Longitudinal outcomes of a work inclusion program in mental health departments in the city of Milan.

BACKGROUND: Work functioning impairment is a key diagnostic and prognostic criterion in patients with psychiatric disorders and work inclusion is a major goal of their therapeutic pathway. Since 2009, the Regional Innovative Program (PIR) TR106, promoted by ASST Fatebenefratelli-Sacco of Milan in collaboration with other Departments of Mental Health and Addictions (DSMDs) in the town of Milan (Italy), has been developing the employment inclusion of psychiatric patients. AIMS: The objective of this study is to evaluate its outcomes over 8 years of observation. METHOD: We reported the results of a retrospective epidemiologic analysis on 2,142 interventions on 1,066 patients recruited, investigating PIR TR106 outcomes per year focusing on different subgroups. We focused on 'positive', 'negative', and 'other' outcomes. RESULTS: We preliminary calculated job maintenance interventions (5%, 107) and excluded these interventions from the overall. We observed 29 job firing (1.4%) and 15 job resignations (0.7%) as negative results (equal to 2.2% of the total) and 388 job hiring (16.6%), 647 traineeships (31.8%), and 413 work formation (20.3%) as positive outcomes (equal to 68.75%). In other outcomes (29.1%) we found 305 dismissals from PIR TR 106 (15%) and transitory outcomes (14.1%).Job hiring increased from 8.9% in 2012 to 23.8 % in 2019 (p < .001), while the dismissals diminished from 26.7% to 13.3% (p < .001). The effectiveness of traineeships in terms of job hiring increased in the ratio of annual job hiring versus job traineeship (+48.8%). The majority of hired patients (15.1%) were affected by a psychotic disorder. A significant hiring increase was observed in patients with psychotic disorders and personality disorders (p < .005). CONCLUSIONS: PIR-TR106 represents a territorial employment inclusion program with progressively increasing effectiveness and specificity, as suggested by changes in outcomes during the 8-year observation. The adaptive capacity and sustainability of the intervention are worth further investigation.

Gender impact on the outcome of rehabilitation programs in psychiatry: Brief report from a metropolitan residential rehabilitative service.

Background: Differences based on gender in the presentation and outcome of many psychiatric conditions have been highlighted in the past years. Moreover, women are often underrepresented in research samples, thus leading to a poorer understanding and addressing of their needs. As regards psychiatric rehabilitation, few studies have focused on the influence of gender on the outcomes of rehabilitation programs. Objectives: This study aimed to analyze the impact of gender on socio-demographic and clinical characteristics, as well as on main rehabilitation outcomes, in a sample of subjects undergoing rehabilitation programs in a metropolitan residential service. Methods: We collected socio-demographic, clinical variables and rehabilitation outcomes of all subjects discharged from the metropolitan residential rehabilitative service of the Luigi Sacco Hospital in Milan, Italy, from January 2015 to December 2021. Gender differences were analyzed through t-test and chi-square for continuous and categorical variables, respectively. Results: In a total sample of 129 subjects equally distributed for gender (50.4% women), all subjects improved after their rehabilitation program, as measured through specific psychometric scales. However, women had a higher proportion of discharges to their own household (52.3% vs. 25% of men). They also showed higher educational status (53.8% completed high school vs. 31.3% of men). Clinically, they showed longer duration of untreated illness (3.6 ± 7.31 vs. 1.06 ± 2.35 years) and lower frequency of substance use disorders compared to men (6.4% vs. 35.9%). Conclusion: The main result of this study shows, in light of an equal improvement in psychopathological and psychosocial functioning after the rehabilitation program, better outcomes in women compared to men, with a higher frequency of return to their own household after the completion of a rehabilitation program compared to men.

Latency to selective serotonin reuptake inhibitor vs benzodiazepine treatment in patients with panic disorder: a naturalistic study.

BACKGROUND: Panic disorder (PD) is a prevalent and impairing anxiety disorder with previous reports suggesting that the longer the condition remains untreated, the greater the likelihood of nonresponse. However, patients with PD may wait for years before receiving a guideline-recommended pharmacological treatment. The widespread prescription of benzodiazepines (BDZ) for managing anxiety symptoms and disorders might delay the administration of pharmacotherapy according to guidelines (eg, selective serotonin reuptake inhibitors, SSRIs). The present study aimed to determine the mean duration of untreated illness (DUI) in a sample of PD patients, to quantify and compare DUI-SSRI to DUI-BDZ, and to compare findings with those from previous investigations. METHODS: Three hundred and fourteen patients with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of PD were recruited from an Italian outpatient psychotherapy unit, and epidemiological and clinical variables were retrieved from medical records. Descriptive statistical analyses were undertaken for sociodemographic and clinical variables, Wilcoxon matched-pair signed rank test was applied to compare the distribution of DUI-SSRI vs DUI-BDZ, and Welch's t test was performed to compare findings with those from previous studies. RESULTS: The mean DUI-SSRI of the total sample was 64.25 ± 112.74 months, while the mean DUI-BDZ was significantly shorter (35.09 ± 78.62 months; P < 0.0001). A significantly longer DUI-SSRI, compared to findings from previous studies, was also observed. CONCLUSIONS: The present results confirm a substantial delay in implementing adequate pharmacological treatments in patients with PD, and highlight the discrepancy between recommendations from international treatment guidelines and common clinical practice in relation to BDZ prescription.

Cannabis use and related clinical variables in patients with obsessive-compulsive disorder.

OBJECTIVE: Limited studies have investigated cannabis use in patients with obsessive-compulsive disorder (OCD), despite its widespread use by patients with psychiatric illnesses. The aim of this study was to assess the frequency, correlates, and clinical impact of cannabis use in an Italian sample of patients with OCD. METHODS: Seventy consecutive outpatients with OCD were recruited from a tertiary specialized clinic. To assess cannabis-related variables, patients completed a questionnaire developed for the purpose of this study, investigating cannabis use-related habits and the influence of cannabis use on OCD symptoms and treatments. A set of clinician and self-reported questionnaires was administered to measure disease severity. The sample was then divided into three subgroups according to the pattern of cannabis use: "current users" (CUs), "past-users" (PUs), and "non-users" (NUs). RESULTS: Approximately 42.8% of patients reported lifetime cannabis use and 14.3% reported current use. Approximately 10% of cannabis users reported an improvement in OCD symptoms secondary to cannabis use, while 23.3% reported an exacerbation of anxiety symptoms. CUs showed specific unfavorable clinical variables compared to PUs and NUs: a significant higher rate of lifetime use of tobacco, alcohol, and other substances, and a higher rate of pre-OCD onset comorbidities. Conversely, the three subgroups showed a similar severity of illness. CONCLUSION: A considerable subgroup of patients with OCD showed a predisposition towards cannabis use and was associated with some specific clinical characteristics, suggesting the need for targeted consideration and interventions in this population.

New challenges in facing cyberchondria during the coronavirus disease pandemic.

Cyberchondria (CYB) is characterized by excessive online searching for medical information and is associated with increasing levels of distress, anxiety, and interference with daily activities. As the use of digital devices and the Internet as a source of everyday information has increased, particularly during the current coronavirus disease (COVID-19) pandemic, so has CYB, becoming an object of interest to clinicians and researchers. The present review will provide an overview of the latest updates in CYB research. Emerging evidence draws attention to various vulnerability factors for developing CYB, including personal characteristics such as female gender, younger age, or a history of mental disorder, as well as engagement in particular forms of online behavior, such as increased use of social media, increased acceptance of online information, and information overload. Additionally, recent studies suggest that CYB may itself act as a mediating factor for increased COVID-19-related psychological burden. However, the data are still very sparse. Knowledge gaps include a universally accepted definition of CYB, severity thresholds to help differentiate nonpathological online health searches from CYB, as well as robustly evidence-based interventions.

A longitudinal analysis of a work inclusion model for psychiatric patients in the Mental Health Departments of the city of Milan.

BACKGROUND: Work functioning impairment is a key diagnostic and transnosographic criterion for psychiatric disorders in both DSM-5 and ICD-11. Occupational inclusion is a fundamental aspect of the care path for patients attending the territorial services provided by the Italian Mental Health and Addiction Departments (DSMDs). Since 2009, the Regional Innovative Programme (PIR) TR106, promoted by the Fatebenefratelli-Sacco hospital of Milan, Italy, in collaboration with six other metropolitan DSMDs, was created to promote integration for people suffering from mental health problems in the city of Milan. METHOD: Here we present the results of a retrospective epidemiologic analysis on 2,142 interventions on 1,066 patients, conducted between 2012 and 2019. RESULTS: Most of the interventions were conducted with people with psychotic disorders (39%), followed by personality disorders (25.2%) and affective disorders (22.2%). The age range of 25 to 54 years represented 91.5% of the whole sample, mainly in the 35 to 44 years range (36.4%). Significant age group-related changes in interventions were observed in the observation period, with a reduction in the interventions provided to subjects of the 35 to 44 age group, and an increase in the 25 to 34 age group. CONCLUSIONS: PIR TR106 provided the most accurate assessment and data collection so far for the city of Milan. Our data characterised psychiatric groups in order to develop specific treatment plans and work inclusion interventions.

A preliminary investigation of Cyberchondria and its correlates in a clinical sample of patients with obsessive-compulsive disorder, anxiety and depressive disorders attending a tertiary psychiatric clinic.

Objectives. This cross-sectional study aimed to investigate the frequency and presentation of cyberchondria (CYB) in patients with obsessive-compulsive disorder (OCD), anxiety disorders (ADs), and major depression disorder (MDD).Methods. Seventy-seven patients (OCD:25, ADs:26, MDD:26) referred to a tertiary psychiatry outpatient clinic and 27 healthy controls (HCs) were included. A 'working' definition of CYB was used to measure CYB frequency. CYB severity was measured with the Cyberchondria Severity Scale (CSS).Results. CYB as currently defined was present in just 1.3% of the combined patients' sample. Using a broader definition (omitting the disability criterion), we found a higher distribution (OCD:12%, ADs:19.2%, MDD:15.4%, HCs:3.7%) and greater CYB symptom severity. Patients with OCD (63.3 ± 18.9) and ADs (63.3 ± 25.9) showed a higher CYB severity, compared with HCs (48.4 ± 9.9, p<.05). In the combined patients' sample, a positive correlation was found between the CSS scores and measures of health anxiety or hypochondriasis. Higher CYB symptom severity emerged in patients with a positive family history of psychiatric disorders and in those prescribed benzodiazepines or mood-stabilisers.Conclusion. CYB represents a common transdiagnostic syndrome in patients with OCD, ADs, and MDD with a spectrum of severity and indicates a variable burden of illness, supporting the need for specific clinical considerations and interventions.Key pointsCyberchondria (CYB) represents a common transdiagnostic syndrome in patients with obsessive-compulsive disorder, anxiety, and depressive disorders.CYB's frequency as a syndrome of compulsive online health searches associated with an increased anxiety and distress was reported in 10-20% patients.Health anxiety/hypochondriasis showed a strong correlation with CYB.Patients with a positive family history of psychiatric disorders and those prescribed benzodiazepines or mood-stabilisers showed higher CYB symptom severity.Considering the spread of Internet use for health-related information, additional studies investigating CYB in clinical samples are encouraged.

Functional interventions as augmentation strategies for obsessive-compulsive disorder (OCD): scoping review and expert survey from the international college of obsessive-compulsive spectrum disorders (ICOCS).

BACKGROUND: Patients with obsessive-compulsive disorder (OCD) commonly exhibit a range of functional difficulties, presumed linked to neurocognitive changes. Evidence-based first-line treatments have limited effect on improving these cognitive-functional problems. Candidate interventions could be used to augment evidence-based treatments by the multi-professional mental health team. METHODS: A scoping review was performed to identify any intervention with at least one peer-reviewed report of clinical improvement in any of the 13 functional domains of the Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13). Next, an online survey of experts of the International College of Obsessive-Compulsive Spectrum Disorders was conducted. RESULTS: Forty-four studies were identified reporting a positive outcome for 27 different kinds of intervention. Twenty-six experts from 12 different countries, including at least one expert from each continent, completed the opinion survey. Five interventions were identified as 'highly promising', none of which was moderated by rater-related factors, suggesting global applicability. CONCLUSION: Patients with OCD may benefit from a detailed functional assessment, to identify areas of unmet need. A variety of interventions show theoretical promise for treating the complex functional difficulties in OCD as adjuncts to first-line treatments, but the published evidence is weak. Randomised controlled trials are needed to determine the clinical effectiveness of these interventions.HighlightsFunctional-cognitive problems are common in patients with OCD.First-line evidence-based treatments have limited effect on these functionalcognitive difficulties.In our scoping review we found 44 studies reporting of improved clinical outcomes in any of the 13 functional domains of the Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13).An online survey of experts of the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) was conducted and identified five interventions as "highly promising" candidate treatments for functional-cognitive problems in OCD.Randomised controlled trials are needed to determine the clinical effectiveness of these interventions.

In Search for Biomarkers in Obsessive-Compulsive Disorder: New Evidence on Saliva as a Practical Source of DNA to Assess Epigenetic Regulation.

BACKGROUND: Brain-Derived Neurotrophic Factor (BDNF) is a promising candidate biomarker in both the development and aetiology of different neuropsychiatric conditions, including obsessive-compulsive disorder (OCD). Most of the studies in the field have been carried out in blood cells, including peripheral blood mononucleated cells (PBMCs), although DNA of high quality can be easily isolated from saliva. OBJECTIVE: The objective of this study was to evaluate the epigenetic regulation of the BDNF gene in the saliva of a clinical sample of OCD patients in order to assess this source as an alternative to blood. METHODS: We first analyzed DNA methylation levels at BDNF in the saliva of subjects suffering from OCD (n= 50) and healthy controls (n=50). Then, we compared these data with the results previously obtained for the same genomic region in blood samples from the same patients and controls (CTRL). RESULTS: Our preliminary data showed a significant reduction of 5mC levels at BDNF gene (OCD: 1.23 ± 0.45; CTRL: 1.85 ± 0.64; p < 0.0001) and a significant correlation between DNA methylation in PBMCs and saliva (Spearman r = 0.2788). CONCLUSION: We support the perspective that saliva could be a possible, reliable source, and a substitute for blood, in search of epigenetic biomarkers in OCD.

Do adolescents and young adults accessing the Emergency Room with substance use receive poor therapeutic indications at discharge? An observational retrospective study.

PURPOSE: Emergency rooms (ERs) are usually the first point of contact with mental health services for adolescents with Substance Use Disorders (SUDs). However, only a minority of them receives proper treatment and follow-up indications, increasing the risk of relapses and poor prognosis. In this perspective, we sought to characterize and compare socio-demographic and clinical characteristics of adolescents with vs without SUDs accessing the ER, assessing potential differences in terms of discharge instructions. METHODS: A sample of 557 ER accesses of patients aged 15-25 years old in need of a psychiatric evaluation or with a psychiatric diagnosis at discharge was retrospectively analyzed. Patients were divided in two subgroups according to the presence of SUDs. RESULTS: About 32.1% of patients had SUDs when accessing the ER. Among these, 62% were unknown to any psychiatric services and 57% were at their psychiatric onset. Nevertheless, considering discharge instructions, patients with current substance use received less therapeutic indication or were less frequently referred to psychiatric facilities, than those without substance use (57.8% vs 42.2%, P = .002). CONCLUSIONS: Substance abuse is strongly linked to psychopathology and ER accesses in young patients. However, we observed a large rate of SUDs patients unknown by any specialized mental health service, who received poor therapeutic and follow-up instructions at discharge. Improving communication between ER operators and young patients with SUDs could longitudinally reduce the risk of addiction and related disability, morbidity and mortality.

Structured Evaluation of Rehabilitation Programs Outcomes in Psychiatry: Application of a Recovery-Centered Model.

Rehabilitation is oriented to psychiatric patients' recovery through specific techniques and structured projects, not yet fully standardized, carried out in territorial services. This study aims to apply an operational structured outcome indicator model (hospitalizations, continuity of care, LAI treatment adherence, working support) through a recovery-centered model in a rehabilitation community in Milan. This observational-retrospective study included 111 patients from a University High Assistance Rehabilitation Community (C.R.A.) based in Milan. Psychopathological and psychosocial functioning was evaluated with Kennedy Axis V, Brief Psychiatric Rating Scale (BPRS), Life Skills Profile (LSP), AR module of the VADO scale. Statistical analyses were performed using SPSS software version 19. Student t test and Wilcoxon Test were used to analyze quantitative variables, while McNemar test for qualitative variables. The minimum level of significance was set at 0.05 (p <0.05). The results showed that CRA rehabilitation program led to significant improvement in global functioning in terms of hospitalization reduction; improved continuity of care; stable adherence to psychopharmacological treatment with Long Acting Injectable (LAI) antipsychotics; stable employment maintenance during the year following discharge from the CRA. This study confirmed the utility of a structured outcome indicator model and highlighted its feasibility in daily clinical context of a rehabilitative community. Our results supported the effectiveness of a community-based rehabilitation program to improve individual functioning and clinical stability. However, further studies are required to better achieve the development of a recovery-oriented rehabilitation model and rigorously define an outcomes evaluation model.

Correlation between pharmacokinetics and pharmacogenetics of Selective Serotonin Reuptake Inhibitors and Selective Serotonin and Noradrenaline Reuptake Inhibitors and maternal and neonatal outcomes: Results from a naturalistic study in patients with affective disorders.

OBJECTIVE: Some studies have linked the use of selective serotonin reuptake inhibitors and selective serotonin and noradrenaline reuptake inhibitors (SSRIs/SNRIs) to the risk of perinatal complications. This study explored the relationship between pharmacokinetics and pharmacogenetics, SSRIs/SNRIs tolerability and effectiveness and maternal and newborn outcomes. METHODS: Fifty-five pregnant women with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnoses of affective disorders, treated with SSRIs/SNRIs, were recruited and, during the third trimester, their blood samples were collected for pharmacokinetic and pharmacogenetic analyses. Plasma levels and metabolic phenotypes were then related to different obstetrical and maternal outcomes. RESULTS: The pharmacokinetic data were more stable for Sertraline, Citalopram, and Escitalopram compared to other molecules (p = 0.009). The occurrence of postnatal adaptation syndrome onset was associated with higher plasma levels for Sertraline (median at delivery: 16.7 vs. 10.5 ng/ml), but not for fluoxetine and venlafaxine. Finally, the subgroup within range plasma concentrations had less blood loss than the below range subgroup (p = 0.030). CONCLUSIONS: Plasma levels of Sertraline, Citalopram and Escitalopram were more frequently in range in late pregnancy when compared to other drugs. Drug plasma concentrations do not strictly correlate with worse perinatal outcomes, but with possible differences between the different drugs.

Anxiety disorders anticipate the diagnosis of bipolar disorder in comorbid patients: Findings from an Italian tertiary clinic.

BACKGROUND: Studies indicate bipolar disorder (BD) syndromal symptoms are commonly preceded by sub-syndromal BD symptoms, dysregulated sleep, irritability, and anxiety. We aimed to evaluate prevalence and clinical correlates of anxiety disorders (ADs) at BD onset in outpatients with versus without at least one AD at BD onset. METHODS: 246 bipolar spectrum outpatients, according to the text revision of the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV-TR), attending Sacco University Hospital in Milan, were recruited and their onset and clinical features assessed retrospectively. Patients were stratified into those with versus without an AD at BD onset (w/A and wo/A), according to a semi-structured clinical interview to provide diagnoses according to (DSM- IV-TR). RESULTS: 29% of patients reported being w/A, among whom Panic Disorder (PD, in 55.6%) was the most frequent AD, and first AD occurred approximately 4 years before BD diagnosis. Patients w/A versus wo/A had higher (p < 0.05) rates of BDII and first mood episode being depression versus elevation (mania/hypomania), and lifetime rates of separation anxiety disorder, substance poly-abuse and benzodiazepine abuse. In contrast, patients wo/A had higher lifetime rates of alcohol and illicit drug use. CONCLUSION: In this naturalistic sample, ADs, in particular PD, preceded BD in almost 1/3 of BD outpatients, and had distinctive clinical correlates. Further investigation into relationships between BD and AD at onset may enhance early BD diagnosis and treatment.