Factor structure of the brief psychiatric rating scale-expanded among outpatients with psychotic disorders in five Southeast European countries: evidence for five factors.

The Brief Psychiatric Rating Scale (BPRS) is a useful tool for measuring the severity of psychopathological symptoms among patients with psychosis. Many studies, predominantly in Western countries, have investigated its factor structure. This study has the following aims: (a) to further explore the factor structure of the BPRS-Expanded version (BPRS-E, 24 items) among outpatients with psychotic disorders in Southeast European countries; (b) to confirm the identified model; and (c) to investigate the goodness-of-fit of the three competing BPRS-E factor models derived from previous studies. The exploratory factor analysis (EFA) produced a solution with 21 items grouped into five factors, thus supporting the existence of a fifth factor, i.e., Disorganization. A follow-up confirmatory factor analysis (CFA) revealed a 19-item model (with two items removed) that fit the data well. In addition, the stability of two out of three competing factor models was confirmed. Finally, the BPRS-E model with 5 factors developed in this cross-national study was found to include a greater number of items compared to competing models.

Healthcare professionals' views on the accessibility and acceptability of perinatal mental health services for South Asian and Black women: a qualitative study.

BACKGROUND: Perinatal mental illness affects one third of new and expectant mothers. Individuals from ethnic minority groups experience higher rates of mental health problems and higher suicide rates. Despite this, women from ethnic minorities-Black and South Asian women in particular-are less likely to receive support from mental health services in the perinatal period. Healthcare professionals (HCPs) who have contact with women during this period have a unique perspective, and their views may provide insights to understand and remedy this health inequality. This study aimed to identify healthcare professionals' views on the current accessibility and acceptability of perinatal mental health services, and ways of improving services by addressing the barriers for these women. METHODS: Semi-structured interviews were conducted with twenty-four healthcare professionals who work with patients in the perinatal period. Purposive sampling was used to select HCPs from a range of different professions (including mental health staff, midwifery, primary care, social care). The data were analysed using Framework Analysis. RESULTS: Three main themes were identified from the data: (1) lack of awareness and understanding of perinatal mental illness and service structure in both healthcare professionals and patients; (2) patients' relationships with family, friends and healthcare professionals can both hinder and facilitate access to services; (3) healthcare professionals encourage raising awareness, flexibility, developing shared understandings and questioning assumptions to improve the accessibility and acceptability of services. CONCLUSION: Key insights into explaining and remedying the health inequalities observed between ethnic groups were proposed by healthcare professionals. Recommendations included sharing information; taking steps to ensure each woman was considered as an individual in her relationship with her culture, ethnicity and childrearing practices; and healthcare professionals addressing their possible unconscious biases through engaging in personal reflexive practices. Reasons these are currently not being implemented deserve further research, and the potential of novel roles such as peer support workers in bridging the space between ideals and practice needs further investigation.

The relations between socio-demographic information and negative symptoms, mental health, and quality of life: a latent profile analysis with psychotic patients in Kosovo.

The current study aims to identify meaningful psychotic patients' profiles by examining certain combinations of patient's demographic and socio-economic variables (sex, age, marital status, number of children, cohabitant and level of education). Moreover, we aim to assess whether there is any significant effect of class membership (profile) on negative symptoms, health state, and quality of life among psychotic patients. A convenience sample of 103 patients (age: M = 22, SD = 1.75), was drawn from the clinical populations of Kosovo. Demographic and socio-economic data was obtained through individual interviews, meanwhile a battery of questionnaires was used to assess negative symptoms, mental health, and quality of life of patients. The 4-class solution was selected as the best fitting model and used in subsequent analyses. Results indicated a significant effect of class membership on health state, quality of life and negative symptoms. Practical implications are discussed.

Clozapine prescription rates in Southeast Europe: A cross-sectional study.

Introduction: International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods: Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results: It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion: Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.

Exploring Black and South Asian women's experiences of help-seeking and engagement in perinatal mental health services in the UK.

Background and aims: In the United Kingdom (UK), Black and South Asian women are less likely than White British women to access support from perinatal mental health services, despite experiencing similar, or higher, levels of distress. This inequality needs to be understood and remedied. The aim of this study was to answer two questions: how do Black and South Asian women experience (1) access to perinatal mental health services and (2) care received from perinatal mental health services? Method: Semi-structured interviews were conducted with Black and South Asian women (n = 37), including four women who were interviewed with an interpreter. Interviews were recorded and transcribed line-by-line. Data were analyzed using framework analysis, by an ethnically diverse multidisciplinary team of clinicians, researchers and people with lived experience of perinatal mental illness. Results: Participants described a complex interplay of factors that impacted on seeking, and receiving help, and benefiting from services. Four themes emerged that captured the highly varied experiences of individuals: (1) Self-identity, social expectations and different attributions of distress deter help-seeking; (2) Hidden and disorganized services impede getting support; (3) The role of curiosity, kindness and flexibility in making women feel heard, accepted and supported by clinicians; (4) A shared cultural background may support or hinder trust and rapport. Conclusion: Women described a wide range of experiences and a complex interplay of factors impacting access to, and experience of, services. Women described services as giving them strength and also leaving them disappointed and confused about where to get help. The main barriers to access were attributions related to mental distress, stigma, mistrust and lack of visibility of services, and organizational gaps in the referral process. These findings describe that many women feel heard, and supported by services, reporting that services provide a high quality of care that was inclusive of diverse experiences and understandings of mental health problems. Transparency around what PMHS are, and what support is available would improve the accessibility of PMHS.

Subjective Quality of Life of Women in the Perinatal Period: A Post Covid-19 Pandemic Exploration in North Macedonia.

Subjective quality of life could be considered one of the indicators of health behavior and wellbeing of women in the perinatal period. Accordingly, the aim of this paper was to examine how women in perinatal period perceive quality of life in various domains. Its relationship to age, number of pregnancies, course of pregnancies, and method of delivery and experience with Covid-19 pandemic was investigated, as well. Our sample consisted of 366 pregnant women in any period of pregnancy who came in for regular outpatient examinations and control, those who were hospitalized due to pathological pregnancy or due to the need for intensive care, as well as women in their postnatal period, one year after delivery, who were seeking professional advice from a gynecologist. The majority were aged 20 to 30 years (53.8%). The findings showed that assessed domains of subjective quality of life were related to a variety of experiences with the Covid-19 pandemic. The results are presented and discussed in detail. Implications and limitations are given, as well.

Job morale of physicians and dentists in Kazakhstan: a qualitative study.

BACKGROUND: Job morale is thought to be particularly low in Kazakhstan, adversely affecting job motivation, job satisfaction and burnout rates. Previous research suggests that high job morale has a better effect on patient outcomes and care quality. We, therefore, conducted a qualitative study to explore experiences underpinning positive and negative job morale, and to generate potential strategies for improving job morale of physicians and dentists working in public healthcare settings in Kazakhstan prior to the COVID-19 pandemic. METHODS: Three focus groups containing 23 participants and 30 individual interviews were conducted, evidencing respondents' explanations of what affects job morale, and possible strategies to improve it. Data was synthesised using a thematic analysis. RESULTS: The themes about what influences job morale were: being unfairly rewarded for work; feeling vulnerable and undervalued; poor working styles and practices; and high internal value-based motivation. Various strategies were identified by participants to improve job morale, and these included: ensuring adequate and equitable financial income; improving the current malpractice system; eliminating poor working styles and practices; and creating a shared responsibility for health. CONCLUSIONS: The current study has found that despite prevailing threats, job morale amongst physicians and dentists working in public healthcare settings in Astana have been prevented from becoming negative by their strong sense of calling to medicine and the satisfaction of helping patients recover. Emphasising this rather traditional understanding of the role of physicians and dentists may be a way to improve job morale throughout training and practice.

Perceived sustainability of psychosocial treatment in low- and middle-income countries in South-Eastern Europe.

BACKGROUND: DIALOG+ is an evidence-based, generic, cost-saving and easily deliverable psychosocial intervention, adaptable to clinicians' personal manner of interaction with patients. It was implemented in mental health services in five low- and middle-income countries in South-Eastern Europe during a 12-month randomised-controlled trial (IMPULSE) to improve the effectiveness of out-patient treatment for people with psychotic disorders. AIMS: To investigate barriers and facilitators to the perceived sustainability of DIALOG+ that has been successfully implemented as a part of the IMPULSE project. METHOD: Three months after the IMPULSE trial's end, perceived sustainability of the DIALOG+ intervention was assessed via a short survey of clinicians and patients who took part in the trial. Quantitative data collected from the survey were analysed using descriptive statistics; content analysis assessed qualitative survey data. The views and experiences of key informants (patients, clinicians and healthcare policy influencers) regarding the sustainability and scale-up of DIALOG+ were further explored through semi-structured interviews. These data were explored using framework analysis. RESULTS: Clinicians mostly appreciated the comprehensiveness of DIALOG+, and patients described DIALOG+ meetings as empowering and motivating. The barrier most commonly identified by key informants was availability of financial resources; the most important facilitators were the clinically relevant structure and comprehensiveness of the DIALOG+ intervention. CONCLUSIONS: Participants showed a willingness to sustain the implementation of DIALOG+. It is important to maintain collaboration with healthcare policy influencers to improve implementation of DIALOG+ across different levels of healthcare systems and ensure availability of resources for implementing psychosocial interventions such as DIALOG+.

Maintenance Therapy of Psychosis Spectrum Disorders in a Real-World Setting: Antipsychotics Prescription Patterns and Long-Term Benzodiazepine Use.

Background: Maintenance therapy of patients with primary psychosis spectrum disorders (PSD) in the Western Balkans has received limited interest so far. The present study aimed to investigate long-term prescription patterns among outpatients with PSD. Methods: Information about prescription of antipsychotics (AP), benzodiazepines (BZD) and other psychotropic medication over a 6-month period was collected from outpatients (n = 134; ICD-10 diagnosis F20-29) recruited by a larger multi-site study, to find mean daily number of psychotropic drugs, AP prescription patterns (including AP daily dose, route of administration, monotherapy vs. polypharmacy) and BZD utilization (long-term add-on BZD therapy). Additionally, sex-differences in the variables were explored. Results: Clinically stable outpatients (age 41.7 ± 11.0; male 62.7%; duration of untreated illness 12.7 ± 8.7 years; mean number of lifetime hospitalizations 2.6 ± 0.7) were prescribed 2.8 ± 1.1 psychotropic medications daily. The mean 6-month AP dose was 14.2 ± 7.8 mg olanzapine equivalents. Long-acting injectable AP was prescribed to 25.2% of the patients. Long-term AP monotherapy was found in 52.7% patients and most of them were prescribed second generation AP (65.2%). Long-term AP polypharmacy (42.7%) was more common in males (p = 0.015). The most frequent co-prescription patterns were first generation AP plus clozapine. The highest rate of long-term AP co-prescription was found for BZD (in 42.7% cases, average 6-months daily dose of 2.8 ± 2.7 mg lorazepam equivalents) and anticholinergics (33.6%). Conclusion: Existing appropriately designed interventions aiming to safely switch the inappropriate therapeutic regimens, i.e. very high prevalence of long-term AP polypharmacy and non-rational BZD co-prescription, should be implemented in the region of Western Balkans.

Corrigendum: Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

[This corrects the article DOI: 10.3389/fpsyt.2021.785144.].

Non-pharmacological interventions for schizophrenia-analysis of treatment guidelines and implementation in 12 Southeast European countries.

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries-Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia-included non-pharmacological interventions. The remaining three countries-Kosovo (UN Resolution), Romania, and Slovenia-have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5-11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

Psychopathology in psychotic disorders: Congruency between self-reported and observer-rated measures highest for affective symptoms and lowest for negative symptoms.

Considering that both observer ratings and patient self-reports on severity of psychopathological symptoms are being used in research and clinical settings, this paper aims to explore the degree of congruence between these two sources. Eighty-two adult outpatients diagnosed with psychotic disorders rated their symptoms using the Brief Symptom Inventory (BSI). Observers assessed patients' functioning using the Brief Psychiatry Rating Scale (BPRS). Self-ratings (overall BSI) were strongly correlated to observers' evaluations (overall BPRS). Anxiety/depression symptoms dimension of the BPRS were significantly associated with all nine symptom dimensions of the BSI, while positive symptoms dimension and unusual and withdrawal behavior in the BPRS showed a significant relationship to seven symptom dimensions as measured with the BSI. Mania/activation in the BPRS was significantly and negatively related only to phobic anxiety in BSI. Eight symptom dimensions of the BSI (interpersonal sensitivity was an exception), as well as unusual and withdrawal behavior and positive symptoms in the BPRS were rated as more severe in unemployed study participants. Self-rated paranoid ideation was higher in less educated participants. No sex or marital status differences were found in the BSI and BPRS dimensions. The obtained pattern of correlations implied that congruence was highest in regards to affective symptomatology, followed by positive symptoms, and lowest for disorganization and withdrawal behavior.

Hospital architecture in times of crisis.

In times of crisis, such as public health emergency, military conflict or natural disaster, health systems face immense pressures. Large-scale crises continue to appear at irregular intervals and healthcare facilities should be prepared to react quickly and flexibly to the increased need for treatment and care. This paper aims to outline key concepts related to healthcare architecture during a mass-scale crisis, discuss challenges, and suggest solutions. Although the field lacks robust research evidence, lessons learned from past and ongoing events clearly indicate that advance planning is essential for effective crisis response. The crisis response has three guiding principles -adaptability, flexibility, and creativity. The interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. A wide range of building typologies can be utilised, including modular containers, tents, lightweight structures, and repurposing civil buildings and public spaces. These interventions must be quick, economic, durable, and easily deployable. Temporary facilities must ensure an effective spatial platform for patients and staff, establish links with existing services, and consider post-crisis life of interventions. While these principles can be considered for any type of healthcare facility and any type of crisis, end-results will depend on baseline infrastructure and available resources.

Physical health of individuals with psychosis - a mixed method study.

People with psychosis have poorer physical health than the general population and this aspect of care delivery has largely been neglected. The IMPULSE trial (ISRCTN 11913964) investigated a psychosocial intervention prompting people with psychosis to discuss their physical health concerns with mental health clinicians. This mixed-method study explored a series of clinical meetings over 6 months to understand how physical health is discussed, what actions are taken, and if these translated into benefits for the participating individuals with psychosis. 221 individuals with psychosis were included, attending 847 clinical meetings over 6 months. Results show that, when prompted, most participants (54%) took up the opportunity to discuss their physical health at least once. These individuals were keen to make changes such as adopt healthy diet, stop smoking, lose weight, etc. Despite taking steps to achieve these goals, after 6 months no improvement was detected in subjective satisfaction with physical health, severity of physical health problems or satisfaction with services. Adopting healthier lifestyle behaviours is difficult even in motivated individuals. Future research is needed to determine innovative approaches to promote lifestyle change in individuals with psychosis.

Factor structure and internal consistency of the Clinical Assessment Interview for Negative Symptoms (CAINS) on a sample of persons with psychotic disorders in Bosnia and Herzegovina.

The assessment of negative symptoms is crucial for development of adequate therapeutic interventions. This is a challenging task due to complex clinical presentation and lack of reliable and valid instruments. This study examined the psychometric characteristics of the Clinical Assessment Interview for Negative Symptoms (CAINS). The sample consisted of 81 persons with schizophrenia or schizoaffective disorder recruited from two health institutions in the Sarajevo Canton: the Clinical Center of the University of Sarajevo and the Psychiatric Hospital of the Sarajevo Canton. The 13 CAINS items grouped into four factors (expression, motivation and satisfaction in the recreational domain, motivation and satisfaction with social relationships, motivation and satisfaction with job and education). The four-factor solution accounted for 87.83% of the variance of manifest items. The reliabilities of extracted factors were as follows: for motivation and satisfaction with social relationships α = 0.897, for motivation and satisfaction with job and education α = 0.961, for Motivation and satisfaction in the recreation domain α = 0.981, and for expression α = 0.938. The highest correlation between factors was found between Motivation and satisfaction with recreation and Motivation and satisfaction with social relationships. On the other hand, the lowest correlation was found between motivation and satisfaction with social relations and motivation and satisfaction with job and education. In conclusion, the study showed that the latent structure of CAINS is adequate, clearly interpretable, and consisted of four factors. The measure can be used for assessment of the negative symptoms in outpatients with psychosis in Bosnia and Herzegovina.

Impact of the hospital built environment on treatment satisfaction of psychiatric in-patients.

BACKGROUND: A hospital built environment can affect patients' treatment satisfaction, which is, in turn, associated with crucial clinical outcomes. However, little research has explored which elements are specifically important for psychiatric in-patients. This study aims to identify which elements of the hospital environment are associated with higher patient satisfaction with psychiatric in-patient care. METHODS: The study was conducted in Italy and the United Kingdom. Data was collected through hospital visits and patient interviews. All hospitals were assessed for general characteristics, aspects specific to psychiatry (patient safety, mixed/single-sex wards, smoking on/off wards), and quality of hospital environment. Patients' treatment satisfaction was assessed using the Client Assessment of Treatment Scale (CAT). Multi-level modelling was used to explore the role of environment in predicting the CAT scores adjusted for age, gender, education, diagnosis, and formal status. RESULTS: The study included 18 psychiatric hospitals (7 in Italy and 11 in the United Kingdom) and 2130 patients. Healthcare systems in these countries share key characteristics (e.g. National Health Service, care organised on a geographical basis) and differ in policy regulation and governance. Two elements were associated with higher patient treatment satisfaction: being hospitalised on a mixed-sex ward (p = 0.003) and the availability of rooms to meet family off wards (p = 0.020). CONCLUSIONS: As hospitals are among the most expensive facilities to build, their design should be guided by research evidence. Two design features can potentially improve patient satisfaction: family rooms off wards and mixed-sex wards. This evidence should be considered when designing or renovating psychiatric facilities.

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey.

BACKGROUND: Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE). OBJECTIVE: To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE. METHODS: An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers. RESULTS: In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia. CONCLUSION: Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

Background: Negative symptoms are core features of schizophrenia and very challenging to be treated. Identification of their structure is crucial to provide a better treatment. Increasing evidence supports the superiority of a five-factor model (alogia, blunted affect, anhedonia, avolition, and asociality as defined by the NMIH-MATRICS Consensus); however, previous data primarily used the Brief Negative Symptoms Scale (BNSS). This study, including a calibration and a cross-validation sample (n = 268 and 257, respectively) of participants with schizophrenia, used the Clinical Assessment Interview for Negative Symptoms (CAINS) to explore the latent structure of negative symptoms and to test theoretical and data-driven (from this study) models of negative symptoms. Methods: Exploratory factor analysis (EFA) was carried out to investigate the structure of negative symptoms based on the CAINS. Confirmatory factor analysis (CFA) tested in a cross-validation sample four competing theoretical (one-factor, two-factor, five-factor, and hierarchical factor) models and two EFA-derived models. Result: None of the theoretical models was confirmed with the CFA. A CAINS-rated model from EFA consisting of five factors (expression, motivation for recreational activities, social activities, vocational, and close/intimate relationships) was an excellent fit to the data (comparative fix index = 0.97, Tucker-Lewis index = 0.96, and root mean square error of approximation = 0.07). Conclusions: This study cannot support recent data on the superiority of the five-factor model defined by the NMIH-MATRICS consensus and suggests that an alternative model might be a better fit. More research to confirm the structure of negative symptoms in schizophrenia, and careful methodological consideration, should be warranted before a definitive model can put forward and shape diagnosis and treatment of schizophrenia.