Association of Childhood Trauma and Personality Dimensions with the Duration of Untreated Psychosis.

BACKGROUND: Understanding causes and consequences of untreated psychosis is important since the duration of psychosis prior to the treatment initiation is a potentially modifiable prognostic factor, and comprehending its impact on outcome may enhance therapeutic strategies. SUBJECTS AND METHODS: This cross-sectional study was performed on a consecutive sample of 105 participants, 47 first episode participants and 58 with multiple episodes. Primary outcome was the duration of untreated psychosis (DUP). We observed three independent variables: childhood trauma measured by Childhood Trauma Questionnaire, psychotic symptoms measured by Positive and Negative Syndrome Scale (PANSS) and personality dimensions measured by the Inventory of Personality Organization (IPO) (primitive defences, identity diffusion and reality testing). All outcomes were observed among total sample and subgroups of first and multiple episode participants. RESULTS: Median DUP in total sample was 60.0 (IQR 14.5-285) days. In the subgroup of multiple episode participants, an association between multiple childhood trauma and shorter DUP was found, while no association between DUP and the existence of any specific trauma was found in neither subgroup, or in total sample. With regards to personality dimensions, in the first episode subgroup, significant positive correlations between DUP and primitive defences and reality testing subscales were found, while no correlations in total sample, nor in multiple episode subgroup were observed. Positive symptoms and general psychopathology correlated positively with DUP in total sample, and in first episode subgroup, while in multiple episodes subgroup only a positive correlation with positive symptoms was found. Total PANSS score positively correlated with the DUP only in the first episode subgroup. CONCLUSIONS: DUP was not associated with specific type of childhood trauma. First episode participants with longer DUP had predominant primitive defences and severely decreased ability to test reality, while there were no correlations between personality dimensions and DUP in multiple episode subgroup.

Telepsychiatry in the Time of the COVID-19 and Earthquake in Zagreb as Odysseus between Scylla and Charybdis.

In this paper we would like to reveal some of the many challenges during the time of the twofold simultaneous trauma; the COVID-19 pandemic and the devastating earthquake in Zagreb. We described the functioning mode of two Day Hospitals for Early Intervention and Psychotic Disorders at Psychiatric Hospital "Sveti Ivan" during the outbreak of the COVID-19 pandemic. We tried to find ways to ensure the necessary continuation of treatment and to provide continuity in times of uncertainty. The vulnerable group of people treated for mental illnesses faced exceptional psychological demands and was in need for care in these moments. Telemedicine, more specifically telepsychiatry, through online therapy and telephone communication made it possible for people treated for psychotic disorders not to feel isolated and rejected. Health care professionals, in a state of distress themselves, should understand, support, be able to reduce anxiety, and provide stability and constancy. The psychotherapeutic approach and the capacity for mentalization allowed us to turn challenges into opportunities. Rapid changes without delay extended our scope of practice in these extraordinarily difficult times.

Clinical Challenges in Patients with First Episode Psychosis and Cannabis Use: Mini-Review and a Case Study.

The influence of cannabis use on the occurrence, clinical course and the treatment of the first psychotic episode (FEP) is well documented. However, the exact link is still not clearly established. The aim of this article is to review and report the noticed increase in the number of hospitalizations of young people with a clinical appearance of severe psychotic decompensation following cannabis consumption and to show the clinical challenges in treatment of the FEP. The case study describes the clinical course of a five selected patients with a diagnosis of the FEP and positive tetrahydrocannabinol (THC) urine test who were hospitalized in a similar pattern of events. They all have a history of cannabis consumption for at least 6 years in continuity and were presented with severe psychomotor agitation, disorganisation, confusion and aggression at admission. Although the chosen drug to treat all patients was atypical antipsychotic and benzodiazepines, the course of the disorder and the clinical response to therapy were noticeably different in each patient. The clinical presentation of FEP in cannabis users can be atypical and highly unpredictable from mild psychotic symptoms to severe substance intoxication delirium. In clinical practice clinicians treating new onset psychosis need to be watchful for cannabis and synthetic cannabinoids induced psychosis. Pharmacotherapeutic interventions include prompt and adequate use of the benzodiazepine, second-generation antipsychotic, and mood-stabilizers. Further research in the pharmacotherapy of cannabis-induced psychosis is required.

Efficacy of Center for Integrative Psychiatry Multimodal Early Intervention Services in Early-Phase Psychosis on Hospital Readmission.

BACKGROUND: Growing body of evidence has opened new opportunities to enhance treatment outcomes during early-phase psychosis (EPP). The objective of this study was to evaluate the effect of the Centre for integrative psychiatry (CIP) multimodal Early Intervention Services (EIS) on time to relapse in the patients with early-phase psychosis (EPP) during 12 and 24 month period. SUBJECTS AND METHODS: We performed a retrospective cohort study on the sample of 454 EPP patients (duration of the diagnosed disorder ≤5 years) admitted to Psychiatric Hospital "Sveti Ivan", Zagreb Croatia, from January 2, 2015, to December 5, 2018, for the acute treatment of EPP. The end of follow up was March 5, 2019. The primary outcome was the time to rehospitalization because of relapse during the 12 months from the hospital discharge. Independent variable was the EIS. RESULTS: We analyzed 454 EPP patients, 260 in EIS group and 194 in no EIS group. After the adjustment for twenty possible confounding factors using the Cox proportional hazard regression, patients who received EIS had significantly and clinically relevantly lower hazard for rehospitalization because of relapse during the first 12 months (HR=0.39; CI95% 0.21-0.61; p<0.001), and during the first 24 months from the hospital discharge (HR=0.56; CI95% 0.39-0.80; p=0.003; sequential Holm-Bonferroni corrected pcorr=0.004). CONCLUSIONS: Our study indicated efficacy of the CIP multimodal EIS in patients with EPP demonstrated through the time to the hospital readmission because of relapse during the 12 and 24 months from the hospital discharge. These results strongly support the need for implementation of multimodal EIS in all patients with EPP.

Improving the quality of life during treatment in the Day hospital for early intervention in Psychiatric Hospital "Sveti Ivan".

BACKGROUND: The Day hospital for early intervention is a time-limited structured therapeutic program based on different psychotherapy and socio-therapy techniques. The aim of this study was to examine the outcomes of the Day hospital treatment for early intervention on self-esteem, and quality of life, and to determine which patients benefit the most from the program. SUBJECTS AND METHODS: The study was conducted on 124 patients with an early phase of psychosis who were treated at the Day hospital. They filled out Rosenberg Self-Esteem Scale, and WHOQOL-BREF upon the admission and again after three months of the treatment. Interaction effects were examined between their sociodemographic characteristics (gender, age, employment status), clinical features (first episode of psychosis or longer duration of illness), and results on applied questionnaires. RESULTS: After three months of the treatment, patients evaluated their self-esteem, overall quality of life and satisfaction with different QoL domains (physical and psychological health, environment) as significantly improved. Younger patients had greater increase in estimated self-esteem compared to older patients. No other significant interactions were found. CONCLUSION: Notwithstanding the limitations of this study, we may conclude that the findings are encouraging and may assist with development of more effective therapeutic approaches.

Early Intervention Services for Early-Phase Psychosis - Centre for integrative psychiatry in Psychiatric Hospital "Sveti Ivan", Croatia.

BACKGROUND: There is a growing body of evidence suggesting that early and effective management in the critical early years of schizophrenia can improve long-term outcomes. The objective of this study was to evaluate time to relapse of the patients with early-phase psychosis treated in the Centre for integrative psychiatry (CIP). SUBJECT AND METHODS: We performed a retrospective cohort study on the sample of 373 early-phase psychosis patients admitted to Psychiatric Hospital "Sveti Ivan", Zagreb Croatia: from January 1, 2015 to December 31, 2017. The primary outcome was time to relapse. RESULTS: Patients who were admitted to group psychotherapeutic program after the end of acute treatment had 70% lower hazard for relapse (HR=0.30; 95% CI 0.16-0.58). Patients who were included first in the psychotherapeutic program and then treated and controlled in the daily hospital had 74% lower hazard for relapse (HR=0.26; 95% CI 0.10-0.67). CONCLUSIONS: In early-phase psychosis, integrative early intervention service has relevant beneficial effects compare to treatment as usual. These results justified the implementation of multimodal early intervention services in treatment of patients with early-phase psychosis.

Day hospital for early intervention for individuals with psychotic disorders.

In long-term outcome studies on individuals with first-episode psychosis, improved remission and recovery rates perhaps reflect the improved treatment in dedicated early intervention program. The first episode is a critical period in which individuals with psychosis, as well as members of their families, are confronted with the illness for the first time. Until nowadays, treatment of first psychotic episodes in Croatia has usually been provided in hospital setting. The day hospital provides comprehensive therapeutic approach that refers to early systematic application of all available and effective therapeutic methods in the initial phases of psychotic disorders, and aims to attain and maintain remission and recovery, as well as insight and adherence to treatment. The day hospital is a time-limited structured program that comprises diagnostic procedures, treatment and rehabilitation based on various group psychotherapy and socio-therapy approaches. It is cheaper than hospital treatment and preferred by patients and their families. The importance of involving family members along with patients in the therapeutic process is recognized. The aim of this paper is to present the first day hospital for early intervention and treatment of individuals with psychotic disorder, established within Psychiatric hospital "Sveti Ivan", Zagreb, Croatia.

Treatment of patients in early phase of psychosis on psychotherapeutic inpatient unit - presentation of the therapeutic programme and evaluation of some aspects.

BACKGROUND: Treatment of early phase of psychosis is important not only for overcoming the acute symptoms but also for the later treatment and attitude towards the illness. Psychotherapeutic approach is an integrative part of this treatment. In Psychiatric hospital "Sveti Ivan" in Zagreb, Croatia both psychotherapeutic and sociotherapeutic methods are used on the inpatient unit for young people with psychosis along with medications. The aim of this work is to present the work on the psychotherapeutic inpatient unit and to investigate whether during the hospitalisation of individuals with first psychotic episode changes occur in attitudes towards medications, quality of life, insight and self-esteem. SUBJECTS AND METHODS: 37 individuals with first psychotic episode (20 men, 17 women) completed the following battery of questionnaires upon hospital admission and before discharge: Drug attitude inventory (DAI-10), The World Health Organization Quality of Life (WHOQOL), Insight scale and Rosenberg's Self-Esteem Scale. RESULTS: Before being discharged from hospital, patients assessed their quality of life as significantly improved over time (p=0.000), especially concerning their physical health (p=0.004), psychological health (p=0.004), and satisfaction with their environment (p=0.001). Also, positive trends were observed in attitudes towards drugs and self-esteem. No changes were shown regarding patients' insight. CONCLUSIONS: The findings are encouraging: during treatment on psychotherapeutic inpatient unit, significant improvement in quality of life was observed, as well as positive trends in self-esteem and attitudes towards medications.

Somatic comorbidities are independently associated with the poor health-related quality of life in psychiatric patients.

BACKGROUND: Despite the increased risk, the quality of somatic healthcare is lower for patients with mental illnesses. Currently dominant approach separates physical and mental, primary and secondary healthcare. Objective of our study was to explore whether somatic comorbidities are associated with a poor HRQoL independently of some sociodemographic and clinical factors. Majority of studies have explored particular somatic and psychiatric illnesses. Therefore we decided to access the problem from the general perspective of the universe of somatic and mental illnesses in the large psychiatric institution. SUBJECTS AND METHODS: This nested cross-sectional study was done during May 2016 at Psychiatric hospital Sveti Ivan, Zagreb, Croatia on the sample of 506 patients diagnosed with psychiatric illnesses (ICD-10: F00-F99). Key outcome was the lowest 25% results on the SF-36 General health sub-scale, indicating the worst HRQoL. Predictors were all detected somatic illnesses. By multivariate logistic regression we controlled different sociodemographic, vital and clinical factors. RESULTS: After adjustment for different sociodemographic and clinical factors, three somatic comorbidities remained independently associated with the worst HRQoL: endocrine, nutritional and metabolic diseases (E00-E90), diseases of respiratory system (J00-J99) and diseases of musculoskeletal system and connective tissue (M00-M99) CONCLUSIONS: Somatic comorbidities in psychiatric patients are associated with the poor HRQoL independently of different sociodemographic, vital and clinical factors and they should be treated seriously and integrally with mental aspects of HRQoL. Early comorbidities detection and adequate pharmacological and psychotherapeutic treatment, as well as the prevention of risk factors, may improve the quality of life and reduce morbidity and mortality of psychiatric patients.

Association between psychopathology and suicidal behavior in schizophrenia. A cross-sectional study of 509 participants.

BACKGROUND: Suicide in schizophrenia is a serious problem--ideation rates go up to 40%, and approximately one half of patients attempt suicide at least once. The distinction between attempters and ideators is vital in everyday clinical practice. AIM: To explore the association between psychopathology and suicidal behavior in a comparative study of three groups of patients with schizophrenia: suicide ideators, suicide attempters, and subjects without suicide ideation and behavior. METHOD: The study included 509 patients: suicide attempters (n = 159), ideators (n = 180), and a comparative group (n = 170). The clinical assessment consisted of a structured psychiatric interview and an evaluation of sociodemographics, suicidality (SIBQ), psychopathology (PANSS), and depression (CDSS). RESULTS: Suicide attempters were more depressed than ideators, and both groups had higher CDSS scores than the comparative group. The overall contribution of positive, negative, and general PANSS symptoms was not statistically significant enough to differentiate ideators from attempters. A principal component analysis of the PANSS items revealed five components: disinhibition, withdrawal, anxiety and guilt, reality distortion, and disorganization. Two logistic regression analyses showed that suicide ideation or attempt was significantly related to depression, anxiety, guilt, gender, age, and number of previous hospitalizations. Compared to suicide ideators, attempters were more depressed, had a higher number of previous hospitalizations, and lower education. CONCLUSION: The results indicate that clinicians should look for depression, anxiety, and guilt feelings, while positive and negative symptoms seem to be less relevant for suicide assessment in schizophrenia.