Loneliness in the presence of others: A mixed-method study of social networks of caregivers of patients with severe mental disorders.

BACKGROUND: One in four families has at least one member with a mental disorder and families are the main caregivers in most patients in low and middle-income countries. Caregivers experience disruption in their routine lives, increased responsibilities, increased need for support, and changes in their network. The role of personal support networks in the health and burden of the caregivers is complex and depends on the context, cultural and socioeconomical variables. In this study, we aimed to investigate the personal support network of caregivers of patients with severe mental illness in Iran. METHODS: By using a mixed-methods design, we focused on the structure and composition of caregiver networks, as well as self-perceived caregiver support. RESULTS: We found that the support network of caregivers was mostly composed of immediate family members whom themselves were selectively chosen as a result of the multidimensional process of interaction between stigma, availability, and the perceived needs of caregivers. The participants mentioned economic and instrumental supports more frequently than emotional support, probably reflecting their unmet basic needs. Advocacy for providing formal systemic supports to caregivers, as well as interventions that expand caregivers personal support network is recommended. CONCLUSIONS: Most participants of the study were relatively isolated and had a small network of support, mostly composed of immediate family members. Stigma was a serious source of family distress for caregivers and a limiting factor in social relationships.

A social network intervention to improve connectivity and burnout among psychiatry residents in an academic institution: a quasi-experimental study.

BACKGROUND: Burnout is common among residents, which could be associated with their professional network characteristics. This study aimed to assess the social networks of psychiatry residents and develop an intervention to improve their network characteristics, burnout, and perception of the educational environment. METHODS: We recruited a cohort of 17 PGY-2 residents and assessed their social networks, burnout, and perception of the educational environment. After the baseline survey, we held a focus group with PGY-2 residents to discuss the results, their network characteristics, and interventions that can improve their relationships. The PGY-2 residents indicated that offering extracurricular opportunities to facilitate friendly interactions among the residents and faculty members would be the most feasible and acceptable intervention. Therefore, four "interest groups" for extracurricular activities were established. Residents and faculty members were invited to participate in interest groups to improve the network characteristics. Some PGY-2 residents and faculty members agreed to moderate interest group sessions (active members). RESULTS: After the intervention, active residents improved significantly in the perceived personal accomplishment subscale of the burnout inventory and their perception of the educational environment. Active faculty members also had a significant increase in their relationships with PGY-2 residents in one domain of social networks. CONCLUSIONS: Enhancing relationships between residents and faculty members through participatory intervention and extracurricular activities can improve faculty-resident connectivity and residents' perception of personal accomplishment and educational environment quality.

Exploring the hidden curriculum of professionalism and medical ethics in a psychiatry emergency department.

PURPOSE: To investigate the hidden curriculum of professionalism in the emergency department. DESIGN AND METHODS: This is a qualitative study that consisted of six in-depth semi-structured interviews and a focus group with psychiatry residents of a teaching hospital program about their perception of professionalism in emergency department. A simple content analysis method has been conducted for the extraction of findings. FINDINGS: Common themes that were detected in the hidden curriculum were "Disregarding the priority of the patients"; "Overriding patient autonomy"; "Non-empathetic care"; "Breaching Confidentiality"; "Injustice in providing care"; and "Dishonesty" PRACTICE IMPLICATIONS: Professional behaviors are mostly learned through the hidden curriculum. The hidden and formal curricula of professionalism are different in several domains. Paying attention to organizational culture and social environment is critical for promoting professionalism.

Development and Evaluation of Acceptability and Feasibility of a Web-Based Intervention for Patients With Bipolar Disorder in Iran: Implementation Study.

BACKGROUND: Psychoeducation for bipolar disorder has a significant impact on symptoms and treatment adherence. In Iran, as a low-resource setting, infrastructural barriers, such as inadequate mental health professionals, difficulties in transportation, and costs of care, may hinder optimum delivery of this evidence-based intervention to patients. OBJECTIVE: This study sought to explore the acceptability and feasibility of a web-based intervention for bipolar patients in Iran. METHODS: A website has been developed as a platform for providing psychoeducational content about bipolar disorder. Patients were chosen via a convenient sampling method in 2018-2019. The main component of the intervention included streaming 7 weekly video clips after attending a single in-person meeting, as well as a medication self-monitoring application. Information was collected about the feasibility and acceptability of the intervention. RESULTS: We invited 45 patients from the day center and the outpatient clinic of Roozbeh psychiatric hospital and some private clinics in Tehran. Of the 23 patients (51%) who attended the first in-person session and provided informed consent, 14 patients dropped out during the study. While 9 patients completed the course (attended 4 or more online sessions), only 5 watched all the video sessions. The rate of adherence to the intervention and frequency of exposure to the website were much higher for those recruited from the private and outpatient clinics. CONCLUSIONS: This web-based intervention can be feasible and acceptable only for a subgroup of patients with specific educational status and socioeconomic level.

Challenges of implementing psychiatric rehabilitation services: a low- and middle-income country case example.

This article aims to explore the barriers and challenges of implementing psychiatric rehabilitation services at a psychiatric hospital in Iran. We performed an internal mixed-methods evaluation by adopting a multi-method approach. The data were organised, analysed and interpreted by the evaluation team. A low participation rate, administrative issues, low fidelity to protocols and incomplete documentation were the main findings. Implementing and maintaining rehabilitation services in low- and middle-income country settings requires more than a mere transfer of models of psychiatric rehabilitation; it needs adaptation to the local context as well as continuous evaluation and quality improvement in an iterative fashion, given the rapidly changing contexts with scarce resources.

Family and Patient Psychoeducation for Severe Mental Disorder in Iran: A Review.

Objective: There are evidence-based practices in the field of family and patient psychoeducation for patients suffering from severe mental disorders. However, given the variation in resources and cultural contexts, implementation of these services, especially in low and middle-income countries is faced with challenges. This study aimed to review articles on family and patient psychoeducation of severe mental disorders in Iran and to find the characteristics of the main components necessary for the implementation of such practices in clinical settings. Method : All published studies on family and patient psychoeducation for severe mental disorders (schizophrenia, schizoaffective, and bipolar disorder) conducted in Iran were searched up to May 2018; and key features and findings of each study were extracted and presented. Results: Forty-eight studies were included in this review, of which 27 were randomized controlled trials, and 20 were quasi-experimental. One study was an implementation and service development report. The main findings of these studies were a significant decrease in relapse rate and/or rehospitalization rate and a significant decrease of burden and distress of families. Conclusion: Despite a wide diversity in approaches, this review showed that different psychosocial interventions in which psychoeducation is one of their core and main components have promising results, demonstrating the significance of this intervention in Iranian mental health research. In our opinion, based on evidence, even with limited resources, it is no longer acceptable to deprioritize some forms of psychoeducation for patients and their families in clinical settings.

Patient and family psychoeducation: Service development and implementation in a center in Iran.

BACKGROUND: Family and patient psychoeducation have demonstrated significant improvement in clinical and social outcomes for patients suffering from severe mental disorders and their families. However, these evidence-based practices are not widely implemented at service delivery level and into routine clinical practice, especially in less developed countries. AIM: The aim of this article is to report the processes of development and implementation of a psychoeducational service for patients with severe mental illnesses and their families in Iran. METHOD: The program was developed at Roozbeh Hospital in Tehran, Iran. A group of clinicians worked on the development phase of the program and drafting the manuals. Then, a series of workshops and supervision sessions were held to train group leaders for implementation of the group psychoeducation for patients and families. In the pilot phase, the services were delivered to two groups of patients and families, and then the manual was revised based on the feedback from group leaders and participants. RESULTS: The program consisted of eight 90-minute weekly patient group sessions and 6 weekly multiple family group sessions. Two manuals for patient education (schizophrenia and bipolar disorder) were developed. Several information sheets were developed and distributed during different sessions of family and patient psychoeducation related to the content of each session. Despite providing the hospital clinicians with the information regarding these new services, less than 10% of the admitted patients were referred by their clinicians. CONCLUSION: Feasibility and sustainability of the program are affected by a number of factors. Low referral rate of clinicians, limited resources of the hospital, issues related to stigma and logistic issues are barriers in implementation of these services. Administrators' and clinicians' understanding of the importance of patient and family psychoeducation seems to be crucial in sustainability of such programs in routine service delivery.

The Effect of Clinical Exposure to Patients on Medical Students' Attitude Towards Mental Illness.

BACKGROUND: Stigma of mental disorders causes a reduction in seeking help from the health care professionals and is evident across the world. OBJECTIVES: The current study aimed to compare medical students' attitude towards mental illness after two different psychiatry clerkships in terms of the level of clinical exposure to patients with mental illness. PATIENTS AND METHODS: Through a quasi-experimental study, all of the 4th-year medical students were invited to enroll this study conducted in Tehran University of Medical Sciences (TUMS). They were non-randomly assigned into two different psychiatry clerkships from January 2009 to January 2010. One group was enrolled in the traditional lecture-based course (low-exposure) while the second group participated in a novel method with increased hours of patient exposure (high-exposure). Attitude towards mental illness (AMI) was measured by a 22-item questionnaire before and after the clerkship and data were compared between the two groups in terms of changing attitude towards mental illness in five different categories. RESULTS: A total of 211 participants were enrolled in the study (115 female) of which 115 students (54.5%) were in low-exposure group and 96 students (45.5%) in the high-exposure group. Generally, AMI scores did not differ between the two groups and did not show any significant changes before and after the psychiatry clerkship. The only exceptions to this were AMI4 category (the concept of etiology of the mental illness), which significantly improved after the clerkship in the low-exposure (P = 0.011) and the high-exposure groups (P = 0.024), respectively. CONCLUSIONS: Exposure of medical students to patients with mental illness did not improve attitude towards mental illness and psychiatric conditions.

Developing an Inpatient Group Psychotherapy Program: Challenges and Lessons Learnt.

In Iran, inpatient group psychotherapy has been limited to transient practices for research purposes or fulfilling personal interest of therapists. The goal of this paper is to share and explain the experience of developing an inpatient group psychotherapy program in Roozbeh Psychiatric Hospital, Tehran, Iran. After theoretical delineation and preparation of a draft of the program guideline, two pilot sessions were held. Based on this initial experience a final treatment guideline was prepared. Afterwards, the program was continued for more than 1 year in a female ward at Roozbeh Psychiatric Hospital. The output of this exercise was a guideline that covers important topics in development of inpatient group psychotherapy. It is concluded that inpatient group psychotherapy has its unique challenges. Of the most important challenges that can be mentioned in this regard are the participation of patients with significant differences in levels of psychopathology and psychiatric signs and symptoms, and high comorbidity with specific personality traits or disorders. Other challenges relevant to the structure of the group include items such as very limited time for working through and inevitable out-of-group contacts.

Comparison of two different curricula in psychiatry clerkship at tehran university of medical sciences.

OBJECTIVES: The aim of this study was to evaluate the efficacy of a new psychiatry clerkship curriculum which was designed to improve the knowledge and skills of medical students of Tehran University of Medical Sciences (TUMS), Iran. METHODS: This quasi-experimental study was conducted in two consecutive semesters from February 2009 to January 2010. In total, 167 medical students participated in the study. In the first semester, as the control group, the clerks' training was based on the traditional curriculum. In the next semester, we constructed and applied a new curriculum based on the SPICES model (student-centered, problem-based, integrated, community-based, elective and systematic).At the end of the clerkship, the students were given two exams: Multiple Choice Questions (MCQ) to assess their knowledge, and Objective Structured Clinical Examination (OSCE) to assess their skills. Baseline data and test performance for each student were analyzed. RESULTS: Compared to the control group, students in the intervention group showed significantly higher OSCE scores (P= 0.01). With respect to MCQ score, no significant difference was found between the two groups. CONCLUSIONS: The results suggest that the revised curriculum is more effective than the traditional one in improving the required clinical skills in medical students during their psychiatry clerkship.

Acute treatment response and its predictors in patients with first-episode psychosis in Iran.

OBJECTIVE: The aim of this paper was to investigate the acute treatment response and its predictors in a sample of patients with first-episode psychosis admitted to a psychiatric hospital in Iran. METHOD: A total of 163 patients with first-episode psychosis were treated with antipsychotics and other medications as prescribed by their treating psychiatrists. Sociodemographic and premorbid data at baseline and clinical data at both baseline and discharge (6+/-1 weeks after admission) were collected. RESULTS: Patients showed a response rate of 71.4% for negative symptoms, 91.5% for positive symptoms and 67.5% for functioning. Those having a positive family history and less severe negative symptoms at baseline were less likely to respond in terms of negative symptoms. Higher premorbid and lower baseline functioning as well as acute onset were associated with the treatment response. CONCLUSIONS: Acute treatment response of first-episode psychosis in a clinical sample of a developing country seems to be higher than that of developed countries. However, predictors of response are comparable.

Celecoxib as adjunctive therapy in schizophrenia: a double-blind, randomized and placebo-controlled trial.

Some evidence suggests that the pathophysiology of schizophrenia is associated with the abnormal immune system, and cytokines may be important in schizophrenia. Cyclooxygenase-2 (COX-2) inhibitors such as celecoxib reduce the production of proinflammatory cytokines including Th1-like cytokines. Indeed, COX-2 inhibitors rebalance type-1 and type-2 immune response. The purpose of the present investigation was to assess the efficacy of celecoxib as an adjuvant agent in the treatment of chronic schizophrenia in an eight-week, double-blind and placebo-controlled trial. Eligible participants in this study were 60 patients with chronic schizophrenia. All patients were inpatients and were in the active phase of the illness, and met DSM-IV criteria for schizophrenia. Patients were allocated in a random fashion, 30 to risperidone 6 mg/day plus celecoxib 400 mg/day (200 mg bid) (morning and evening) and 30 to risperidone 6 mg/day plus placebo. Although both protocols significantly decreased the score of the positive, negative and general psychopathological symptoms over the trial period, the combination of risperidone and celecoxib showed a significant superiority over risperidone alone in the treatment of positive symptoms, general psychopathology symptoms as well as PANSS total scores. The means Extrapyramidal Symptoms Rating Scale for the placebo group were higher than in the celecoxib group over the trial. However, the differences were not significant. The results of this study suggest that celecoxib may be an effective adjuvant agent in the management of patients with chronic schizophrenia and anti-inflammatory therapies should be further investigated.