[Concordance analysis of referrals from Primary Care to Mental Health]. / Análisis de concordancia de las derivaciones de atención primaria a salud mental.

APPROACH: Proper coordination between Primary Care (PC) and Mental Health Units (MHU) is needed, and referrals between the two systems are an important issue. We attempt to analyse various aspects on the variation between referrals from PC to MHU in the Burgos area. METHODOLOGY: Descriptive cross-sectional study, including all first-time referral patients from PC to MHU in Burgos in 2006: 1132 referrals. RESULTS: Waiting time for the first consultation with the specialist was less than 30 days in 38% of cases, and between 30 and 45 days in 36.1% of the case. The agreement between Family Doctors (FD) requests (psychiatry/clinical psychology) and the specialist performing first consultation was very high (Kappa Index 0.784). The most common diagnosis in PC were anxiety disorders (29%) and depression disorders (25%). The most common diagnosis in MHU were adaptation disorders (26%), anxiety disorders (21%), and depression disorders (19%). Diagnostic agreement between Primary care and Specialist care was low (Kappa Index 0.342). Specialists judged referrals appropriate or very appropriate in 72.4% of the cases, and deemed the information in the referral form to be adequate in 56.7% of the cases. As regards the referral type (ordinary, preferential or urgent), the agreement between PC and Mental Health specialists was very low (Kappa Index 0.179). In 75.9% of referrals, psychiatrist and clinical psychologist indicated not having had previous contact with the primary care physician. Almost half (47.7%) of referred patients indicated previous pharmacological treatment in PC. CONCLUSIONS: The degree of agreement between PC and MHU was very high in terms of specialist requested and attending specialist (psychiatry/clinical psychologist), was low in terms of diagnostic agreement, and it was very low in terms of referral type. This suggests a need to reinforce the relationship between both care systems.

[Diagnostic variability in a cohort of patients with multiple admissions in the last two decades]. / Variabilidad en los diagnósticos de una cohorte de reingresadores en las dos últimas décadas.

OBJECTIVE: To investigate possible changes in the admission pattern correlated with improvement in psychiatric attention and if there is variability in the diagnosis of patients previously identified as having multiple admissions during the study period. MATERIAL AND METHODS: Our study is based on fifty-nine patients who were admitted on at least ten occasions between 1983-2000. The medical records of the frequent users were reviewed and data were extracted on several variables: principal psychiatric diagnosis (DSM-IV TR criteria) and diagnostic changes as main variables and period, admissions density, admission interval and period between last admission and the end of study, as related variables. STATISTICAL ANALYSES: Friedman's variance non-parametric analysis for related samples, Pearson's chi-squared test and sequence graphing. RESULTS AND DISCUSSION: Improved psychiatric care in our city would seem to correlate with the decreasing number of patients with multiple admissions to the point where there have been no admissions in the past year. Diagnosis (DSM-IV axis I and II) variables showed important variations from one admissions to the next. The psychosocial and adaptation problems that became manifest during the successive admissions tended to improve over time as did the overall functioning of the patients. Our findings suggest that this population is composed of three distinct subgroups. Identification of the subgroups may have important implications for the management and treatment modality.

[Clinical use of sustained release of alprazolam: A naturalistic study]. / Utilización clínica de Alprazolam de liberación sostenida: un estudio naturalístico.

OBJECTIVES: Alprazolam extended release formulation (Alprazolam XR) is a new formulation with useful features in the treatment of pathological anxiety, when compared both to the original formulation of alprazolam or to other benzodiazepines, as it adds to the well known properties of alprazolam a sustained clinical effect. The available investigational clinical trials show good efficacy for this new formulation. There is the need, however, of observational studies in the clinical setting that confirm its usefulness. METHODS: We present an observational prospective naturalistic study of all the pathological anxiety cases that followed treatment with Alprazolam XR in two psychiatry outpatient centres. Sixty-eight (68) patients were included in the study. The treatment period was 21 weeks. In each of the 4 control visits, efficacy (HAMA, GCI, GCI improvement) and tolerability (adverse events) were assessed, as well as the dose, dosage pattern and need of change of the medication. RESULTS: Global anxiety (HAMA, GCI and CGI improvement) showed a significant reduction throughout the study. There was a reduction in the number of panic attacks and in the severity of agoraphobia. Global clinical impression (efficacy and tolerability) was good or very good in 75% of the patients, both assessed by the investigator and by the patient. Fifty percent (50%) of the patients had an adverse event (mainly sedation), most cases being mild and transient. Fifty-eight percent (58%) of the patients needed a change in the dosage regimen (dose, number of daily doses), mostly due to clinical dose adjustment. Some patients needed a change in the dosage due to adverse events. Sixteen patients that had been treated with the conventional formulation of alprazolam and started treatment with Alprazolam XR needed a slightly higher dose of the extended release formulation. In these cases the change of medication was easy. CONCLUSION: The clinical use of Alprazolam XR in the treatment of pathological anxiety was useful in most of the patients (75%). The dose regime was usually 2-3 mg in two daily doses, with a trend to lower the dose (1-2 mg in a single dose) in the third or fourth control. The change from the conventional formulation to the extended release was not difficult in most of the patients.

[Premenstrual dysphoric disorder: long-term treatment with fluoxetine and discontinuation]. / Trastorno disfórico premenstrual: tratamiento a largo plazo con fluoxetina y discontinuación.

INTRODUCTION: Premenstrual Dysphoric Disorder (PMDD) is characterized by debilitating mood and behavioral changes in the weed preceding menstruation that interfere with normal functioning. The diagnosis requires that symptoms be recurrent and persistent. We report here the results of an open-label study with 20 patients with PMDD according DSM-IV with and without a concomitant diagnosis of MDD (Major Depression) treated with fluoxetine during 6 and 18 months. METHOD: 9 patients with PMDD and MDD, and 11 patients only with PMDD were treated with fluoxetine 20 mg/d during 6 months. After that, 9 women continued treatment until complete 18 months of treatment and 11 women discontinued by their own decision, because the complete absence of symptomatology. Women who discontinued treatment were followed at the 18 months to the assessment of the evolution. The efficacy was assessed by CGI, HAMA, HAMD and un TDP scale monthly during the first 6 month and in the visit at 18 month. RESULTS: All patients completed the 6 months of treatment with a good tolerance. The most common adverse events were decrease of the libido, gastric complains, nervousness and insomnia. These events were mild and don't produce any withdrawn. There were a significant change in all scales at 6 month assessment: HAM-D (22.4 vs. 5.3, p < 0.000), HAM-A (23.8 vs 8.7, p < 0.000) and TDP (36.4 vs. 18, p < 0.000). There weren't differences among patients with and without concomitant diagnosis of MDD. Among patients who continued taking fluoxetine the improvement was maintained at the 18 month-assessment. Patients who discontinued treatment with fluoxetine after 6 months suffered a worsening in their symptomatology at the 18 month assessment (CGI = 3.18 vs. CGI = 4.81, p < 0.005). CONCLUSIONS: Fluoxetine is an effective and well-tolerated treatment for the long treatment of PMDD. The remission is maintained at least during 18 month of treatment. Symptomatology reappears after treatment discontinuation in most of the women.

[Premenstrual dysphoric disorder: an epidemiological study]. / Trastorno disfórico premenstrual: un estudio epidemiológico.

Most women have symptoms of premenstrual dysphoric disorder (PDD) and 3-10% have symptoms that interfere with either work or social life. The diagnosis of PDD is based on recurrent and persistent symptoms which are confirmed in repeated evaluations. The epidemiology has not been established because of difficulties in studying this disorder. The 1-year prevalence of PDD symptoms of an intensity and frequency to meet DSM-III-R criteria in a group of women representative of the general population of Burgos (Spain) was studied using a PDD scale based on DSM-III-R criteria. On average, each symptom occurred in 28.6% of women in many or every cycle during the study year. 30.5% of women scored over 20 on the scale, meaning that they had at least 5-10 of the DSM-III-R criteria in every menstrual cycle. Symptom intensity was significantly greater in women whose work or social life was affected, who consulted for PDD, were treated for PDD, and had less-skilled jobs. The scale had a high internal consistency (alpha-0.84). Factorial analysis detected "dysphoria" as the main symptom, the physical symptom "edema", a secondary "psycho-social" factor, and "pain". Discriminant analysis of the ten items on the scale as a function of the cutoff score of 20 correctly identified 94% of the women meeting DSM-III-R criteria.

[Prognostic factors in schizophrenic patients]. / Factores pronósticos en pacientes esquizofrénicos.

INTRODUCTION: A series of factors have been identified, linked to the prognosis of the schizophrenia, such as the form of the starting point, the existence of the causing factors, time of evolution, personal and familiar psychiatric antecedents, the civil state, the working situation, the sex, the social class, age of onset and kind of symptomatology. METHODOLOGY: T look into such factors in a sample of 65 schizophrenic patients, it was collected some information about all the variables and relative data in the clinic history, in a formal way, during the admission of the patient in the year 1987/88. In February, 1993, all the cases have been revised and have been qualified as "the best prognosis" or "the worst prognosis", according to some points, such as number of re-admissions, actual symptomatology, level of social and laboural operation. The total sample of patients was dichotomied according to the prognosis variable and the two sub-samples were compared in respect to all the variables related to the prognosis. RESULTS: The factors associated with a "best prognosis", include the situation of the laboural activity and the biggest level of adaptation in the previous year to the admission. The presence of self-reference delusion, hallucinations and insomnia, have been associated with a "worst prognosis". CONCLUSIONS: It hasn't been possible to reply, in this study, with the prognosis of the schizophrenia, giving evidence of the methodological difficulties and the heterogeneous results in this kind of studies.

[Psychosocial factors in duodenal ulcer]. / Estudio de la morbilidad psiquiátrica en personal sanitario.

"Burn-out" is a kind of assistential laboral stress which affects the professions which involve an interpersonal relationship with beneficiaries of the job, such us health workers. It originates emotional alterations which lead to feelings of emptiness and personal failure or laboral inability. The revisions about studies of mental disorders in health workers fall upon such laboral stress and remark that in such professional people there is a bigger prevalence of disorders because of the use of substances and of depression. To analyse the mental disorders in health workers by means of the retrospective study of a sample in a general hospital which asked for a psychiatric consultation, sociodemographic variables, clinico-diagnostic and variables related to laboral activity were analysed. The sample is constituted by 112 patients of an average age of forty years old and preferentially females (79.5%). In the sample, some professions are represented above all expectations; they are nurses, physicians, the laboral category of "boss and managers" and the laboral regimen of "permanents". The more frequent psychiatric disorders were the adjustment disorders and code V, the affective disorders and the anxiety disorders (23-33%), the disorders caused by the use of substances and the psychotic disorders are limited (5%). The laboral activity was considered an important factor in 43% of the cases and the mental disorder caused laboral inability, transitory or permanent in half of the patients. It is detected a relationship between the diagnostic and variables such as sex, laboral category, laboral inability, psychosocial stress level and GAF and there hasn't been detected any association between mental disorders and age, profession, laboral regimen and laboral stress.

[Metabolic changes of iron in mental patients]. / Alteraciones del metabolismo del hierro en pacientes psiquiátricos.

Ferro metabolism abnormalities have been related to behavioral and intelectual performance, depression and low response antidepressants in adults. For studying the clinical meaning of those abnormalities in psychiatric patients, sideremia, transferrin and transferrin saturation level were determined in 228 in-patients. The results show a decreased sideremia and transferrin saturation level in elder patients, and more severe abnormalities in patients with a history of somatic disorders and in those with current somatic pathology associates to psychiatric pathology. There is an increasing cortisol postdexametasona in low transferrin patients, as the only data that relate ferro metabolism and depression. Relation between ferro metabolism and: response to treatment, neuropsychological performance and others demographic, clinical, developmental and biological features of the studied have not been detected.

[Treatment of affective disorders with clonazepam]. / Tratamiento de trastornos afectivos con clonazepan.

On the basis of the hypothetical utility of clonazepam (CLN) for the treatment of affective disorders, by means of previous references and etiopathogenic hypothesis like the Kindling phenomenon we have been developing a study in order to evaluate that usefulness and efficacy which, includes 32 patients with affective disorders; 23 of them with a diagnosis of bipolar disorder (manic) the greatest part of the subjects had been previously treated with lithium antidepressants or neuroleptics, and clonazepam was introduced because of an inadequate response, treatment intolerance or searching for a specific effect. Our results suggest a prevalence of partial and good responses (85%) The same in the objective evaluations as in the subjective ones being the levels of response higher than in previous treatments. The study supports the use of CLN in the treatment of patients who suffer from affective disorders, particularly in hypomanic episodes.

[Shopping disorder and the abnormal use of attire]. / El trastorno de adquisición y uso anormal del atuendo.

Eight women and one man affected by the denominated "Dressing Disorder" are described. We show, analyze and discuss their social and demographic features, antecedents, onset and course, acquiring behaviours and its consequences, diagnosis, gnosographic features, results of the psychodiagnostic tests, evolutive relationships with the psychiatric diagnosis and treatment undergone. By the light of these data we propose a pathogenic scheme which remarks the importance of the Depression and Bulimia as precipitations or causative factors, because they give use to a low self-esteem and a use of anomalous defense mechanisms which origin the altered acquiring behaviours. Criteria for its diagnosis are proposed and more appropriate denominations are discussed.

[Minor neurological signs in obsessive-compulsive disorders]. / Signos neurológicos menores en los trastornos obsesivo-compulsivos.

Present and classic observations allow us to relate the obsessive-compulsive disorder (OCD) with different structural and functional anomalies, disorders and neurological findings which let us elaborate etiopathogenic and therapeutic hypothesis. From this and from our experience in the study about soft neurologic signs (SNS) in psychiatry, we explored 20 patients with OCD (DSM-III), compared with 28 phobic disorders and 20 healthy controls, following a SNS protocol and picking up demographic and clinical variables. We besides administered intellectual efficiency exams (WAIS) and neuropsychological tests (Benton/Bender), blind to the SNS exploration. The OCD group showed a higher global incidence of SNS, and especially more alterations in movement's coordination in upper extremities and balance with a trend to show more anomalies in dominance-laterality. This higher incidence of SNS didn't correlate with age, familiar or personal psychiatric history, indicators of neuropsychological impairment and pharmacotherapy. Men with OCD showed more SNS than women did, and as men have higher schooling rates, we found a relationship between SNS and schooling. OCD group showed a trend to be more intelligent than healthy controls, reaching significant higher scores in verbal than in manipulative scales. This lower manipulative score could relate with SNS, suggesting a possible concordance or significant relation with neurobiologic hypothesis, but not supporting neuroevolutionary and organic impairment theories as OCD etiopathogenesis.

[Seasonal variations in dexamethasone suppression test in psychiatric patients]. / Estudio de las variaciones estacionales de la prueba de supresión por dexametasona en pacientes psiquiatricos.

The existence of seasonal variations in the dexamethasone suppression test (D.S.T.) has been remarked. In a sample of 345 patients with affective symptomatology and various psychiatric diagnostics, patient with major depression have higher non suppression levels in spring and winter; a similar but stronger seasonal variations is observed in patients with melancholic and patients with psychotic syndrome showed a similar tendency. In patients with diagnostics different from depression (dementia, schizophrenia, mania, anxiety disorders), the non suppression level is higher in winter. Some similarities with the contributions of other authors are observed but in general disagreements are more frequent, which suggests us the influence of latitude and geo-climatic changes, since the seasonal variability can not be explained by means of seasonal changes in demographic or clinical variables, as diagnostic or psychiatric syndrome.