Remote crisis intervention and suicide risk management in COVID-19 frontline healthcare workers.

Introduction: Despite the propagation of virtual mental health services for vulnerable groups during COVID-19 pandemic, the implementation and evaluation of remote evidence-based practices (EBP) to manage them in low- and middle-income countries remains scarce. In the current study, we describe and evaluate the implementation process and clinical impact of brief, remote, manualized EBP for crisis intervention and suicide risk management among healthcare workers attending patients with COVID-19 (COVID-19-HCWs) in Mexico. Methods: The implementation process comprised community engagement of volunteer mental health specialists, creation of new clinical teams with different disciplines and skills, intervention systematization through manuals and education through 4-h remote training as main strategies. Mexican COVID-19-HCWs who had used a free 24-h helpline rated their pre- and post-intervention emotional distress. Therapists recorded patients' pre-intervention diagnosis, severity, and suicide risk, the techniques used in each case, and their post-treatment perception of COVID-19-HCWs' improvement at the end of the intervention. Results: All techniques included in the intervention manual were employed at least in one case (n = 51). At the beginning of the intervention, 65.9% of the COVID-19-HCWs were considered moderately ill or worse according to Clinical Global Impression-Severity (CGI-S) scores, whereas at the end, 79.4% of them were perceived as much or very much improved according to CGI-Improvement scores (CGI-I), and their emotional distress had been significantly reduced (p < 0.001). Discussion: This prospective study provides evidence that implementation of remote EBP is feasible and useful to reduce emotional distress and suicide risk among COVID-19-HCWs from a middle-income country. However, this study was limited by lack of a control group, improvement ratings provided by therapists and non-anonymous satisfaction ratings.

Developments in Group Transference-Focused Psychotherapy.

Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.

A global field study of the international classification of diseases (ICD-11) mood disorders clinical descriptions and diagnostic guidelines.

BACKGROUND: We report results of an internet-based field study evaluating the diagnostic guidelines for ICD-11 mood disorders. Accuracy of clinicians' diagnostic judgments applying draft ICD-11 as compared to the ICD-10 guidelines to standardized case vignettes was assessed as well as perceived clinical utility. METHODS: 1357 clinician members of the World Health Organization's Global Clinical Practice Network completed the study in English, Spanish, Japanese or Russian. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of eleven pairs of case vignettes. RESULTS: Clinicians using the ICD-11 and ICD-10 guidelines achieved similar levels of accuracy in diagnosing mood disorders depicted in vignettes. Those using the ICD-11 were more accurate in identifying depressive episode in recurrent depressive disorder. There were no statistically significant differences detected across classifications in the accuracy of identifying dysthymic or cyclothymic disorder. Circumscribed problems with the proposed ICD-11 guidelines were identified including difficulties differentiating bipolar type I from bipolar type II disorder and applying revised severity ratings to depressive episodes. Clinical utility of ICD-11 bipolar disorders was found to be significantly lower than for ICD-10 equivalent categories. LIMITATIONS: Standardized case vignettes were manipulated to evaluate specific changes. The degree of accuracy of clinicians' diagnostic judgments may not reflect clinical decision-making with patients. CONCLUSIONS: Alignment of the ICD-11 with current research appears to have been achieved without sacrificing diagnostic accuracy or clinical utility though specific training may be necessary as ICD-11 is implemented worldwide. Areas in which the ICD-11 guidelines did not perform as intended resulted in further revisions.

Clinical efficacy of a combined acceptance and commitment therapy, dialectical behavioural therapy, and functional analytic psychotherapy intervention in patients with borderline personality disorder.

OBJECTIVE: Borderline personality disorder (BPD) consists of a persistent pattern of instability in affective regulation, impulse control, interpersonal relationships, and self-image. Although certain forms of psychotherapy are effective, their effects are small to moderate. One of the strategies that have been proposed to improve interventions involves integrating the therapeutic elements of different psychotherapy modalities from a contextual behavioural perspective (ACT, DBT, and FAP). METHODS: Patients (n = 65) attending the BPD Clinic of the Instituto Nacional de Psiquiatría Ramón de la Fuente Muñíz in Mexico City who agreed to participate in the study were assigned to an ACT group (n = 22), a DBT group (n = 20), or a combined ACT + DBT + FAP therapy group (n = 23). Patients were assessed at baseline and after therapeutic trial on measures of BPD symptom severity, emotion dysregulation, experiential avoidance, attachment, control over experiences, and awareness of stimuli. RESULTS: ANOVA analyses showed no differences between the three therapeutic groups in baseline measures. Results of the MANOVA model showed significant differences in most dependent measures over time but not between therapeutic groups. CONCLUSIONS: Three modalities of brief, contextual behavioural therapy proved to be useful in decreasing BPD symptom severity and emotional dysregulation, as well as negative interpersonal attachment. These changes were related to the reduction of experiential avoidance and the acquisition of mindfulness skills in all treatment groups, which may explain why no differences between the three different intervention modalities were observed. PRACTITIONER POINTS: Brief adaptations of acceptance and commitment therapy and dialectical behavioural therapy are effective interventions for BPD patients, in combined or isolated modalities, and with or without the inclusion of functional analytic psychotherapy. The reduction of experiential avoidance and the acquisition of mindfulness skills are related with the diminution of BPD symptoms severity, including emotional dysregulation and negative interpersonal attachment.

Changes in facial emotion expression during a psychotherapeutic intervention for patients with borderline personality disorder.

Emotional dysregulation is one of the main features of Borderline Personality Disorder (BPD). Therefore, it constitutes a central therapeutic objective of the interventions that have proven to be effective for these patients, including the Acceptance and Commitment Therapy (ACT). However, benefits on emotional regulation have been evaluated through self-report instruments, and an anatomically based, objective, and precise measurement of the ability to change the type, duration and frequency of emotions is still needed. OBJECTIVE: To assess facial emotion expression, valence and arousal during an ACT based intervention, between initial, middle and final therapeutic sessions for BPD patients. METHOD: Using the FaceReader 7.0, 29 recordings of individual therapeutic sessions for BPD patients during an ACT intervention trial were analyzed. RESULTS: Happiness and fear intensity increase from the beginning to the end of the sessions, while sadness decreases. Emotional valence exhibits a significant decrease in its negative value during sessions from -0.13 (S.D. = 0.12) at the initial part of the sessions to -0.06 (S.D. = 0.08) by the end of the sessions, with a moderate effect size (Cohen d = 0.69). Emotional arousal increased from the beginning to the end of sessions and whole intervention. CONCLUSION: The emotional valence and arousal differed according to the psychotherapeutically process involved during ACT intervention, suggesting that the systematic analysis of facial expressions allows a rigorously examination of the relations between emotions, physiological processes, and instrumental behavior experimented though a psychotherapeutically process.

Needs assessment of informal primary caregivers of patients with borderline personality disorder: psychometrics, characterization, and intervention proposal / Evaluación de las necesidades de los cuidadores primarios informales de pacientes con trastorno límite de la personalidad: psicometría, caracterización y propuesta de intervención

Abstract Introduction Informal Primary Caregivers (IPC) of people with borderline personality disorder (BPD) experience a significant burden, making it important to determine their specific needs. Objectives Cross-sectional study aimed at adapting and establishing the reliability of the Questionnaire on the Needs of Family Members of People with Severe Mental Disorders to identify felt and unfelt needs that may or may not have been met in IPCs of patients with BPD and suggest intervention strategies to effectively address them. Method The adapted version of the instrument was completed by 80 IPCs of patients with confirmed BPD diagnosis. Results Cronbach's alpha coefficients for different groups of needs evaluated through the instrument were: Knowledge/information = .77, Instrumental support = . 78, Participation = .63, and Personal support = .74; and for the total score = .86. The most important unmet felt needs were: 1. having information on interventions for patients and caregivers, legal and administrative aspects, and available support services; 2. having coping skills to deal with crises and manage patients' risk behaviors; 3. receiving professional care to reduce stress; and 4. being listened by health professionals, express their personal opinions, and need for rest. Conclusions The adapted instrument showed satisfactory internal consistency in IPCs of patients with BPD. The results highlight the urgent need for interventions for this population, focusing on psychoeducation, assertiveness training, stress management, and problem solving.

Resumen Introducción Los cuidadores primarios informales (CPI) de pacientes con trastorno límite de personalidad (TLP) soportan una pesada carga, por lo que es importante conocer sus necesidades específicas. Objetivos Estudio transversal dirigido a adaptar y determinar la confiabilidad del Cuestionario de Necesidades de Familiares de Personas con Trastornos Mentales Graves a fin de identificar las necesidades sentidas y no sentidas que han sido satisfechas o no en los CPI de pacientes con TLP y sugerir estrategias de intervención para que reciban una atención efectiva. Método Ochenta CPI de pacientes con diagnósticos confirmado de TLP completaron la versión adaptada del instrumento. Resultados Los coeficientes alpha de Cronbach para los cuatro grupos de necesidades evaluadas mediante el instrumento fueron: Conocimientos/información = .77, Apoyo instrumental = .78, Participación = .63, y Apoyo personal = .74; y para el total de la escala = .86. Las necesidades sentidas y no satisfechas que destacaron fueron: 1. tener información de intervenciones para el paciente y los cuidadores, aspectos legales y administrativos, y servicios disponibles para apoyarse; 2. contar con herramientas para afrontar crisis y manejar conductas de riesgo de los pacientes; 3. ser atendidos profesionalmente para reducir el estrés; y 4. ser escuchados por los profesionales de salud y tomados en cuenta en relación con sus opiniones personales y necesidad de descanso. Conclusiones El instrumento adaptado mostró una consistencia interna satisfactoria en CPI de pacientes con TLP. Los resultados resaltan la necesidad urgente de intervenciones para esta población, enfocadas en psicoeducación, entrenamiento asertivo, manejo del estrés ansiedad y solución de problemas.

Psychometric properties of a culture-adapted Spanish version of AIDA (Assessment of Identity Development in Adolescence) in Mexico.

BACKGROUND: The construct "identity" was discussed to be integrated as an important criterion for diagnosing personality disorders in DSM-5. According to Kernberg, identity diffusion is one of the relevant underlying structures in terms of personality organization for developing psychopathology, especially borderline personality disorder. Therefore, it would be important to differentiate healthy from pathological development already in adolescence. With the questionnaire termed AIDA (Assessment of Identity Development in Adolescence), a reliable and valid self-rating inventory was introduced by Goth, Foelsch, Schlueter-Mueller, & Schmeck (2012) to assess pathology-related identity development in healthy and disturbed adolescents. To test the usefulness of the questionnaire in Mexico, we contributed to the development of a culture-specific Spanish translation of AIDA and tested the reliability and aspects of validity of the questionnaire in a juvenile Mexican sample. METHODS: An adapted Spanish translation of AIDA was developed by an expert panel from Chile, Mexico, and Spain in cooperation with the original authors, focusing on content equivalence and comprehensibility by considering specific idioms, life circumstances, and culture-specific aspects. The psychometric properties of the Spanish version were first tested in Mexico. Participants were 265 students from a state school (N = 110) and private school (N = 155), aged between 12 and 19 years (mean 14.15 years). Of these, 44.9% were boys and 55.1% were girls. Item characteristics were analyzed by several parameters, scale reliability by Cronbach's Alpha, and systematic effects of gender, age, and socioeconomics by an analysis of variance (ANOVA). We evaluated aspects of criterion validity in a juvenile justice system sample (N = 41) of adolescent boys in conflict with the law who displayed various types of behavioral problems by comparing the AIDA scores of a subgroup with signs for borderline pathology (N = 14) with the scores obtained in the student sample using T-tests. RESULTS: The psychometric properties of the Spanish version of AIDA proved satisfactory in the Mexican sample for items as well as scales. The reliability coefficients were α = .94 for the total scale "Identity Diffusion", α = .85 and .92 for the two primary scales "Discontinuity" and "Incoherence", and between α = .70 and .83 for the subscales. However, some items of the item pool in the Spanish version of AIDA did not meet all criteria for test equivalence and should thus be reformulated, taking the Mexican culture into account. Significant effects for gender and age were found. In line with our theory, the AIDA scores in the domains "Discontinuity" (high effect size) and "Incoherence" (medium effect size) were markedly higher in the delinquent boys than in the student group. CONCLUSION: The Spanish version of AIDA can be used in Mexico with satisfying psychometric properties, with only minor adaptions required. Our study contributes to the intercultural applicability of the AIDA instrument using the construct "identity integration vs. diffusion" as it was defined in the AIDA model for diagnostic purposes. Cultural differences, even those present in the various Spanish-speaking countries, should be modeled carefully.

Ultrastructural changes and immunolocalization of P-selectin in platelets from patients with major depression.

Depression is considered an important risk factor in patients with cardiovascular disease (CVD). Although the biological mechanism is unknown, it has been suggested that hyperactivity of platelets may have an important role in the onset and evolution of cardiovascular damage. The goals of this study were to evaluate by transmission electron microscopy and immunohistochemistry the presence of ultra-structural variations in platelets from individuals with recent diagnosis of major depression disease (MDD, patients without previous anti-depressant treatment and from healthy control subjects.). Platelets from depressed patients had a greater proportion of dendritic forms compared with those obtained from control subjects. Morphological changes, such as dilation of open canalicular and dense tubular systems, platelet vacuolization, electrodense pattern of membranes, and a different immunolocalization of P-selectin were observed in the platelets from depressed patients compared with those isolated from healthy subjects. Our results revealed ultra-structural changes in platelets isolated from patients with MDD suggestive of enhanced platelet activation.

Tryptophan and serotonin in blood and platelets of depressed patients: Effect of an antidepressant treatment

Abstract: Platelets llave serotonin (5-HT) uptake and storage mechanisms similar to those from neurons. In addition, they represent nearly 99% of blood 5-HT concentration. For these characteristics, platelets are considered useful biomarkers of the serotonergic synaptic neurotransmission, particularly in psychiatric disturbances such as depression. However, most studies which have evaluated platelet 5-HT concentrations in depression have not shown similar findings. It has been suggested that changes in plasma tryptophan (TRP) concentrations might modify 5-HT concentration in the brain, as well as in platelets. Likewise, decreased plasma concentrations of TRP have been found in depressed patients, and the selective 5-HT reuptake inhibitors (SSRIs) induce changes in platelet 5-HT concentration. Considering the controversy surrounding platelet 5-HT concentrations in depressed patients, and the fact that blood 5-HT and TRP have not been studied in the Mexican population, we decided to study 5-HT and tryptophan concentrations in blood and platelets from depressed and control Mexican subjects to evaluate a possible correlation with the severity of depression. The effect of fluoxetine and citalopram treatment on blood and platelet 5-HT and TRP concentrations in depressed patients was also studied. Material and methods Depressed patients The patients of this study were carefully selected and evaluated. Scales based on semi-structured interviews were applied (MINI and SCID-II) by clinical investigators to reduce any possible bias in patient selection. The influence of the seasonal variability on the 5-HT or TRP blood concentrations was controlled by pairing depressed patients and healthy subjects according to age, gender and, in the case of women, menstrual cycle phase. Patients with a complete remission of depression symptoms (defined as a score not higher than 5 points in the Hamilton's scale, and lower than 7 points in Beck's scale) were asked for a blood sample to measure platelet and blood concentrations of 5-HT and TRP. The patients were weighted before the treatment and after their improvement. Control subjects The control group was integrated by 30 healthy subjects, 24 women and 6 men, with an average age of 32.3 ± 10.8 years. Participants were recruited from the overall Mexican population, interviewed by a psychiatrist, and evaluated with the structured interview MINI and the SCID-II, all these to discard any psychiatric diagnose. None of them had received any pharmacological treatment during the three weeks prior to the study. Control and depressed women were paired according to their menstrual cycle phase. All participants received a detailed explanation of the study, and those who voluntarily accepted the stipulations signed an informed consent document. Control and patient subjects were clinically examined and studied with routine laboratory tests (blood count, blood chemistry, urinalysis, and thyroid function test). Blood sample procedures 5-HT and TRP measurements in total blood preparation were carried out according to the method described by Anderson, and were quantified by high performance liquid chromatography (HPLC). Statistical analysis The differences were statistically determined through an analysis of variance (ANOVA), with the assistance of the SPSS 12.00 (Statistical Software by SPPS Inc.). Results Results from laboratory tests, such as blood count, blood chemistry, thyroid function (T3, T4 and TSH) and urinalysis were normal in depressed subjects, as well as in healthy volunteers. Platelet number, blood 5-HT concentration, platelet content of 5-HT, and blood tryptophan concentration showed no significant differences in depressed patients in comparison to control subjects. 5-HT values in blood and platelet were significantly lower than the initial concentrations in patients after antidepressant treatment. Discussion and conclusions Discrepancies between our study and those found in the literature can be explained with three different approaches: ethnical, physiological, and methodological, as is further discussed. The significant decrease produced by the antidepressant treatment in blood and platelet serotonin concentration may be a consequence of the action of SSRIs, due to a 5-HT diminished uptake by the platelet. Considering our results, we conclude that: Blood and platelet 5-HT concentrations were not different between depressed patients and healthy volunteers. Blood TRP concentrations were not different between depressed patients and healthy volunteers. SSRIs (fluoxetine or citalopram) used in the treatment of depressed patients induced a significant decrease in blood and platelet content of 5-HT, and had no effect in TRP concentrations. Based on these results, neither blood/platelet 5-HT nor blood tryptophan concentrations seem to be good biological markers of depressive patients status. However, 5-HT, but not tryp-tophan, might be a reference point for pharmacological treatment effect.

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