major depression, 24% by alcohol dependency and 28.7% were dependent on drugs. Borderline personalities were present in 28% of the suicide group compared to 5% in the control group. Forty five percent (45%) of the subjects who had killed themselves had consulted a mental health professional in the year preceding the suicide compared to 5% in the control group. However, 78.5% of the suicide group had consulted during the same period a health professional compared to 73.3% of the controls.

Evaluating the closure or downsizing of psychiatric hospitals: social or clinical event?

OBJECTIVES: The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalization have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalization, particularly as regards the downsizing/closure and role of psychiatric hospitals. METHODS: I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalization is driven today by the same forces that were present at the outset of the movement. RESULTS: I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research. CONCLUSIONS: Lessons are drawn on how to fill certain vacant cells of the matrix.

Comprehensive community care without long stay beds in mental hospitals: trends from an Italian good practice area.

Despite the scientific evidence that long stays in mental hospitals are clinically deleterious, inhumane and probably not cost-effective, this practice still occurs in most Western countries. The continued use of long stay beds in mental hospitals is a policy decided by many authorities, including psychiatrists. Alternatives to the mental hospital exist and may limit the use of hospital beds through comprehensive community care that also includes proper residential provisions. Alternatives may also decrease, but not impede the tendency to chronicity in some patients, who become long term users of these community services. Italy passed a law in 1978 prohibiting admissions to mental hospitals and encouraging the development of community care. In South Verona, Italy, the policy has been properly implemented and evaluated. Data from the case register and intensive studies of a cohort of patients will be used to show that long stay hospitalization can be discontinued while meeting the needs of the most severely handicapped patients. Implications of South Verona's experience for future training of psychiatrists will also be discussed.

Mobility of schizophrenic patients, non-psychotic patients and the general population in a case register area.

This preliminary study attempts to evaluate the effect of a community psychiatric service on residential mobility by comparing a cohort of schizophrenic patients over a 5-year period with that of non-psychotic and general population control groups in South Verona, a case register area in Northern Italy. No significant differences were found between the groups for different types of movement (within South Verona/outside catchment area of South Verona/outside City of Verona), except for movements within South Verona between the schizophrenic group and neurotic group. The former tended to move less than the latter. The sociodemographic factors associated with movements of the general population in Verona were being male and single, whereas place of birth was less important. The results showed that in the two patient groups as well as in the general population in South Verona, the percentages of those who moved outside the case-register area ranged between 1.5%-4.4% over a one-year period, and between 7.3%-13.8% over a five-year period, indicating a relatively consistent denominator for the Case Register.

[Implementation of intensive follow-up in the community: lessons to be considered]. / L'implantation du suivi intensif dans la communauté: des leçons à tirer du passé.

OBJECTIVE: To examine various issues concerning the implementation of a program for assertive community treatment (ACT). METHOD: In-depth interviews were conducted with participants of an ACT project implemented in the 1970s. A quality analysis was undertaken, assessing the issues that prevented the expansion of such an approach as well as issues to be considered in future implementation of ACT. RESULTS: Social, cultural, organizational, professional, and economic factors were identified that will continue to play decisive roles in the integration of such a program. The ACT implementation in question occurred at the same time as the shift to community psychiatry, without having been linked to that approach. Currently, social factors such as self-help groups and parents foster the implementation of such programs. The organizational factors include the importance of linking ACT to existing health care services, as well as adapting ACT to these services. The association of this type of project with a research team did not ensure a successful implementation. A third factor is the psychiatrist's training and motivation with respect to the practice of this approach. Finally, economic issues are playing a larger role in the implementation of this approach. CONCLUSION: This study relates different issues regarding the implementation of an ACT. The results represent assumptions that need to be confirmed by assessing ACT implementation in Quebec as well as in the rest of Canada.

Assessing the needs for care of non-psychotic patients. A trial with a new standardized procedure.

Recent psychiatric epidemiological studies using standardized interviews in the community have yielded high rates of non-psychotic disorders. The implications for service provision in terms of treatment and planning remain unclear. No methodology exists to link the individual needs for care and services to problems associated with disorders. The Needs for Care Assessment Schedule (NFCAS) is a relatively new procedure for assessing the needs of long-term mentally ill patients, mostly psychotic and attending psychiatric services. We report here a trial application of a modified version of the NFCAS on a sample of 39 non-psychotic patients, most of whom were attending psychiatric outpatient services. The results show that the modified procedure requires further refinement to achieve acceptability and reliability. Some improvements are suggested for refining items and for the collation of others. The difficulties encountered underline the key issues in developing such technology: specifying the threshold for recognizing the problems, detailing the interventions considered appropriate, defining the model of care and specifying the composition of the research team.

Excess mortality by natural causes of Italian schizophrenic patients.

The risk of mortality over a 5- to 8-year period for a total 1-year prevalence cohort of schizophrenic patients extracted by means of the South-Verona Psychiatric Case Register (Italy) was assessed using three methods: (1) case control with both non-psychotic patients and the general population matched for sex and age; (2) indirect standardization using mortality tables; (3) a recently described method using survival tables. All methods yielded an excess mortality associated with schizophrenia, close to the two-fold increase described in other studies, while the survival tables method produced a higher standardized mortality ratio (SMR). The increased SMR did not appear solely attributable to suicide. Most deaths were attributable to natural causes. This is a departure from other recently reported mortality studies. The possible reasons are discussed.

Reliable use of the Present State Examination by psychiatric nurses for clinical studies of psychotic and nonpsychotic patients.

Four psychiatric nurses were trained with the French version of the Present State Examination, 9th edition (PSE-9). Reliability was tested on 18 cases of psychotic and nonpsychotic patients. The reliability indexes were comparable to those reported for the English version of PSE-9. These preliminary results indicate that further training may improve reliability for the nurses. It also warrants other trials in which psychiatric nurses will be used as interviewer with instruments that require clinical judgement.

Homicide followed by suicide: a Quebec case series, 1988-1990.

Homicide followed by suicide is a rare but tragic event. Psychiatrists and mental health professionals are often called upon to comment publicly on the event or to help the "hidden victims," the survivors of the tragedy. There were 39 such cases in Quebec between 1988 and 1990, and they have been reviewed through the examination of the coroner's files. The epidemiological rates of homicide, suicide, homicide-suicide and the sociodemographic and clinical characteristics of the perpetrators and victims are presented and compared with the international literature. Sociological and psychopathological hypotheses are presented with a special reference to the possibility of various subgroups of perpetrators. Research needs to be pursued along the lines of more detailed case studies of psychopathological characteristics using the psychological autopsy approach. The reconstruction of the couple's relationship and of the final circumstances leading up to the tragedy may provide warning indices that could be helpful in preventing such tragedies.

Psychiatrists' ratings of expressed emotion.

The purpose of this study was to determine the extent to which psychiatrists are familiar with the concept of expressed emotion and to determine the extent of its use in their day-to-day practices. We also wished to test the ability of psychiatrists to estimate the expressed emotion status of the relatives of their patients. Following the assessment of expressed emotion in 96 relatives using the Camberwell Family Interview, the psychiatrists treating the schizophrenic patients were surveyed about their knowledge of expressed emotion and were asked to estimate the expressed emotion of their relatives. Thirty-five percent of the respondents use the expressed emotion concept daily in their practice. When the Camberwell Family Interview ratings of expressed emotion were compared with those from the psychiatrists, the agreement rate was no better than chance (45.7%). Without formal training in the use of the Camberwell Family Interview, practitioners are cautioned against ascribing an expressed emotion status to the relatives of their patients.

["What's up, doc?" The context, limitations, and issues for clinicians in evidence-based medicine]. / "What's up, doc?" Le contexte, les limites et les enjeux de la médecine fondée sur des données probantes pour les cliniciens (Evidence-Based Medicine).

BACKGROUND: The evidence-based medicine approach could be considered a new name given to the contemporary medicine dialectics between the practice of an art and the insight provided by the best scientific data. METHODS: In this 3-part article, the background is introduced, then the design limits of the approach are shown through an example of metaanalysis applied to 4 psychiatric situations, and the conclusion is left to a clinician. RESULTS: In the background, evidence-based medicine is first associated with the period of budget cuts, then with the widespread popularity of the Internet. A few snags in this seemingly flawless system are seen when the subjective items involved in metaanalysis are taken into account. There are also problems linked to unpublished data, homogenization of populations studied, and the assumption that only random studies lead to valid scientific knowledge. The clinician will probably not be surprised and will link this to the old debate between empiricists and rationalists. CONCLUSION: In its purest form, evidence-based medicine supports the necessary continuous inquiry about our practices.

Cost-effectiveness analysis of psychiatric deinstitutionalization.

BACKGROUND: The cost-effectiveness of the eventual deinstitutionalization of patients with severe and persistent mental disorders who are currently hospitalized in long-term care remains a controversial matter. METHODS: A retrospective cohort of 96 pairs of psychiatric hospital patients with 1 member deinstitutionalized between 1989 and 1998 was followed up for nearly 10 years. All use of medical and social services was documented. Patients were evaluated at the start and end of the study on various clinical and social dimensions, as well as on quality of life. RESULTS: On several dimensions, deinstitutionalized patients scored more positively than did those patients still hospitalized. The lower daily cost of living accommodations for deinstitutionalized patients easily offsets the cost of services required for treatment in the community. CONCLUSION: Deinstitutionalization, as implemented in the hospital studied, remains for many patients a less costly option than continued hospitalization and is likely to improve their mental state and well-being.