Factors associated with the onset of major depressive disorder in adults with type 2 diabetes living in 12 different countries: results from the INTERPRET-DD prospective study.

AIMS: To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries. METHODS: People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables. RESULTS: In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS. CONCLUSION: This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries.

AIMS: To assess the prevalence and management of depressive disorders in people with Type 2 diabetes in different countries. METHODS: People with diabetes aged 18-65 years and treated in outpatient settings were recruited in 14 countries and underwent a psychiatric interview. Participants completed the Patient Health Questionnaire and the Problem Areas in Diabetes scale. Demographic and medical record data were collected. RESULTS: A total of 2783 people with Type 2 diabetes (45.3% men, mean duration of diabetes 8.8 years) participated. Overall, 10.6% were diagnosed with current major depressive disorder and 17.0% reported moderate to severe levels of depressive symptomatology (Patient Health Questionnaire scores >9). Multivariable analyses showed that, after controlling for country, current major depressive disorder was significantly associated with gender (women) (P<0.0001), a lower level of education (P<0.05), doing less exercise (P<0.01), higher levels of diabetes distress (P<0.0001) and a previous diagnosis of major depressive disorder (P<0.0001). The proportion of those with either current major depressive disorder or moderate to severe levels of depressive symptomatology who had a diagnosis or any treatment for their depression recorded in their medical records was extremely low and non-existent in many countries (0-29.6%). CONCLUSIONS: Our international study, the largest of this type ever undertaken, shows that people with diabetes frequently have depressive disorders and also significant levels of depressive symptoms. Our findings indicate that the identification and appropriate care for psychological and psychiatric problems is not the norm and suggest a lack of the comprehensive approach to diabetes management that is needed to improve clinical outcomes.

The INTERPRET-DD study of diabetes and depression: a protocol.

AIM: People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe. METHOD: INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated. RESULTS: Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use. CONCLUSIONS: Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression.

Development of the ITHACA Toolkit for monitoring human rights and general health care in psychiatric and social care institutions.

Background. Human rights violations are commonly experienced by people in psychiatric and social care institutions. States and private organizations providing such health and social services must comply with international human rights law. Monitoring of such compliance is increasingly recognized as a vital component in ensuring that rights are respected and violations are brought out in the open, remedied and prevented. Aims. The Institutional Treatment, Human Rights and Care Assessment (ITHACA) project produced a method to document violations and good practice with the aim of preventing human rights violations and improving general health care practice in psychiatric and social care institutions (www.ithacastudy.eu). Methods. A methodological and implementation study conducted across 15 European countries developed and assessed the ITHACA Toolkit in monitoring visits to 87 mental health organizations. Results. The toolkit is available in 13 European languages and has demonstrated applicability in a range of contexts and conditions. The information gathered through monitoring visits can document both good practice and areas for improvement. Conclusions. The ITHACA Toolkit is an acceptable and feasible method for the systematic monitoring of human rights and general health care in psychiatric and social care institutions that explicitly calls for the participation of service users in the monitoring of human rights violations and general health care practice.

Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience.

OBJECTIVE: To describe the development of a community-based mental health service, the patterns of care provided by this new service established in 1978 and its costs. METHOD: The South-Verona Psychiatric Case Register, the South-Verona Outcome Project and studies designed to assess costs provided process and outcome data. RESULTS: This paper summarizes descriptive statistics as well as the results of some evaluative studies conducted over the last 25 years in Verona, Italy. It reports patterns of care provided over the years by this new, comprehensive community-based service, targeted to the severely mentally ill but available also to all other residents in the area who need mental health care. CONCLUSION: Developing community-based mental health care requires a series of coordinated actions that need to be pursued over a long period of time. Service evaluation, including costs assessment, is an important part of this exercise.

Off-label and non-classical prescriptions of antipsychotic agents in ordinary in-patient practice.

OBJECTIVE: To estimate the proportion of off-label prescriptions of antipsychotics (APs) in ordinary in-patient practice. METHOD: From the South-Verona Psychiatric Case Register all admissions to the in-patient unit during 2001-02 were extracted. Prescriptions of APs were defined off-label when dispensed outside the licensed indications. In addition, the proportion of "non-classical prescriptions" was calculated. RESULTS: During the 2 years surveyed AP agents were prescribed in 311 cases. Nearly 50% of second-generation AP prescriptions were for an off-label indication. In contrast, <15% of first-generation AP prescriptions were for an off-label indication. About 30% of first- and second-generation agents were prescribed for a non-classical indication. CONCLUSION: Approved labels for second-generation AP agents cover a much narrower range of indications than any of the first-generation agents, and this explains the higher proportion of off-label prescriptions. In contrast, the everyday use of first- and second-generation APs cover a similar range of clinical indications.

Italian psychiatric reform 20 plus years after.

OBJECTIVE: To describe the current situation of mental health care in Italy and implementation of mental health reform legislation. METHOD: The current mental health care system and studies of the implementation of psychiatric reform are described. RESULTS: The 1978 reform law inaugurated fundamental changes in the care system (prohibiting admissions to state mental hospitals, stipulating community-based services, allowing hospitalization only in small general-hospital units). Uneven reform implementation was reported initially. However, in 1984 in- and out-patient services in the community were available to >80% of the population. There is a comprehensive network of in- and out-patient, residential and semi-residential facilities. Recently, services have been jeopardized by the managed-care revolution, and non-profit organizations supplement the public system (especially residential care, employment and self/mutual help). CONCLUSION: Implementation of the psychiatric reform law has been accomplished, and the year 1998 marked the very end of the state mental hospital system in Italy.

[The Italian reform, 18 years after: history, execution and consequences]. / La réforme italienne, 18 ans après: historique, implantation et conséquences.

In 1978 a radical psychiatric reform was passed in Italy, that revolutionized the mental health delivery system. The reform has attracted international attention for its resolute commitment to getting rid of the traditional state hospital and implementing a nationwide mental health system without this type of hospital. The paper begins by depicting its preparation, then after charting the main features of the reform and its implications, it moves on to providing data on the implementation. In the following years relevant legislation has supplemented the reform and is covered in the paper. Other concurrent elements of the implementation process are mentioned and existing empirical studies reviewed.

Effectiveness in psychiatric care. III: Psychoeducation and outcome for patients with major affective disorder and their families.

This hypothesis-generating study had the objective of dissecting the process of psychiatric care in an attempt to understand outcomes for patients and their families. In all, 24 patients who carried a DSM-III diagnosis of major affective disorder were identified 12-18 months after hospital admission. The patients, their families, and their doctors were interviewed using instruments measuring delivery of treatment and achievement of treatment goals; findings were then correlated with resolution of the index episode and patient global outcome. Delivery of patient and family psychoeducation was associated with better resolution of the index episode and better global outcome.

Effectiveness in psychiatric care: IV. Achieving effective medication management for major affective disorder.

Although effective medications for the treatment of Axis I disorders have been developed, achieving adequate, let alone, optimal medication regimens has been difficult. This hypothesis-generating study had the objective of dissecting the process of medication-management among 24 previously hospitalized affective disorder patients, their families, and their doctors in Italy, Japan, and the United States as well as identifying their outcomes. The data demonstrated significant positive associations between outcome and delivery of adequate medication as well as psychoeducation (about the illness and its treatment) to both patient and family. These results suggested that, regardless of country, medication was necessary but insufficient without the practitioner delivering a family intervention and psychoeducation.

Effectiveness in psychiatric care. I. A cross-national study of the process of treatment and outcomes of major depressive disorder.

Recent research suggests that, despite the development of effective psychiatric treatment, there is marked underuse of care. This pilot study had the objective of dissecting the process of care in an attempt to understand outcomes for patients with major affective disorder and for their families. Twenty-four patients with a DSM-III diagnosis of major affective disorder were identified 12 to 18 months after hospital admission in three countries (Italy, Japan, and the United States). The patients, their families, and their doctors were interviewed separately and then together, using instruments measuring delivery of treatment (using an ideal treatment criteria set) and percentage of achievement of treatment goals. These measures were then (using parametric and nonparametric statistics) correlated with resolution of the index episode and the patient's global outcome (using the Global Assessment Scale). The data demonstrated that physicians delivered about half (52%) and, subsequently, achieved about half (54%) of what would be considered ideal care to patients and other family members. The mean resolution of the index episode at follow-up was only 3.0 (on a 0- to 5-point scale). There was a significant positive association between the most important outcome measure, i.e., the resolution of the episode, and the achievement of treatment goals for both the patient (p less than .07) and the family (p less than .005). Patients and families with the best resolutions received significantly more good treatment than those with the worst resolutions (p less than .02), most notably with regard to medication (p less than .002).

Measuring the treatment environment of a psychiatric ward and a community mental health center after the Italian reform.

In 1978 a major psychiatric reform drastically changed the Italian psychiatric system by the closing of admissions to mental hospitals and the development of psychiatric units in general hospitals and of alternative services in the community. The paper presents the results of a study in which two treatment environments set up according to the reform, i.e. a psychiatric unit in a general hospital and a community mental health center run by the same staff, were examined using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environment Scale (COPES). In addition, validity studies of the Italian versions of the WAS and COPES are presented. Both instruments were found to be feasible and useful, easily understood, easy to administer and relatively well accepted by the psychiatric staff. The quality of the two scales has been confirmed by psychometric analysis, with the exception of the independence of scales. No major differences between the two environments emerged, both showing characteristics consistent with the new treatment philosophy.

Training psychiatrists in the community: a report of the Italian experience.

In 1978 a revolutionary mental health act was passed in Italy. By closing large mental hospitals and replacing them with community programs, it required a radical shift in psychiatric practice. The authors discuss the background philosophy, principles, and practical implications of this change. They describe a model program and training design of a 4-year residency in which psychiatrists learn the skills for community work while actually working in the community. The residency differs from most U.S. residencies in having trainees responsible for patients wherever they are being treated (residents are not rotated between services), its strong team orientation, and the value placed on community work.

South Verona's psychiatric service: an integrated system of community care.

Italy's mental health law of 1978 mandated the closing of state mental hospitals to new and former patients and the creation of comprehensive community-based service systems. The authors describe the organization, facilities and services, and treatment principles of one system created in accordance with the law--the South Verona Community Psychiatric Service, which serves a population of 75,000. Case register data for South Verona for the years 1978 to 1984 reflect the changes mandated by the law. They also indicate that despite an increase in admissions to the psychiatric ward in the general hospital following the closing of the state hospital, there was a substantial overall decrease in the number of hospital beds occupied per day by South Verona residents after passage of the law, and that a substantial proportion of patients with functional psychosis were able to be treated as outpatients.

Bringing into action the psychiatric reform in South-Verona. A five year experience.

The organization of psychiatric care in Verona prior to the new Italian Mental Health Act, and the organization of the new South-Verona Community Psychiatric Service (CPS) implemented in 1978 after the approval of the new law, are described. Case-register data for the period 1979-1983 are also reported. To compare in-patient care provided in South-Verona after the Reform with that of the previous year, data on hospital admissions during 1977 were collected retrospectively. From 1977 to 1983 compulsory admissions have decreased by 67%, the average number of occupied beds per day and the average length of in-patient stay have decreased by 34%, while the total rates of admission have increased by 4%. The long-stay in-patient rate, which was already considerably low in 1977 (48/100,000), is still decreasing slightly and no "new" long-stay patients have accumulated in psychiatric institutions during the past three years. In South-Verona most of the patients are treated outside the hospital and the same staff is responsible for in- as well as for out-patient care (which includes domiciliary visits and day care), to ensure therapeutic continuity. Although it lacks some complementary facilities the South-Verona CPS in its five years of experience has been able to bring into action the psychiatric reform as indicated by the new Law.