Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries.

BACKGROUND: Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians' treatment choices for post-traumatic stress disorder (PTSD). METHODS: The case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148). RESULTS: About 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct "profiles" of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines. CONCLUSIONS: Clinicians' decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.

An expert review of clozapine in Eastern European countries: Use, regulations and pharmacovigilance.

OBJECTIVES: To compare the prevalence, regulations, and pharmacovigilance practices of clozapine use in Eastern European countries (except Russia). METHODS: Questionnaires and data from administrative databases (2016 and 2021), package inserts and national guidelines were collected from 21 co-authors from 21 countries. Reports of clozapine adverse drug reactions (ADRs) sent to the global pharmacovigilance database (VigiBase™) were analyzed from introduction to December 31, 2022. RESULTS: Clozapine prescription among antipsychotics in 2021 varied six-fold across countries, from 2.8 % in the Czech Republic to 15.8 % in Montenegro. The utilization of antipsychotics in both 2016 and 2021 was highest in Croatia, and lowest in Serbia in 2016, and Montenegro in 2021, which had half the defined daily dose (DDD)/1000/day compared to the Croatian data. From 2016 to 2021, the prevalence of antipsychotic use increased in almost all countries; the proportion of clozapine use mainly remained unchanged. Differences were detected in hematological monitoring requirements and clozapine approved indications. Only a few national schizophrenia guidelines mention clozapine-induced myocarditis or individual titration schemes. The VigiBase search indicated major underreporting regarding clozapine and its fatal outcomes. By comparison, the United Kingdom had less than half the population of these Eastern European countries but reported to VigiBase more clozapine ADRs by 89-fold and clozapine fatal outcomes by almost 300-fold. CONCLUSION: Clozapine is under-utilized in Eastern European countries. Introducing individualized clozapine treatment schedules may help to maximize clozapine benefits and safety. Major improvement is needed in reporting clozapine ADRs and fatal outcomes in Eastern European countries.

Exploring the Mediating Role of Parental Anxiety in the Link between Children's Mental Health and Glycemic Control in Type 1 Diabetes.

Pediatric diabetes type 1 diabetes mellitus (T1D), as a chronic, incurable disease, is associated with psychoemotional and socioeconomic burden for the whole family. Disease outcomes are determined by the metabolic compensation of diabetes, characterized by the level of glycated hemoglobin (HbA1c). The caregivers play a critical role in the metabolic control of children with T1D. The aim of this study was to investigate which environmental factors may explain the relationship between diabetes compensation and anxiety and depression of a child. The cross-sectional interdisciplinary study recruited dyads from adolescents and their parents (N = 251). Adolescent and parent groups were screened for anxiety and depression. General linear model (GLM) mediation analysis was performed to determine the potential mediating effect of surrounding factors on the relationship between dependent variables (glycated hemoglobin) and independent variables (the child's anxiety and depression symptoms). The study revealed that the relationship between HbA1c and the child's anxiety and depression is fully mediated (B = 0.366, z = 4.31, p < 0.001) by parental anxiety. Diabetes metabolic control in adolescents with T1D is related to adolescents' mental health via parents' anxiety. This means that parents' anxiety plays a more significant role in the level of HbA1c than the anxiety and depression of the adolescent.

Challenges facing mental health systems arising from the COVID-19 pandemic: Evidence from 14 European and North American countries.

We assessed challenges that the COVID-19 pandemic presented for mental health systems and the responses to these challenges in 14 countries in Europe and North America. Experts from each country filled out a structured questionnaire with closed- and open-ended questions between January and June 2021. We conducted thematic analysis to investigate the qualitative responses to open-ended questions, and we summarized the responses to closed-ended survey items on changes in telemental health policies and regulations. Findings revealed that many countries grappled with the rising demand for mental health services against a backdrop of mental health provider shortages and challenges responding to workforce stress and burnout. All countries in our sample implemented new policies or initiatives to strengthen mental health service delivery - with more than two-thirds investing to bolster their specialized mental health care sector. There was a universal shift to telehealth to deliver a larger portion of mental health services in all 14 countries, which was facilitated by changes in national regulations and policies; 11 of the 14 participating countries relaxed regulations and 10 of 14 countries made changes to reimbursement policies to facilitate telemental health care. These findings provide a first step to assess the long-term challenges and re-organizational effect of the COVID-19 pandemic on mental health systems in Europe and North America.

Depression and brain fog as long-COVID mental health consequences: Difficult, complex and partially successful treatment of a 72-year-old patient-A case report.

SARS-CoV-2 (COVID-19) infection can result in long-term health consequences i.e., long COVID. The clinical manifestations of long COVID include depression, anxiety, brain fog with cognitive dysfunction, memory issues, and fatigue. These delayed effects of COVID-19 occur in up to 30% of people who have had an acute case of COVID-19. In this case report, a 72-year-old, fully vaccinated patient without pre-existing somatic or mental illnesses, or other relevant risk factors was diagnosed with long COVID. Nine months following an acute COVID-19 infection, the patient's depressive symptoms improved, but memory and concentration difficulties persisted, and the patient remains unable to resume work. These long-term symptoms are possibly linked to micro-hemorrhages detected during examinations of the patient's brain following COVID-19 infection. Patient treatment was complex, and positive results were attained via antidepressants and non-drug therapies e.g., art, music, drama, dance and movement therapy, physiotherapy, occupational therapy, and psychotherapy.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries.

BACKGROUND: While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe. METHODS: We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style - Staff questionnaire and a set of questions regarding clinicians' expertise, training, and practice. RESULTS: SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style. CONCLUSIONS: The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

Case Report: Severe Side Effects Following Treatment With First Generation Antipsychotics While Cariprazine Leads to Full Recovery.

Schizophrenia is a psychiatric disorder characterized by positive, negative, cognitive and affective symptoms. Patient cooperation with health care professionals, compliance with the treatment regime, and regular use of medications are some of the preconditions that need to be met for a favorable disease course. A negative experience following the use of a first-generation antipsychotic to treat first-episode psychosis can negatively affect a patient's motivation for further medication use. In the clinical case reported here, cariprazine was able to restore one such patient's confidence in therapy and facilitated their cooperation with the physician, thereby ensuring effective control of negative and positive symptoms and good functioning for a period of 1 year. Cariprazine may be a good option for maintenance therapy following first-episode psychosis, especially in situations in which a patient has had a negative first experience associated with antipsychotic medication use.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis.

BACKGROUND: Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period. METHODS: We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels. FINDINGS: Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings. INTERPRETATION: Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries. FUNDING: Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Hyponatremia caused by water intoxication: successful treatment of psychiatric disturbances with olanzapine and fluoxetine.

Hyponatremia is a frequent, yet often unrecognized result of water intoxication caused by psychogenic polydipsia in patients with psychiatric disorders such as schizophrenia and anorexia nervosa. The consequences of hyponatremia may include cerebral edema with tonic-clonic seizures and, in extreme cases, death. In cases of hyponatremia seen in psychiatric practices, the use of psychotropic drugs is often necessary to address both the underlying psychiatric problem and reduce the hyponatremia. Therefore, a patient's clinical condition, the risk of side effects, the possible effect of the medication on hyponatremia and a history of prior medication use should be considered when selecting appropriate psychotropics. The present clinical case details the beneficial effects of olanzapine and fluoxetine in treating a patient with anorexia nervosa and body dysmorphic disorder experiencing acute hyponatremia, and the stable effect the medications achieved over a period of 2.5 years of maintenance therapy.

The assessment of factors associated with patient satisfaction in evaluation of mental health care center.

AIMS: The study was conducted to explore patient satisfaction and to identify factors associated with patient satisfaction with the care in psychiatric wards using Psychiatric Inpatient Patient Experience Questionnaire On-Site (PIPEQ-OS) self-assessment tool. Such studies to detect factors associated with patient satisfaction in mental health care have not yet been conducted in Latvia. METHODS: Cross-sectional study was conducted over 6-month period in 2018. Total amount of 773 mental health care patients were offered to fill in the questionnaire in subacute and acute wards. From them, 419 (54.2%) filled and returned the questionnaire and 354 (45.8%) refused to fill it. Descriptive statistical analysis and factor correlation was done. RESULTS: Response rate was found to be 54.2%. Patients generally showed high satisfaction with received care. However, lower satisfaction rates were found in items related to engagement of relatives and patients in the treatment process, as well as patients were less satisfied with information provided. Statistically significant higher satisfaction was associated with organic mental disorders compared to schizophrenia spectrum disorders, as well as with female gender, older age, being employed or pensioner, being married or divorced. Patient education level did not show significant association with self-assessment scores. CONCLUSION: The study revealed possible directions for improvement in the future in terms of providing information to patients, involvement of relatives and patients in the process of treatment. Further studies with more patients and involvement of other hospitals are required to assess factors associated with the satisfaction to organize care and to plan treatment according to the needs of the patients.

Provision of community-based mental health care, Latvia.

PROBLEM: In Latvia, the move towards community-based mental health-care services has been slow. APPROACH: The hospital managers of the only psychiatric hospital in Riga decided to establish two community-based clinics that were financially and administratively integrated with the hospital. The clinics were established using a step-wise approach by redistributing resources, including psychiatrists, nurses and beds, from the hospital to the new clinics. In 2005, the Veldre clinic started outpatient consultations and day care admissions. In 2009, Pardaugava clinic opened as an outpatient clinic. In 2012, an open-door inpatient ward with 30 beds was transferred from the psychiatric hospital to Veldre. In 2013, Pardaugava clinic opened a day care clinic and an open-door inpatient ward, transferring 26 beds from the psychiatric hospital. LOCAL SETTING: Latvians have worse mental health indicators than those of the average population in Europe. Mental care has traditionally focused on inpatient care. RELEVANT CHANGES: The clinics are now providing most of the outpatient services and the number of inpatients treated at the hospital has declined from 5696 patients in 2004 to 4957 patients in 2018. Patients are treated in a more open and patient-centred environment. LESSONS LEARNT: The administrative and financial integration of the new community-based clinics within the existing structures of the hospital is a successful approach. Transferring resources to the clinics seems to have improved the quality of care without requiring additional funding apart from the initial investment costs. Involving the staff members during the planning phase reduced resistance to the project.

Comparison of psychotropic medication use in the Baltic countries.

Purpose: While the pivotal role of pharmacotherapy in psychiatry is universal, significant regional differences exist in drug use patterns. Herewith we compare the use of ATC psychotropic drugs (N05, psycholeptics and N06A, antidepressants) in 2010-2015 in the three Baltic Countries with reference to the Nordic Countries.Methods: Data were obtained from the national authorities on medicines as expressed in DDD per 1000 inhabitants per day. A semi-structured questionnaire was used for expert statements on the rationale of current use of medicines.Results: During the observation period the use of antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants steadily increased, while the growth in use of anxiolytics stagnated in the more recent years. Antipsychotic use was the largest in Lithuania and the lowest in Estonia. The use on anxiolytics in Lithuania was more than twice of that in Estonia and Latvia. Conversely, the use of hypnotics and sedatives was about three times higher in Estonia than in Latvia or Lithuania. Antidepressant use was dominated by the selective serotonin reuptake inhibitors in all three countries, but overall was much lower in Latvia as compared to Lithuania and Estonia. As compared to the Nordic Countries in 2015, antidepressants are used at much lower level throughout Baltics, probably reflecting underdiagnostics of depression and anxiety disorders.Conclusion: While the health-care expenditures in Estonia, Latvia and Lithuania are largely similar, as is the cultural and recent political background of these EU member countries, the extent and the pattern of psychotropic drug use is remarkably variable.

Vai iedzīvotāji var atļauties maksāt par veselības aprūpi? Jauni pierādījumi par finansiālo aizsardzību Latvijā

Šis apskats ir viens no pētījumiem, kas veikti dalībvalstīs, lai gūtu jaunus pierādījumus par finansiālo aizsardzību Eiropas veselības sistēmās. Finansiālā aizsardzība ir visaptverošas veselības aprūpes centrālais jautājums un būtiskākais aspekts, kas raksturo veselības sistēmu veiktspēju.

Improving quality of psychiatric care in Latvia by measuring patient experiences.

In Latvia, as in many former Soviet Union countries, there used to be little priority given to systematic assessments of the quality of psychiatric care. Furthermore, using the experiences of patients as a measure of quality was unthinkable because psychiatric patients were seen as incapable of assessing quality of psychiatric services. Over the past few years, and facilitated by Latvia's progress along the route of Western democracy and participation in international organizations (EU, OECD), as well as funding support from the EU, several policy documents have been developed with the aim of improving healthcare quality. Simultaneously, several small-scale initiatives have emerged aiming at the promotion of quality of care, such as the quality award, and the quality comparison of psychiatric hospitals. Furthermore, the Psychiatric Inpatient Patient Experience Questionnaire for on-site measurement (PIPEQ-OS) has recently been adapted for use in Latvia. The first application of PIPEQ-OS in a psychiatric hospital in Riga reveals high patient responsiveness, interest and surprise about being asked to participate in the decision-making process regarding treatment and pharmaceutical choices. More widespread use of the PIPEQ-OS has considerable potential for (1) improving information about treatment shortcomings from the patients' perspective and (2) improving the treatment process by opening doors of cooperation with patients and changing deep-rooted paradigms.

Can people afford to pay for health care? New evidence on financial protection in Latvia

Financial protection is weaker in Latvia than in many other European Union (EU) countries. Latvia’s health system relies heavily on out-of-pocket payments. The share of out-of-pocket payments in total health spending is consistently among the highest in the EU. Stronger financial protection will require additional public investment in the health system. Latvia’s public spending on health is lower than it can afford, given its gross domestic product. Any increase in public spending should be used to expand National Health Service coverage and prioritize stronger protection for poor adults and regular users of health care. This review is part of a series of country-based studies generating newevidence on financial protection in European health systems.

Prevalence and sociodemographic characteristics of self-reported suicidal behaviours in Latvia in 2010: A population-based study.

BACKGROUND: The fact that Latvia is among the countries with the highest suicide mortality rates in the European Union highlights the importance of research in this field. AIMS: The aims of the study were to determine the 2010 prevalence of self-reported suicidal behaviours in Latvia, to identify sociodemographic risk factors and to examine sequences for reporting of suicidal behaviours. METHODS: Computer assisted personal interviews were carried out to gather information on a representative sample of the Latvian population aged 18 to 64 (n = 2816). The study sample was selected using a combination of stratified random sampling and quota methods. RESULTS: Last year prevalence of any type of suicidal behaviour was 18.5% - nearly threefold lower than observed in 2000 (52.6%). Middle age, non-cohabitation status and lower level of education were significant risk factors for serious types of suicidal behaviour (suicidal ideation, suicidal plans, suicide attempts) among men, but only lower level of education was for women. Risk factors regarding mild types of suicidal behaviour (life-weariness, death wishes) were the same for men and women: older and middle aged, non-cohabitation status, and lower level of education. A total of 79.6% reported a continuous pattern of suicidal behaviours. CONCLUSIONS: Several sociodemographic risk factors for suicidal behaviours have been found. Further research is needed to clarify additional risk factors, especially in the high-risk groups studied and specific determinants contributing to reduction in prevalence of suicidal behaviours and suicide mortality in Latvia.

Changes in the provision of institutionalized mental health care in post-communist countries.

BACKGROUND: General psychiatric and forensic psychiatric beds, supported housing and the prison population have been suggested as indicators of institutionalized mental health care. According to the Penrose hypothesis, decreasing psychiatric bed numbers may lead to increasing prison populations. The study aimed to assess indicators of institutionalized mental health care in post-communist countries during the two decades following the political change, and to explore whether the data are consistent with the Penrose hypothesis in that historical context. METHODOLOGY/PRINCIPAL FINDINGS: General psychiatric and forensic psychiatric bed numbers, supported housing capacities and the prison population rates were collected in Azerbaijan, Belarus, Croatia, Czech Republic, East Germany, Hungary, Kazakhstan, Latvia, Poland, Romania, Russia and Slovenia. Percentage change of indicators over the decades 1989-1999, 1999-2009 and the whole period of 1989-2009 and correlations between changes of different indicators were calculated. Between 1989 and 2009, the number of general psychiatric beds was reduced in all countries. The decrease ranged from -11% in Croatia to -51% in East Germany. In 2009, the bed numbers per 100,000 population ranged from 44.7 in Azerbaijan to 134.4 in Latvia. Forensic psychiatric bed numbers and supported housing capacities increased in most countries. From 1989-2009, trends in the prison population ranged from a decrease of -58% in East Germany to an increase of 43% in Belarus and Poland. Trends in different indicators of institutionalised care did not show statistically significant associations. CONCLUSIONS/SIGNIFICANCE: After the political changes in 1989, post-communist countries experienced a substantial reduction in general psychiatric hospital beds, which in some countries may have partly been compensated by an increase in supported housing capacities and more forensic psychiatric beds. Changes in the prison population are inconsistent. The findings do not support the Penrose hypothesis in that historical context as a general rule for most of the countries.