Prescribing Patterns of Psychotropic Drugs and Risk of Violent Behavior: A Prospective, Multicenter Study in Italy.

BACKGROUND: This prospective cohort study aimed at evaluating patterns of polypharmacy and aggressive and violent behavior during a 1-year follow-up in patients with severe mental disorders. METHODS: A total of 340 patients (125 inpatients from residential facilities and 215 outpatients) were evaluated at baseline with the Structured Clinical Interview for DSM-IV Axis I and II, Brief Psychiatric Rating Scale, Specific Levels of Functioning scale, Brown-Goodwin Lifetime History of Aggression, Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, and State-Trait Anger Expression Inventory-2. Aggressive behavior was rated every 15 days with the Modified Overt Aggression Scale and treatment compliance with the Medication Adherence Rating Scale. RESULTS: The whole sample was prescribed mainly antipsychotics with high levels of polypharmacy. Clozapine prescription and higher compliance were associated with lower levels of aggressive and violent behavior. Patients with a history of violence who took clozapine were prescribed the highest number of drugs. The patterns of cumulative Modified Overt Aggression Scale mean scores of patients taking clozapine (n = 46), other antipsychotics (n = 257), and no antipsychotics (n = 37) were significantly different (P = .001). Patients taking clozapine showed a time trend at 1-year follow-up (24 evaluations) indicating a significantly lower level of aggressive behavior. Patient higher compliance was also associated with lower Modified Overt Aggression Scale ratings during the 1-year follow-up. CONCLUSION: Both inpatients and outpatients showed high levels of polypharmacy. Clozapine prescription was associated with lower Modified Overt Aggression Scale ratings compared with any other antipsychotics or other psychotropic drugs. Higher compliance was associated with lower levels of aggressive and violent behavior.

Remote assessment of disease and relapse in major depressive disorder (RADAR-MDD): a multi-centre prospective cohort study protocol.

BACKGROUND: There is a growing body of literature highlighting the role that wearable and mobile remote measurement technology (RMT) can play in measuring symptoms of major depressive disorder (MDD). Outcomes assessment typically relies on self-report, which can be biased by dysfunctional perceptions and current symptom severity. Predictors of depressive relapse include disrupted sleep, reduced sociability, physical activity, changes in mood, prosody and cognitive function, which are all amenable to measurement via RMT. This study aims to: 1) determine the usability, feasibility and acceptability of RMT; 2) improve and refine clinical outcome measurement using RMT to identify current clinical state; 3) determine whether RMT can provide information predictive of depressive relapse and other critical outcomes. METHODS: RADAR-MDD is a multi-site prospective cohort study, aiming to recruit 600 participants with a history of depressive disorder across three sites: London, Amsterdam and Barcelona. Participants will be asked to wear a wrist-worn activity tracker and download several apps onto their smartphones. These apps will be used to either collect data passively from existing smartphone sensors, or to deliver questionnaires, cognitive tasks, and speech assessments. The wearable device, smartphone sensors and questionnaires will collect data for up to 2-years about participants' sleep, physical activity, stress, mood, sociability, speech patterns, and cognitive function. The primary outcome of interest is MDD relapse, defined via the Inventory of Depressive Symptomatology- Self-Report questionnaire (IDS-SR) and the World Health Organisation's self-reported Composite International Diagnostic Interview (CIDI-SF). DISCUSSION: This study aims to provide insight into the early predictors of major depressive relapse, measured unobtrusively via RMT. If found to be acceptable to patients and other key stakeholders and able to provide clinically useful information predictive of future deterioration, RMT has potential to change the way in which depression and other long-term conditions are measured and managed.

Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

The cross-national epidemiology of specific phobia in the World Mental Health Surveys.

BACKGROUND: Although specific phobia is highly prevalent, associated with impairment, and an important risk factor for the development of other mental disorders, cross-national epidemiological data are scarce, especially from low- and middle-income countries. This paper presents epidemiological data from 22 low-, lower-middle-, upper-middle- and high-income countries. METHOD: Data came from 25 representative population-based surveys conducted in 22 countries (2001-2011) as part of the World Health Organization World Mental Health Surveys initiative (n = 124 902). The presence of specific phobia as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition was evaluated using the World Health Organization Composite International Diagnostic Interview. RESULTS: The cross-national lifetime and 12-month prevalence rates of specific phobia were, respectively, 7.4% and 5.5%, being higher in females (9.8 and 7.7%) than in males (4.9% and 3.3%) and higher in high- and higher-middle-income countries than in low-/lower-middle-income countries. The median age of onset was young (8 years). Of the 12-month patients, 18.7% reported severe role impairment (13.3-21.9% across income groups) and 23.1% reported any treatment (9.6-30.1% across income groups). Lifetime co-morbidity was observed in 60.5% of those with lifetime specific phobia, with the onset of specific phobia preceding the other disorder in most cases (72.6%). Interestingly, rates of impairment, treatment use and co-morbidity increased with the number of fear subtypes. CONCLUSIONS: Specific phobia is common and associated with impairment in a considerable percentage of cases. Importantly, specific phobia often precedes the onset of other mental disorders, making it a possible early-life indicator of psychopathology vulnerability.

Suicidality and its relationship with depression, alcohol disorders and childhood experiences of violence: results from the ESEMeD study.

BACKGROUND: Suicidality constitutes a major health concern in many countries. The aim of the present paper was to analyse 10 of its risk factors and their interdependence. METHODS: Data on suicidality, mental disorders and experience of childhood violence was collected from 8796 respondents in the European Study of the Epidemiology of Mental Disorders (ESEMeD). The CIDI was used to assess mental disorders. Individuals were randomly divided into two subgroups. In one, a Graphical Markov model to predict suicidality was constructed, in the second, predictors were cross-validated. RESULTS: Lifetime suicidality was predicted mainly by lifetime depression and early experiences of violence, with a pseudo R-square of 12.8%. In addition, alcohol disorders predicted suicidality, but played a minor role compared with the other risk factors in this sample. CONCLUSION: In addition to depression, early experience of violence constitutes an important risk factor of suicidality. LIMITATIONS: This is a cross-sectional and retrospective study assessing risk factors for suicidality, not for suicide itself.

Use of general practitioners versus mental health professionals in six European countries: the decisive role of the organization of mental health-care systems.

OBJECTIVE: To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems. METHODS: Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP- for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands). RESULTS: Among respondents consulting GPs and/or MHPs in the past year (n = 1,019), respondents from the MHP- group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders. CONCLUSIONS: Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys.

BACKGROUND: Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition. RESULTS: Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings. CONCLUSIONS: Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles.

PURPOSE OF REVIEW: In this review, we provide an update of recent studies on the age of onset (AOO) of the major mental disorders, with a special focus on the availability and use of services providing prevention and early intervention. RECENT FINDINGS: The studies reviewed here confirm previous reports on the AOO of the major mental disorders. Although the behaviour disorders and specific anxiety disorders emerge during childhood, most of the high-prevalence disorders (mood, anxiety and substance use) emerge during adolescence and early adulthood, as do the psychotic disorders. Early AOO has been shown to be associated with a longer duration of untreated illness, and poorer clinical and functional outcomes. SUMMARY: Although the onset of most mental disorders usually occurs during the first three decades of life, effective treatment is typically not initiated until a number of years later. There is increasing evidence that intervention during the early stages of disorder may help reduce the severity and/or the persistence of the initial or primary disorder, and prevent secondary disorders. However, additional research is needed on effective interventions in early-stage cases, as well as on the long-term effects of early intervention, and for an appropriate service design for those with emerging mental disorders. This will mean not only the strengthening and re-engineering of existing systems, but is also crucial the construction of new streams of care for young people in transition to adulthood.

Including information about co-morbidity in estimates of disease burden: results from the World Health Organization World Mental Health Surveys.

BACKGROUND: The methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one's own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles. METHOD: Face-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects. RESULTS: The best-fitting model included condition main effects and interactions of types by numbers of conditions. Neurological conditions, insomnia and major depression were rated most severe. Adjustment for co-morbidity reduced condition-specific estimates with substantial between-condition variation (0.24-0.70 ratios of condition-specific estimates with and without adjustment for co-morbidity). The societal-level burden rankings were quite different from the individual-level rankings, with the highest societal-level rankings associated with conditions having high prevalence rather than high individual-level severity. CONCLUSIONS: Plausible estimates of disorder-specific effects on VAS can be obtained using methods that adjust for co-morbidity. These adjustments substantially influence condition-specific ratings.

Mental disorders and termination of education in high-income and low- and middle-income countries: epidemiological study.

BACKGROUND: Studies of the impact of mental disorders on educational attainment are rare in both high-income and low- and middle-income (LAMI) countries. AIMS: To examine the association between early-onset mental disorder and subsequent termination of education. METHOD: Sixteen countries taking part in the World Health Organization World Mental Health Survey Initiative were surveyed with the Composite International Diagnostic Interview (n=41 688). Survival models were used to estimate associations between DSM-IV mental disorders and subsequent non-attainment of educational milestones. RESULTS: In high-income countries, prior substance use disorders were associated with non-completion at all stages of education (OR 1.4-15.2). Anxiety disorders (OR=1.3), mood disorders (OR=1.4) and impulse control disorders (OR=2.2) were associated with early termination of secondary education. In LAMI countries, impulse control disorders (OR=1.3) and substance use disorders (OR=1.5) were associated with early termination of secondary education. CONCLUSIONS: Onset of mental disorder and subsequent non-completion of education are consistently associated in both high-income and LAMI countries.

Patterns of admission to acute psychiatric in-patient facilities: a national survey in Italy.

BACKGROUND: A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy. METHOD: Sociodemographic, clinical and treatment-related information was collected for 1577 patients admitted to 130 public and 36 private in-patient facilities in Italy during an index period in the year 2004. All patients were also rated using the 24-item Brief Psychiatric Rating Scale (BPRS) and the Personal and Social Performance (PSP) rating scales. RESULTS: Non-affective psychoses (36%) were the most common diagnoses and accounted to a large extent for compulsory admissions. Private facilities were more likely to admit patients with organic mental disorders and substance abuse/dependence and less likely to admit patients with non-affective psychoses. Overall, 77.8% of patients had been receiving treatment by a mental health professional in the month prior to admission. In 54% of cases, the admission was solicited by patients' family members. The main factors preceding admission were impairment in work or social functioning, social withdrawal, and conflict with family members. Agitation, delusions and/or hallucinations, and the presence of multiple problems were associated with compulsory admissions, whereas depressive and anxiety symptoms were associated with voluntary admissions. CONCLUSIONS: In a mixed, public-private psychiatric care system, like the Italian one, public and private facilities admit patients with widely different clinical characteristics and needs. Family support represents an important resource for most patients, and interventions specifically addressed to relieving family burden are warranted.

Which factors affect the costs of psychiatric residential care? Findings from the Italian PROGRES study.

UNLABELLED: In the latest years, mental hospitals have gradually been replaced by a community-based network of facilities, including non-hospital residential facilities (RFs). Little information is still available about their costs. Our aims were to estimate the costs of Italian RFs and to evaluate which factors affect the cost of RFs and their patients. METHOD: A representative sample of 265 Italian RFs, hosting 2962 patients, was selected for the study. RFs costs and costs of psychiatric, medical and informal care were estimated. RESULTS: Patients in RFs cost between 7851 and 34 650 US$ per year; to this amount, it should be added from 2032 to 4702 US$ per year for the community psychiatric services (CPS). Significant differences were found by facility type, geographical areas, number of beds and age and diagnosis. About 45% of the variability for RF costs and 19% for CPS costs was explained by the regression models. CONCLUSION: The results can be useful to inform service planning and resource allocation.

The prescription of psychotropic drugs in psychiatric residential facilities: a national survey in Italy.

OBJECTIVE: This paper reports the prescriptions of psychotropic drugs made to 2962 patients living in 265 residential facilities (RFs) in Italy. METHOD: Structured interviews were administered to RF managers and staff to obtain data on patients' sociodemographic and clinical characteristics; information about current drug prescriptions were obtained from clinical records. RESULTS: Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (+/-1.1). The association of one atypical antipsychotic with one benzodiazepine represented the most common prescription profile. The variable most consistently associated with a higher likelihood of receiving polypharmacy was a history of admission to an acute general hospital psychiatric ward in the previous 12 months. Many prescriptions were loosely related to specific diagnoses. CONCLUSION: Psychotropic drug prescription patterns for severe patients living in RFs are characterized by substantial rates of polypharmacy. Specific guidelines may be helpful for long-stay patients living in RFs, who exhibit complex care needs.

Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: The European Study of Epidemiology of Mental Disorders (ESEMeD) project was designed to evaluate the prevalence, the impact and the treatment patterns in Europe. This paper presents an overview of the methods implemented in the project. METHOD: ESEMeD is a cross-sectional study in a representative sample of 21 425 adults, 18 or older, from the general population of Belgium, France, Germany, Italy, the Netherlands and Spain. The Composite International Diagnostic Interview (WMH-CIDI) was administered by home interviews from January 2001 to August 2003 using Computer Assisted Personal Interview (CAPI) technology. Data quality was controlled to ensure reliability and validity of the information obtained. RESULTS: Response rate varied from 78.6% in Spain to 45.9% in France. Less than 4% of the individuals had errors in the checking procedures performed. CONCLUSION: The sampling methodologies, comprehensive psychiatric instruments and quality control procedures used have rendered the ESEMeD database a unique and important source of information about the prevalence, the disability burden and unmet medical needs of mental disorders within Europe.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) is a new cross-sectional study investigating the prevalence and the associated factors of mental disorders, as well as their effect on health-related quality of life and the use of services in six European countries. This paper describes the rationale, methods and the plan for the analysis of the project. A total of 22,000 individuals representative of the non-institutionalized population aged 18 and over from Belgium, France, Germany, Italy, the Netherlands and Spain are being interviewed in their homes. Trained interviewers use a computer-assisted personal interview (CAPI) including the most recent version of the Composite International Diagnostic Interview (CIDI, 2000), a well-established epidemiological survey for assessing mental disorders. This is the first international study using the standardized up-to-date methodology for epidemiological assessment. Sizeable differences in prevalence, impact and level of need that is met by the health services are expected. The analysis of these differences should facilitate the monitoring of ongoing mental health reform initiatives in Europe and provide new research hypotheses.

Quality of life assessment in HIV-positive persons: application and validation of the WHOQOL-HIV, Italian version.

QoL assessment is currently considered essential for clinical trials in HIV infection, as commonly used end-points (CD4 level, viral load, opportunistic diseases) are inadequate to catch the complexity of treatment outcomes. The World Health Organization has recently developed a standardized set of instruments to assess subjective quality of life (QoL) in different medical conditions, including HIV infection. Here we report evidence for the acceptability, reliability and validity of the Italian version of the WHOQOL-HIV. The Italian version of WHOQOL-HIV has been administered in a sample of 151 HIV-positive persons, consecutively attending the largest infectious diseases hospital in southern Italy. Mean time of administration and percentage of missing responses, Cronbach alpha, Pearson coefficient and oneway ANOVA were applied to assess, respectively, acceptability, reliability, convergent and disciminant validity, and sensitivity to change. Mean time of administration was 28 minutes; only 2 questionnaires showed more than 20% of missing responses. Cronbach alpha was above 0.70 in 22 of the 28 sections of the WHOQOL-HIV; it ranged between 0.53 and 0.68 in the remaining 6 sections. Each of the 7 QoL principal domains correlated with overall QoL at a significance level p < 0.001. Moreover, correlation between principal domains were always statistically significant (p < 0.01) with only two exceptions. Finally, mean scores in each QoL domain were in the expected direction (worse in AIDS patients as compared to asymptomatic and symptomatic persons). The Italian version of WHOQOL-HIV is a valid and reliable instrument to assess subjective QoL in HIV-positive persons. It seems potentially useful to assess patients' life satisfaction, and to calibrate standards of care in different stages of the infection.

[Quality of life assessment: validation of the Italian version of the WHOQOL-Brief]. / La valutazione della qualità della vita: validazione del WHOQOL-Breve.

OBJECTIVE: To test the psychometric properties of the Italian version of the WHOQOL-BRIEF (e.g., construct and internal validity, concurrent validity with the MOS SF-36 and test-retest reliability). The WHOQOL-BRIEF is a 26-items self-report instrument which assesses four domains assumed to represent the Quality Of Life (QOL) construct: physical domain, psychological domain, social relationships domain and environment domain, plus two facets for assessing overall QOL and general health. METHODS: Data have been collected in three sites (Bologna, Modena and Padua), located in the North of Italy, in the framework of the international WHOQOL project. According to the study design, the sample had to include about 50% males and 50% females, 50% of subjects below and 50% above the age of 45, all in contact with various health services. A subsample has been re-interviewed after 2-3 weeks in order to study test-retest reliability. After the WHOQOL-BRIEF, most subjects have also been administered the MOS-SF36 in order to test the concurrent validity between these two instruments. RESULTS: The instrument was administered to 379 subjects (1/6 healthy and 1/6 sick), chosen to be representative of a variety of different medical conditions. Seventy patients, who displayed stable health conditions, have been reassessed after 2-3 weeks to study test-retest reliability. The WHOQOL-BRIEF domains has shown good internal consistency, ranging from 0.65 for the social relationships domain to 0.80 for the physical domain; it has been able to discriminate between in- and out-patients and between the two age groups considered in the present study (< 45, > or = 45 years). Only physical and psychological domains were found to discriminate between healthy and ill subjects. No gender differences in the mean scores for the four domains were found. Concurrent validity between the WHOQOL-Brief and the MOS-SF-36 was satisfactory, and specific for the physical and psychological health domains. Test-retest reliability values were also good, ranging from 0.76 for the environment domain to 0.93 for the psychological domain. CONCLUSIONS: This study shows that the WHOQOL-BRIEF is psychometrically valid and reliable, and that it is also potentially useful in discriminating between subjects with different health conditions in clinical settings.

Epidemiology and social costs of low back pain and fibromyalgia.

Low back pain and fibromyalgia represent two of the most common disorders in developed countries. On the whole, up to 75% of the general population has, at some time, suffered from low back pain. A percentage ranging between 5 and 10% of them develops a chronic illness. In most countries, the incidence rate per year of low back pain is 5%. Most low back pain episodes occur between the ages of 25 and 55 years. Most studies have not found any clear influence between genders and frequency of low back pain. There is a relationship between low back pain and occupation, with those who have physically demanding jobs being more at risk. As regards fibromyalgia, the prevalence rates range between 6 and 20%, with a higher frequency among females and between the ages of 25 and 55 years. The direct and indirect costs of low back pain approach $24 billion per year in the U.S. It is in view of its high prevalence among populations of developed countries, of its heavy psychosocial and financial implications, and of the burden imposed on health services, that low back pain represents a severe public health problem.