Telemedicine in Service of Family Doctors in North Macedonia: Search for the New Frontier for Medical Professionals.

Introduction: Innovative medical technologies such as telemedicine, telehealth, and artificial intelligence have great potential in North Macedonia. Our nation was a leader in the region in advancing internet connections. A key barrier to wider adoption has been human resources. Material and Methods: Family doctors are skilled and trained enough to accept and use these technologies in everyday work. In our School of Family Medicine, we thought that additional training was necessary. This was the key objective of our task-if telemedicine and telehealth are presented to a critical mass of doctors as yet another tool that will make their day-to-day work easier, the "chain reaction" of adopting and applying telemedicine and telehealth would not be stopped. Discussion: To further study this objective, we started with a pilot project with a course in telemedicine and telehealth for future family medicine specialists. Telepsychiatry and teledermatology were the first modules to be taught. In addition, telehealth care equipment was also presented to participants. Conclusion: Participants' reactions were very positive.

Factor structure of the brief psychiatric rating scale-expanded among outpatients with psychotic disorders in five Southeast European countries: evidence for five factors.

The Brief Psychiatric Rating Scale (BPRS) is a useful tool for measuring the severity of psychopathological symptoms among patients with psychosis. Many studies, predominantly in Western countries, have investigated its factor structure. This study has the following aims: (a) to further explore the factor structure of the BPRS-Expanded version (BPRS-E, 24 items) among outpatients with psychotic disorders in Southeast European countries; (b) to confirm the identified model; and (c) to investigate the goodness-of-fit of the three competing BPRS-E factor models derived from previous studies. The exploratory factor analysis (EFA) produced a solution with 21 items grouped into five factors, thus supporting the existence of a fifth factor, i.e., Disorganization. A follow-up confirmatory factor analysis (CFA) revealed a 19-item model (with two items removed) that fit the data well. In addition, the stability of two out of three competing factor models was confirmed. Finally, the BPRS-E model with 5 factors developed in this cross-national study was found to include a greater number of items compared to competing models.

Clozapine prescription rates in Southeast Europe: A cross-sectional study.

Introduction: International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods: Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results: It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion: Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.

Depression and Anxiety in Adolescents and their Caregivers: A Cross-Sectional Study from North Macedonia.

Introduction: Mental health problems have increased internationally during the COVID-19 pandemic. Adolescents and their caregivers form a vulnerable group for the development of mental health problems. However, most data stems from high-income countries, and there is a clear lack of prevalence rates and potential risk factors from Balkan countries. No data is available on the impact of the COVID-19 pandemic on mental health in adolescents and their caregivers in North Macedonia. Materials and methods: A cross-sectional study was conducted on adolescents and their caregivers in a school setting in rural and urban areas of North Macedonia. Survey items assessed symptoms of depression, anxiety, and respondents' fear of COVID-19, as well as a number of risk factors, such as gender and living environment. Results: 506 adolescents and 492 caregivers completed the survey. Symptoms of depression and anxiety were mild to moderate in adolescents and their caregivers. Women and girls generally scored higher than men and boys, and adolescents in high school scored higher than those in elementary school. Prevalence rates for depression were 29.2% for adolescents and 10.4% for caregivers, while rates of anxiety were 23.7% for adolescents and 6.1% for caregivers. Conclusion: This study provides a first insight into the mental health of adolescents and their caregivers after the COVID-19 pandemic in North Macedonia. Further research is required to investigate the relatively low rates of caregivers' mental health problems compared to data from other countries.

Subjective Quality of Life of Women in the Perinatal Period: A Post Covid-19 Pandemic Exploration in North Macedonia.

Subjective quality of life could be considered one of the indicators of health behavior and wellbeing of women in the perinatal period. Accordingly, the aim of this paper was to examine how women in perinatal period perceive quality of life in various domains. Its relationship to age, number of pregnancies, course of pregnancies, and method of delivery and experience with Covid-19 pandemic was investigated, as well. Our sample consisted of 366 pregnant women in any period of pregnancy who came in for regular outpatient examinations and control, those who were hospitalized due to pathological pregnancy or due to the need for intensive care, as well as women in their postnatal period, one year after delivery, who were seeking professional advice from a gynecologist. The majority were aged 20 to 30 years (53.8%). The findings showed that assessed domains of subjective quality of life were related to a variety of experiences with the Covid-19 pandemic. The results are presented and discussed in detail. Implications and limitations are given, as well.

Corrigendum: Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

[This corrects the article DOI: 10.3389/fpsyt.2021.785144.].

Non-pharmacological interventions for schizophrenia-analysis of treatment guidelines and implementation in 12 Southeast European countries.

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries-Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia-included non-pharmacological interventions. The remaining three countries-Kosovo (UN Resolution), Romania, and Slovenia-have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5-11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

Psychopathology in psychotic disorders: Congruency between self-reported and observer-rated measures highest for affective symptoms and lowest for negative symptoms.

Considering that both observer ratings and patient self-reports on severity of psychopathological symptoms are being used in research and clinical settings, this paper aims to explore the degree of congruence between these two sources. Eighty-two adult outpatients diagnosed with psychotic disorders rated their symptoms using the Brief Symptom Inventory (BSI). Observers assessed patients' functioning using the Brief Psychiatry Rating Scale (BPRS). Self-ratings (overall BSI) were strongly correlated to observers' evaluations (overall BPRS). Anxiety/depression symptoms dimension of the BPRS were significantly associated with all nine symptom dimensions of the BSI, while positive symptoms dimension and unusual and withdrawal behavior in the BPRS showed a significant relationship to seven symptom dimensions as measured with the BSI. Mania/activation in the BPRS was significantly and negatively related only to phobic anxiety in BSI. Eight symptom dimensions of the BSI (interpersonal sensitivity was an exception), as well as unusual and withdrawal behavior and positive symptoms in the BPRS were rated as more severe in unemployed study participants. Self-rated paranoid ideation was higher in less educated participants. No sex or marital status differences were found in the BSI and BPRS dimensions. The obtained pattern of correlations implied that congruence was highest in regards to affective symptomatology, followed by positive symptoms, and lowest for disorganization and withdrawal behavior.

Social distance and stigma towards persons with serious mental illness among medical students in five European Central Asia countries.

The study investigated behavioral measures of social distance (i.e., desired proximity between self and others in social contexts) as an index of stigma against those with mental illness among medical students in the Republic of North Macedonia, Turkey, Azerbaijan, Kazakhstan, and Poland, using the Reported and Intended Behavior Scale (RIBS), a standardized, self-administered behavioral measure based on the Star Social Distance Scale. The students' responses to standardized clinical vignettes on schizophrenia, and depression with suicidal ideation, were also assessed. A total of 257 North Macedonian (females, 31.5%; 1-4 grades, 189; 5-6 grades, 68); 268 Turkish (females, 43.3%; 1-4 grades, 90; 5-6 grades, 178); 450 Kazakh (females, 28.4%, 71.6%; 1-4 grades, 312; 5-6 grades, 138); 512 Azerbaijani (females, 24%; 1-4 grades, 468; 5-6 grades, 44; females, 24%), and 317 Polish (females, 59.0%; 1-4 grades, 208; 5-6 grades, 109) students were surveyed. The responses on the RIBS social distance behavior measures did not improve with advancing medical school grade, but students across all sites viewed schizophrenia and depression as real medical illnesses. The results support the development of enhanced range of integrated training opportunities for medical student to socially interact with persons with mental illness sharing their experiences with them.

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey.

BACKGROUND: Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE). OBJECTIVE: To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE. METHODS: An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers. RESULTS: In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia. CONCLUSION: Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

Background: Negative symptoms are core features of schizophrenia and very challenging to be treated. Identification of their structure is crucial to provide a better treatment. Increasing evidence supports the superiority of a five-factor model (alogia, blunted affect, anhedonia, avolition, and asociality as defined by the NMIH-MATRICS Consensus); however, previous data primarily used the Brief Negative Symptoms Scale (BNSS). This study, including a calibration and a cross-validation sample (n = 268 and 257, respectively) of participants with schizophrenia, used the Clinical Assessment Interview for Negative Symptoms (CAINS) to explore the latent structure of negative symptoms and to test theoretical and data-driven (from this study) models of negative symptoms. Methods: Exploratory factor analysis (EFA) was carried out to investigate the structure of negative symptoms based on the CAINS. Confirmatory factor analysis (CFA) tested in a cross-validation sample four competing theoretical (one-factor, two-factor, five-factor, and hierarchical factor) models and two EFA-derived models. Result: None of the theoretical models was confirmed with the CFA. A CAINS-rated model from EFA consisting of five factors (expression, motivation for recreational activities, social activities, vocational, and close/intimate relationships) was an excellent fit to the data (comparative fix index = 0.97, Tucker-Lewis index = 0.96, and root mean square error of approximation = 0.07). Conclusions: This study cannot support recent data on the superiority of the five-factor model defined by the NMIH-MATRICS consensus and suggests that an alternative model might be a better fit. More research to confirm the structure of negative symptoms in schizophrenia, and careful methodological consideration, should be warranted before a definitive model can put forward and shape diagnosis and treatment of schizophrenia.

Psychometric Characteristics of the Macedonian Version of Clinical Assessment Interview for Negative Symptoms (CAINS).

BACKGROUND: Despite the importance of effective assessment and treatment of negative symptoms among patients with psychosis, no validated instruments are available in the Republic of North Macedonia. The aim of this paper was to explore psychometric properties, namely factorial structure, internal consistency, convergent and discriminant validity of the Clinical Assessment Interview for Negative Symptoms (CAINS). SUBJECTS AND METHODS: In this cross-sectional study 82 outpatients diagnosed with psychosis (64 with schizophrenia and 18 with bipolar disorder; female=34, mean age=41.05±10.09) were assessed. RESULTS: The exploratory factor analysis revealed two factorial structure of the negative symptoms as measured by the CAINS, i.e. 'expression and motivation' and 'pleasure'. Two items aimed to measure motivation for family relations and motivation for work/school activities loaded on the expression factor instead on motivation and pleasure factor which differs from the original version of the CAINS. Convergent validity was proven by positive relationship to negative symptoms as measured by the BPRS. Positive, but weak correlation with BPRS positive symptoms demonstrated its discriminant validity. Internal consistency of overall CAINS scale and its two subscales was very high. CONCLUSION: The CAINS can be used to assess negative symptoms in individuals with psychosis in the Macedonian clinical context. Consequently, this work can provide a foundation for further clinical advancement and research of negative symptoms in Macedonian healthcare.

Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: an observational intervention study.

BACKGROUND: Community Mental Health Teams (CMHTs) deliver healthcare that supports the recovery of people with mental illness. The aim of this paper was to explore to what extent team members of five CMHTs newly implemented in five countries perceived that they had introduced aspects of the recovery-oriented, strength-based approach into care after a training week on recovery-oriented practice. In addition, it evaluated what the team members' perceptions on their care roles and their level of confidence with this role were. METHOD: An observational intervention study using a quantitative survey that was administered among 52 health professionals (21 Nurses, 13 Psychiatrists, 9 Psychologists, 8 Social Workers) and 14 peer workers including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions was conducted. The measures were self-reported. Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables (TMSA tool and demographic data). The standard technique to calculate scale scores for each subscale of the RSA-P was used. Bivariate linear regression analyses were applied to explore the impact of predictors on the subscales of the RSA-P. Predictors with significant effects were included in multiple regression models. RESULT: The RSA-P showed that all teams had the perception that they provide recovery-oriented practice to a moderately high degree after a training week on recovery-oriented care (mean scores between 3.85-4.46). Health professionals with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p = 0.036, B = - 0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles. CONCLUSION: The findings suggest that a one-week training session on community-based practices and collaborative teamwork may enhance recovery-oriented practice, but the role of nurses and peer workers needs further attention. TRIAL REGISTRATION: Each trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209 ); Montenegro, Kotor (Trial Reg. No. NCT03837340 ); Romania, Suceava (Trial Reg. No. NCT03884933 ); Macedonia, Skopje (Trial Reg. No. NCT03892473 ); Bulgaria, Sofia (Trial Reg. No. NCT03922425 ).

Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study.

BACKGROUND: Implementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources. METHODS: Thirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants' accounts. RESULTS: Six major themes were identified. Three themes (Intervention characteristics; Carers' involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention's implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists' time constrains. CONCLUSIONS: This study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe - a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Patient Satisfaction with Use of Telemedicine in University Clinic of Psychiatry: Skopje, North Macedonia During COVID-19 Pandemic.

Background: There is increasing interest in the use of telemedicine as a means of health care delivery especially in circumstances of pandemics. This is partly because technological advances have made the equipment less expensive and simpler to use and partly because increasing health care costs and patient expectations have increased the need to find alternative modes of health care delivery. Introduction: Telemedicine and telepsychiatry, in particular, are rapidly becoming important delivery approaches to providing clinical care and information to patients in cases wherein the medical resources and the patients are very hard to be brought together with respect to rules of behavior in case of epidemics. The reliance on technology to bridge the obstacles between the patients (consumers) and medical resources (providers) can create problems that impact service delivery and outcomes, but in cases such as this (COVID-19 pandemics), this is virtually the only tool for providing clinical care and information to patients. Materials and Methods: A client satisfaction survey was undertaken in a daily hospital (a part of University Clinic of Psychiatry in Skopje). The anonymous modified self-report questionnaire (short form patient satisfaction questionnaire [PSQ-18]) covering demographic, gender, and age variables was endorsed by 28 participants. The mean age of the subjects was 40.25 ± 22 years, with a small majority of men (18 participants) versus women (11 participants). Results: Overall satisfaction with psychiatric care was high (80.22%). None of the demographic or other variables correlated significantly with satisfaction. Discussion: We had to reduce rate and time length of our face-to-face contacts with patients as a result of pandemics but they were able to reach their doctors virtually at all times. Conclusions: Many mental health professionals are using widely available, commercial software downloaded from the internet to provide care directly to a patient's home.

Community mental healthcare: new developments and innovative strategies.

PURPOSE OF REVIEW: The aim of this scoping review was to identify and map the available evidence on recent innovations in community mental healthcare across the globe. RECENT FINDINGS: This review highlights the different innovative approaches and strategies being currently used in the field of community mental health. Key approaches found in the reviewed studies include collaborative care with the inclusion of peer workers, growing use of e-health and telepsychiatry, improved reforms on national mental health policies and de-institutionalization, modification of outreach models and mental health promotion in the community. The studies reviewed here suggest that continued innovation and implementation of new models and strategies have the potential to reduce the burden of disease and increase the quality of life for patients with mental health issues. SUMMARY: Growing body of evidence shows that integrative care is the new standard of care for people with mental illnesses, with necessity of continuity of care from emergency department to community mental health services. Social determinants of rehabilitation and recovery, and peers support remain a new main topic of research in area of treatment of people with severe mental illnesses. E-health tools are becoming prevalent in the processes of promotion, prevention and treatment in mental healthcare.

Treatment of Depressive Conditions in Pregnancy.

BACKGROUND: Mother's mental state during pregnancy is of substantial importance for the mother, but also for the infant and his/her future growth and development. Depressive maternal disorders during pregnancy have a significant influence on the development of the baby during pregnancy as well as on the future development and mother-baby relation, the breastfeeding process and care for the baby. AIM: This study aimed to determine the influence of SSRI antidepressant therapy and psychosocial and therapeutic interventions on depression during pregnancy. It was also our aim to determine the relation between severity of depression and sociodemographic characteristics. METHODS: The study included 40 women, with diagnosis F32 and F33 according to ICD 10, that is, with severe depressive disorder within depressive episodes or recurrent depressive disorder. Patients were evaluated at the beginning of the treatment and 3 months after antidepressant treatment. They were followed-up for two years. RESULTS: The results obtained have shown that a larger number of mothers treated with antidepressant medications, had normal childbirth with the unremarkable condition of both, the mother and the newborn baby. CONCLUSION: A well-combined treatment of maternal depression during pregnancy reduces the risk of postpartum depression, which is by itself a prerequisite for normal emotional and behavioural development of the child.

Personality Characteristics as Predictive Factors for the Occurrence of Depressive Disorder.

BACKGROUND: The depressive disorder is one of the most frequent mental disorders, which is often associated with severe dysfunctionality. Personality traits are considered as important factors for the occurrence of depressive disorder. AIM: To determine the specificity of personality dimensions as predictive factors of depressive disorder. METHODS: This research was conducted at the University Psychiatric Clinic Skopje as a "case-control" study. TCI-R (temperament and character inventory - revised) was used as the main research instrument. RESULTS: There are specific personality traits expressed through high scores of Harm Avoidance and low scores of Self -Directedness traits as predictive factors related to an incidence of the depressive disorder. CONCLUSION: The results of this study show that certain personal traits, and more specific HA and SD, are with a specific predictability of the depressive disorder.

Character and Temperament Dimensions in Subjects with Depressive Disorder: Impact of the Affective State on Their Expression.

BACKGROUND: The depression is a cross-cultural condition that occurs in all cultures and within all nations with certain specificities, even though there are some differences in its manifestation. The hereditary load is of major importance, but also the individual personality factors, in the form of risk factors, are associated with the occurrence of depression. Personality characteristics have a significant impact on the occurrence of the recurrent depressive disorder and the outcome of the treatment as well. AIM: To identify the specific personality traits in people with the recurrent depressive disorder and the impact of the affective state on them. METHODS: Three questionnaires were used: a general questionnaire, Beck's scale of depressive symptoms, and TCI-R (inventory for temperament and character). RESULTS: The most indicative differences in the dimensions are found in the Harm avoidance and the Self-direction dimensions, and most variable dimensions dependent on effective state are Novelty seeking and Reward dependence. CONCLUSION: The people with the recurrent depressive disorder have a different profile of personality traits (temperament and character) compared with the control group, and their characteristics depend on their current affective state.

Enduring Personality Changes after Intense Stressful Event: Case Report.

BACKGROUND: World statistical data show that a large number of individuals suffer from posttraumatic stress disorder (PTSD) after exposure to the intense traumatic event. PTSD can have a chronic course with enduring changes in the functioning of the person. CASE PRESENTATION: Here we report two adult individuals of different gender and education who were exposed to the extremely severe stressful event after which difficulties in psychological functioning developed. The first case we present is a 46-year-old man, with completed high education, divorced, father of two children, who lives with his parents, and is retired. Disorders appeared 20 years ago when he was exposed to extremely severe stressful events in war circumstances that included captivity, torture, and loss of fellow soldiers. The second case is a 50-year-old female patient, with a university degree, professor of art, married, and mother of two children of whom the son died six years ago. She suffered from disorders after the sudden injury of her son that ended with his death. CONCLUSION: Posttraumatic stress disorder after the intense stress is a risk of development enduring personality changes with serious individual and social consequences.