Differences in Resilience, Self-Stigma and Mental Health Recovery between Patients with Schizophrenia and Depression.

INTRODUCTION: There is growing evidence that resilience is a key factor for prevention of mental disorder. Low resilience levels were found in individuals at clinical high risk to psychosis and schizophrenia. Higher level of resilience was associated with better functioning, less severe negative, anxiety and depressive symptoms. Low level of self stigma is associated with recovery from schizophrenia. Aim of this paper was to determine whether resilience and self-stigma are significant predictors of mental health recovery in patients diagnosed with schizophrenia and depression treated in a rehabilitation-oriented program. SUBJECTS AND METHODS: 51 patients diagnosed with psychoses and 53 patients with depression treated in day hospital participated in this study. Internalized Stigma of Mental Illness Scale (ISMI), The Boston University Empowerment Scale (BUES), Perceived Devaluation and Discrimination (PDD) Scale, Mental Health Recovery Measure (MHRM) and Resilience questionnaire were used. RESULTS: Self-stigma positively correlates with PDD (r=0.44; p=0.000), and negatively with BUES (r=-0.78; p=0.000), resilience (r=-0.51; p=0.000) and with recovery (r=-0.59; p=0.000) in two groups. In addition, a higher PDD score indicates poorer levels of empowerment (r=-0.42; p=0.000), resilience (r=-0.35; p=0.000) and recovery (r=-0.44; p=0.000). Mental health empowerment, resilience and recovery all correlate significantly and positively with each other. Cross-group comparison results show the best results for patients with schizophrenia. Sociodemographic factors do not affect resilience, self-stigma nor recovery. CONCLUSION: Self-stigma and resilience are connected with moderate correlation. Research supports the need for interventions that prevent self-stigma and increase resilience in the treatment of schizophrenia patients.

Guidelines for Individual and Group Psychodynamic Psychotherapy for the Treatment of Persons Diagnosed with Psychosis and/or Schizophrenia.

The hereby presented guidelines for the use of psychodynamic psychotherapy are based on references and research in the field of individual and group therapy and they refer to psychotherapy for patients suffering from the first psychotic episode, schizophrenia, schizoaffective psychosis, bipolar disorder and paranoid psychosis. The aim was to provide an overview of present literature and to give recommendations based on current knowledge. Clinical experience and research of the outcomes of psychodynamic psychotherapy encourage positioning of such treatments among recommendations for treating various mental disorders, as well as in the field of psychotherapy of patients with psychotic disorders (PD).

A blind spot on the global mental health map: a scoping review of 25 years' development of mental health care for people with severe mental illnesses in central and eastern Europe.

Just over 25 years have passed since the major sociopolitical changes in central and eastern Europe; our aim was to map and analyse the development of mental health-care practice for people with severe mental illnesses in this region since then. A scoping review was complemented by an expert survey in 24 countries. Mental health-care practice in the region differs greatly across as well as within individual countries. National policies often exist but reforms remain mostly in the realm of aspiration. Services are predominantly based in psychiatric hospitals. Decision making on resource allocation is not transparent, and full economic evaluations of complex interventions and rigorous epidemiological studies are lacking. Stigma seems to be higher than in other European countries, but consideration of human rights and user involvement are increasing. The region has seen respectable development, which happened because of grassroots initiatives supported by international organisations, rather than by systematic implementation of government policies.

Effects of a Group Psychoeducation Program on Self-Stigma, Empowerment and Perceived Discrimination of Persons with Schizophrenia.

BACKGROUND: Self-stigma adversely affects recovery from schizophrenia. Analyses of self stigma reduction programs discovered that few studies have investigated the impact of education about the illness on self-stigma reduction. The objective of this study was to determine whether psychoeducation based on the principles of recovery and empowerment using therapeutic group factors assists in reduction of self-stigma, increased empowerment and reduced perception of discrimination in patients with schizophrenia. SUBJECTS AND METHODS: 40 patients participated in psychoeducation group program and were compared with a control group of 40 patients placed on the waiting list for the same program. A Solomon four group design was used to control the influence of the pretest. Rating scales were used to measure internalized stigma, empowerment and perception of discrimination. Two-way analysis of variance was used to determine the main effects and interaction between the treatment and pretest. Simple analysis of variance with repeated measures was used to additionally test effect of treatment onself-stigma, empowerment and perceived discrimination. RESULTS: The participants in the psychoeducation group had lower scores on internalized stigma (F(1,76)=8.18; p<0.01) than the patients treated as usual. Analysis also confirmed the same effect with comparing experimental group before and after psychoeducation (F(1,19)=5.52; p<0.05). All participants showed a positive trend for empowerment. Psychoeducation did not influence perception of discrimination. CONCLUSION: Group psychoeducation decreased the level of self stigma. This intervention can assist in recovery from schizophrenia.

The impact of a rehabilitation day centre program for persons suffering from schizophrenia on quality of life, social functioning and self-esteem.

BACKGROUND: Presently few studies demonstrate improved outcomes in patients with schizophrenia treated in day rehabilitation centres. One reason is the absence of an evidence based protocol for rehabilitation in such centres. Hence further research is required to assess whether such a protocol will improve psychosocial outcomes. AIMS: We performed a controlled evaluation study of a protocol based rehabilitation day program (RDC) for persons suffering from schizophrenia. METHODS: Patients from the experimental group (N=50) were treated within the RDC for a 6 month period. The control group were patients on the waiting list for the RDC. Quality of life (MANSA), social functioning (OSA) and self-esteem (Rosenberg) were measured before and after the intervention. RESULTS: Statistically significant improvement was shown in social functioning measured by OSA (F(1,96)=33.7; p<0.001), quality of life measured by MANSA (F(1,96)=69.3; p<0.001) and self esteem measured by Rosenberg scale (F(1,96)=84.5; p<0.001) for patients treated in the RDC compared with the control group, conversely, the control group outcomes deteriorated. CONCLUSION: An evidence based protocol for rehabilitation within the RDC lead to improved social outcomes and recovery for persons suffering from schizophrenia.

Stigma in clinical practice.

Much more is known about attitudes toward mental illness and social stigma, the viscious cycle of its consequences and how to fight the social stigma in public, but much less is known about how to combat the stigma and self stigma in clinical practice. Stigma theories have not been enough to understand the feelings and experience of people with mental illness. Conceptual framework that understands stigma as consisting of difficulties of knowledge (ignorance or misinformation), problems of attitudes (prejudice), and problems of behaviour (discrimination) have not o been enough to understand stigma dynamics in the patient therapist interaction. Understanding the psychodynamic aspects of internalized stereotype of mental illness in the patient- therapist relationship may improve our competency to deal with stigma and self stigma in clinical practice.

[Excessive daytime sleepiness--as possible suicidal equivalent in people with depressive disorder]. / Prekomjerna dnevna pospanost kao moguci suicidalni ekvivalent u osobe oboljele od depresivnog poremecaja.

This paper presents the case of a patient suffering from atypical depression, with excessive daytime sleepiness, which was a suicidal equivalent. Patients who suffer from depression and sleep disorders can have an increased risk of suicidality, and to them should pay increased attention. Field of suicide as a means of resolving conflicts and unconscious mental escape from the reality of the obstacles, including sleep and daytime sleepiness, which may represent a form of "temporary suicide". The authors recommend that hypersomnia, daytime sleepiness in depressed patients and other sleep disorders should be treated as a potential risk factor for suicidal behavior.

[Diagnostic and therapeutic algorithm for the treatment of premenstrual dysphoric disorder]. / Dijagnosticke i terapijske smjernice za lijecenje predmenstruacijskog disforicnog poremecaja.

Many women experience psychological and physical symptoms associated with menstrual cycle. In 3% to 5% of women that meet the criteria for premenstrual dysphoric disorder, the symptoms are severe and impair their social and occupational functioning. Although the etiology of premenstrual dysphoric disorder is unknown, the symptoms of dysphoria, including depression and anxiety, have been associated with serotonergic dysregulation. Selective serotonin reuptake inhibitors, taken only during the symptomatic luteal phase, are considered as first-line therapy for premenstrual dysphoric disorder.

[The organization of mental health care in community]. / Organizacija zastite mentalnog zdravlja u zajednici.

Integration of the psychiatry in primary care is beneficial for the early detection of mental disorder, better outcome of mental disorder and reduction of stigma. Psychiatry is a leading profession in organisation of mental health services. General practitioners (GPs) in Europe deal with mental disorders in their everyday practice, so the same is expected in Croatia. Graduate and postgraduate education of our GPs is insufficient for this new role. The paper compares actual situation in Croatia with forthcoming needs. The paper suggests that community psychiatry, anti-stigma program, continuing medical education of GPs and network of consultant psychiatrists give the best results in the early detection and treatment of mental disorder.

Case management - a pillar of community psychiatry.

This review is describing different models of case management, showing their similarities and differences with regards to the way they operate. Good relationship between patient and case manager, application of the biopsychosocial model, availability of psychosocial treatment methods and rehabilitation programs, and individual treatment plan are all important factors in case management's success. Large number of studies supports the application of case management in practice as effective treatment method in treating people with severe mental disorder, particularly those, who are less co-operative. Therefore, the implementation of case management into psychiatric practice should be supported.

Psychodynamic understanding and psychotherapeutic approach to psychoses.

The historical development of the psychodynamic approach to psychotherapy is described. The origins of ISPS are described, and ISPS Croatia and Slovenia are introduced.

Trauma, shame and psychotic depression experienced by ex-POWs after release.

Modern societies are growing ever more sensitive to the various sources and many kinds of psychic traumas, resulting even in psychotic reactions or states of functioning. Especially the war captivity situation represents the prolonged basis for chronic severe psychic stress and traumatisation, that may become deleterious even for the core self of the person. Severely psychotraumatized war veterans, or ex-POWs in the aftermath of the war captivity situation, survivors of extreme forms of violence and humiliation, are very reluctant to recall traumas. This avoidant behaviour is many times one of the most prominent symptoms that should be recognised and confronted in order to start the retraumatising process of healing the previously unthinkable traumas. The authors believe that shameful feelings are at the very basis of the psychotraumatised persons' withdrawal, depression, suicidal attempts, and even psychotic answers. The main feature of the first phase of any therapeutic work with these patients is the mourning process that should be gradually unfolded. The clinical examples will illustrate therapeutic work with these patients. The authors will expose some basic psychodynamic approaches and concepts regarding shame. This difficult feeling will be put in relationship with the psychotic answers. In that frame of reference the concept of 'near psychosis' will be described.

Gender and schizophrenia.

In accordance with the predominant view on the neurobiology of schizophrenia, most of the research on the differences in the illness between men and women has been studied on the basis of sex difference as a biological category rather than on the basis of gender as a psychosocial category. There are gender- identity difficulties observed in schizophrenia. Problems associated with gender can be a major source of instability and vulnerability during the development of the first and later psychotic episodes. There is a need for future research to view sex difference through gender perspectives. Findings from a gender study may have utility for the development of differential treatment interventions for men and women and may improve the outcome of the illness in general. The study of the complex role of gender in illness processes is an important research direction that would enhance our understanding of the heterogeneity in the manifestation and subjective experience of schizophrenia.

[Atipical antipsychotics in relation with social functioning]. / Atipicni antipsihotici i socijalno funkcioniranje.

We studied influence of type of antipsychotics in relation with social functioning in sample of 123 patients diagnozed with schizophrenia accordingto lCD 10 criteria. On atypicals (olanzapin, risperidon, clozapin) were 39 patients, 26 female and 13 male. The social functioning scale according to Bellak et al was used for assessment of social functioning. Results of our study show that there is no difference in social functioning between patients on atypical in comapration with patients on typical antipsychotics. We observed a positive trend of better social functioning in group of patients who takes atypicals. Results also showed that women had better social functioning comparing to males Education and duration of illness were not in relation with social functioning.

[Have we forgotten neurological diseases with psychological symptoms? Case study: Huntington's chorea]. / Da li smo zaboravili na neuroloske bolesti s psihickim simptomima? Prikaz slucaja: Huntingtonova horeja.

Huntington's cohrea is neurodegenerative disorder with high incidence of different psychiatric symptomathology including mood symptoms, dementia and psychotic symptoms. Very often psychic symptoms come before the typical motor symptoms. This paper demonstrates difficulties in diagnostic process for Huntington's chorea in the case when psychiatric symptoms come before the motor symptoms. We should take in account neurodegenerative disorder in the case of psychiatric disorder with atypical clinical pictures without adequate response on standard treatment.

[Importance of an interpersonal approach and object relation theories for the organization of treatment at the psychiatric hospital]. / Vaznost interpersonalnog pristupa i teorije objektnih odnosa za organizaciju lijecenja u psihijatrijskoj bolnici.

The importance of interpersonal relationships for the organization of the psychiatric hospital as a therapeutic setting is presented through the theoretical framework of object relations and milieu therapy. From the point of view of psychodynamic approach the majority of hospitalized patients show the pathology of self and object relations. So, the familiarity with these theories for the optimal planning of treatment of these patients is of a particular importance. The concepts of following authors are discussed in this paper: Winnicot, Kohut, Mahler, and Klein, as well as a concept of projective identification and milieu therapy.

Serotonin transporter 5HTTLPR polymorphism and affective disorders: no evidence of association in a large European multicenter study.

The available data from preclinical and pharmacological studies on the role of the serotonin transporter (5-HTT) support the hypothesis that a dysfunction in brain serotonergic system activity contributes to the vulnerability to affective disorders (AD). 5-HTT is the major site of serotonin reuptake into the presynaptic neuron, and it has been shown that the polymorphic repeat polymorphism in the 5-HTT promotor region (5-HTTLPR) may affect gene-transcription activity. 5-HTT maps to chromosome 17 at position 17q11.17-q12, and the 5-HTTLPR polymorphisms have been extensively investigated in AD with conflicting results. The present study tested the genetic contribution of the 5-HTTLPR polymorphism in a large European multicenter case-control sample, including 539 unipolar (UPAD), 572 bipolar patients (BPAD), and 821 controls (C). Our European collaboration has led to efforts to optimize a methodology that attenuates some of the major limitations of the case-control association approach. No association was found with primary psychiatric diagnosis (UPAD and BPAD) and with phenotypic traits (family history of AD, suicidal attempt, and presence of psychotic features). Our negative findings are not attributable to the lack of statistical power, and may contribute to clarify the role of 5-HTTLPR polymorphism in AD.

Lack of association between the 5HT2A receptor polymorphism (T102C) and unipolar affective disorder in a multicentric European study.

We report here a case-control association study with T102C polymorphism in the serotonin 2A receptor gene (HTR2A) in patients affected by unipolar affective disorder (UPAD) and in controls. A total of 284 subjects were genotyped (142 UPAD and 142 controls). All subjects were interviewed using standard diagnostic interviews and matched. A homogenous population of unipolar patients with suicidal attempt was identified. Conditional logistic regression was applied. No association of the HTR2A polymorphism was found in the overall sample of 142 UPAD-control pairs regarding allele and genotype frequencies (P=0.36 and P=0.52 respectively) and homo-heterozygote distributions (P=0.91). This study confirms, in a multicentric European sample, the earlier observations that the T102C HTR2A polymorphism is not associated with UPAD. Nevertheless, a type 2 statistical error cannot be excluded. Therefore, to exclude the implication of HTR2A in UPAD, this result must be replicated in larger samples and in other populations using the transmission disequilibrium test and different polymorphisms around HTR2A.

[Evaluation of residency programs in psychiatry]. / Procjena programa specijalizacije iz psihijatrije.

The paper investigates the characteristics of psychiatric residency in Croatia. During 1998 psychiatric residents were sent an anonymous questionnaire with questions related to obligatory training program in psychiatry according to regulations, control system, personal satisfaction, quality, supervising system, mentor, lectures, scientific work and literature. Data were analyzed by percentage analyses and chi square method. The results show some difficulties in respecting the obligatory program during the residency, insufficient supervision of clinical work, irregular consultation with mentor and unspecified educational material. Residents propose better program transparency, possibility to choose between the institutions, standardization of the program, precise definition of the mentor and supervision. Implementation of more transparent methods in the quality control of the training in psychiatry, as well as the importance of harmonization of psychiatric training in Croatia within UEMS requirements is suggested.

European combined analysis of the CTG18.1 and the ERDA1 CAG/CTG repeats in bipolar disorder.

Several groups have reported association between large CAG/CTG repeats in the genome and BP disorder using the Repeat Expansion Detection (RED) method. Molecular interpretation studies demonstrated that around 90% of the large CAG/CTG repeats detected by RED can by explained by repeat size at either the CTG18.1 or ERDA-1 locus. In this study we report the findings on a large European BP case-control sample analysed for these two frequently expanded repeats. The frequency of expanded alleles (>40 repeats) at the CTG18.1 locus was significantly higher in the subgroup of patients with a more severe phenotype BPI and a positive first degree family history than in a group of matched controls (9% vs 5%). No difference in ERDA-1 expansion frequency was seen between BP cases and matched controls. We conclude that the ERDA-1 locus is not related to the BP phenotype while expanded alleles at the CTG18.1 locus cannot be excluded as a vulnerability factor for BP disorder.