Proyecto Piloto de Unidad Funcional para Mujeres con Esquizofrenia: Modelo Asistencial de Observatorio-Monitorización-Intervención / Pilot project of a functional unit for women with Schizophrenia: observatory-monitoring-intervention Care model

En los Centros de Salud Mental de Adultos (CSMAs) del Hospital Universitari Mutua Terrassa, en enero de 2023, iniciamos un proyecto piloto de innovación asistencial denominado Unidad Funcional para Mujeres con Esquizofrenia. El objetivo principal de esta comunicación es describir el proceso de designación de las mujeres diana en la unidad, y describir las funciones de los Observatorios de salud física, salud mental y de factores de riesgo psicosocial e inclusión de estas pacientes en los observatorios de salud. De forma complementaria, se describirá el diseño de las Estaciones de Monitorización /Equipos de Vigilancia y las actuaciones o intervenciones específicas centradas en la atención de las necesidades individuales. En la primera fase del proyecto (Enero-Marzo 2023) se revisan las historias clínicas de las mujeres con esquizofrenia para revisar vinculación a profesionales y programas comunitarios. Se describen necesidades de salud física y se revisan antecedentes de consumo de sustancias, uso de benzodiazepinas y opioides, así como aspectos de seguridad farmacológica. En la segunda fase del proyecto (Abril-Junio 2023) se han desarrollado 5 grupos de trabajo (Observatorios de Salud y de Riesgo Psicosocial): 1)Morbi-mortalidad somática, 2)hiperprolactinemia, 3)consumo de sustancias, 4)exclusión social y discriminación, y 5)prescripción y seguridad farmacológica. En la tercera fase del proyecto (Jumio-Septiembre 2023) se desarrollan los Equipos de Vigilancia/Monitorización en Morbi-Mortalidad Somática, hiperprolactinemia, consumo de sustancias, exclusión social/discriminación y seguridad farmacológica, así como intervenciones específicas: colaboración con otras especialidades médicas, consultoría con atención primaria, grupos de ejercicio físico y equipos de intervención en crisis.(AU)

In the context of the Adult Community Mental Health Units (CMHUs) of the Mutua Terrassa University Hospital, we initiated a pilot project of clinical innovation called the Functional Unit for Women with Schizophrenia in January 2023. The main objective of this report is to describe the process of designing a unit targeting women, to characterize the functions of the observatories of Physical Health, Mental Health, and Psychosocial Risk Factors, and to illustrate how these observatories provide surveillance of women’s health needs. The report also describes Monitoring Stations, Vigilance teams, and specific interventions.In the first phase of the project (January - March 2023), medical records from all women with schizophrenia were reviewed to ascertain compliance with clinical appointments and community programs. During this phase, we reviewed physical health records, history of substance use disorders including the use of benzodiazepines and opioid drugs, as well as related aspects of drug safety. In the second phase of the project (April - June 2023), five Observatories of health and social risk factors were developed: 1) somatic morbi-mortality, 2) hyperprolactinemia, 3) use of substances, 4) social exclusion and discrimination, and 5) prescription and drug safety. In the third phase of the project (June-September 2023), we are developing Monitoring Stations or Vigilance teams in these five areas as well as introducing specific interventions: collaboration with primary care and other medical specialties, consultation with primary care teams, physical exercise groups, and crisis intervention units.(AU)

Monitoring the Effectiveness of Treatment in Women with Schizophrenia: New Specialized Cooperative Approaches.

Women with schizophrenia have specific health needs that differ from those of men and that change through successive life stages. We aimed to review the biopsychosocial literature on schizophrenia that addresses clinically important questions related to the treatment of women, including somatic morbi-mortality, hyperprolactinemia, comorbid substance use disorders, social risk factors, and medication effectiveness/safety. Data search terms were as follows: (Morbidity AND mortality) OR hyperprolactinemia OR ("substance use disorders" OR addictions) OR ("social risk factors") OR ("drug safety" OR prescription) AND women AND schizophrenia. A secondary aim was to describe a method of monitoring and interdisciplinary staff strategies. Schizophrenia patients show an increased risk of premature death from cardiovascular/respiratory disease and cancer compared to the general population. The literature suggests that close liaisons with primary care and the introduction of physical exercise groups reduce comorbidity. Various strategies for lowering prolactin levels diminish the negative long-term effects of hyperprolactinemia. Abstinence programs reduce the risk of victimization and trauma in women. Stigma associated with women who have serious psychiatric illness is often linked to reproductive functions. The safety and effectiveness of antipsychotic drug choice and dose differ between men and women and change over a woman's life cycle. Monitoring needs to be multidisciplinary, knowledgeable, and regular.

Schizophrenia: A Review of Social Risk Factors That Affect Women.

Social risk factors are long-term or repeated environmental exposures in childhood and youth that change the brain and may, via epigenetic effects, change gene expression. They thus have the power to initiate or aggravate mental disorders. Because these effects can be mediated via hormonal or immune/inflammatory pathways that differ between men and women, their influence is often sex-specific. The goal of this narrative review is to explore the literature on social risk factors as they affect women with schizophrenia. We searched the PubMed and Scopus databases from 2000 to May 2023 using terms referring to the various social determinants of health in conjunction with "women" and with "schizophrenia". A total of 57 studies fulfilled the inclusion criteria. In the domains of childhood and adult abuse or trauma, victimization, stigma, housing, and socioeconomics, women with schizophrenia showed greater probability than their male peers of suffering negative consequences. Interventions targeting appropriate housing, income support, social and parenting support, protection from abuse, violence, and mothering-directed stigma have, to different degrees, yielded success in reducing stress levels and alleviating the many burdens of schizophrenia in women.

Sleep Disturbances in At-Risk Mental States and First Episode of Psychosis: A Narrative Review on Interventions.

Sleep disturbances are a common yet often overlooked symptom of psychosis that can drastically affect the quality of life and well-being of those living with the condition. Sleep disorders are common in people diagnosed with schizophrenia and have significant negative effects on the clinical course of the illness and the functional outcomes and quality of life of patients. There is a limited number of studies addressing this question in first-episode psychosis (FEP). In this narrative review, we aimed to provide an overview of sleep disorders in populations with FEP and at-risk mental states (ARMS). The review was focused on the various treatments currently used for sleep disorders, including both non-pharmacological and pharmacological treatments. A total of 48 studies were included. We found that sleep disturbances are associated with attenuated psychotic symptoms and other psychopathological symptoms in ARMSs. The association of sleep disturbances with the transition to psychosis has been poorly investigated. Sleep disturbances have an impact on the quality of life and the psychopathological symptoms of people suffering from FEP. The non-pharmacological treatments include cognitive behavioral therapy for insomnia, bright light therapy, cognitive restructuring techniques, sleep restriction therapy, basic sleep hygiene education, and the provision of portable sleep trackers. Other treatments include antipsychotics in acute phases and melatonin. The early intervention in sleep disturbances may improve overall prognosis in emerging psychosis populations.

Critical Issues in the Management of Agitation, Aggression, and End-of-Life in Delusional Disorder: A Mini-Review.

Background: Compared to other psychotic disorders, there is little information about staging care in delusional disorder (DD). Unlike schizophrenia, this is a disorder that begins in middle age, a time at which chronic medical comorbidities have already begun to impact global functioning. With age, the combination of psychological and somatic conditions leads to new behaviours, e.g., agitation, aggression, and behaviours that require specific preventive and interventive measures. With further age, knowledgeable end-of-life care becomes necessary for this population. Aim: The aim of this article was to review existing evidence on the management of these successive phases. Methods: We conducted a narrative review using PubMed and ClinicalTrials.gov and searched for the following terms: (agitation OR aggressivity OR aggression OR palliative OR "end-of-life") AND ("delusional disorder"). Results: We found that the literature was sparse. Existing evidence suggests that medical causes are frequently at the root of agitation and aggression. With respect to management, de-escalation strategies are generally preferred over pharmacotherapy. Specific delusional syndromes, e.g., de Clérambault, Othello, Capgras, Fregoli, as well as folie à deux, are associated with aggression. The somatic subtype of DD is the one most often requiring palliative care at the end of life. Conclusions: We conclude that insufficient attention has been given to the care needs of the accelerated aging process in DD.

Seventy Years of Treating Delusional Disorder with Antipsychotics: A Historical Perspective.

For many decades, delusional disorder (DD) has been considered a treatment-resistant disorder, with antipsychotics acknowledged as the best, though imperfect, treatment. It is possible that the discovery of the right drug could turn treatment resistance into treatment response. The goal of this narrative review is to provide a historical perspective of the treatment of DD since the introduction of antipsychotics 70 years ago. The following search terms were used to scan the literature: antipsychotics AND "delusional disorder". Findings were that therapy for DD symptoms has changed over time. Initial reports suggested that the drug of choice was the antipsychotic pimozide, and that this drug was especially effective for the somatic subtype of DD. Subsequent studies demonstrated that other antipsychotics, for instance, risperidone and olanzapine, were also highly effective. Treatment response may vary according to the presence or absence of specific symptoms, such as cognitive defect and depression. Clozapine, partial D2 agonists, and long-acting injectable drugs may be more effective than other drugs, but the evidence is not yet in. Because of the absence of robust evidence, treatment guidelines for the optimal management of DD are not yet available.

Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders.

BACKGROUND: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. AIMS: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. METHODS: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. RESULTS: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. CONCLUSIONS: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.

Do Sex/Gender and Menopause Influence the Psychopathology and Comorbidity Observed in Delusional Disorders?

Background: While sex differences and gonadal hormone levels are taken seriously in the understanding and treatment of schizophrenia, their influence in the psychopathology of delusional disorders (DD) remains unknown. Methods: Our strategy was to conduct a narrative review of the effects of (a) sex/gender difference and (b) menopause on delusional content, affective and anxiety-related comorbidity, substance use disorders, cognition, aggressivity, and suicide risk in DD. Results: Because the literature is scarce, our results are tentative. We found that erotomania was more prevalent in women than in men, and especially in women with premenopausal onset. In contrast, jealous and somatic delusions were more commonly seen in DD women with postmenopausal onset. With respect to depressive comorbidity, women with premenopausal onset appear more vulnerable to depression than those with later onset. Age at menopause is reported to correlate positively with intensity of suicidal ideation. Anxiety symptoms may be related to estrogen levels. Men present with higher rates of substance use disorders, particularly alcohol use. Conclusions: Many male/female differences in DD may be attributable to sociocultural factors but menopause, and, therefore, levels of female hormones, influence symptom expression in women and mediate the expression of psychiatric comorbidities. Further research in this area promises to lead to improved individualized treatment.

Delusional Disorder in Old Age: A Hypothesis-Driven Review of Recent Work Focusing on Epidemiology, Clinical Aspects, and Outcomes.

The theme, strength, and duration of a delusion are considered important in distinguishing one psychosis of old age from another. Research results, however, are mostly based on studies conducted on one form of psychosis, namely schizophrenia. The aim of this hypothesis-driven narrative review is to gather clinically important information about the psychosis identified as delusional disorder (DD), as it affects persons of senior age. We hypothesized that DD becomes relatively prevalent in old age, especially in women; and that it is associated with demonstrable brain changes, which, in turn, are associated with cognitive defects and poor pharmacological response, thus increasing the risk of aggression and suicide. Computerized searches in PubMed and ClinicalTrials.gov were conducted using the following search terms: (delusional disorder) AND (elderly OR old OR aged OR psychogeriatrics). A total of 16 recent studies (including case reports) were reviewed. Our hypotheses could not be definitively confirmed because research evidence is lacking. In order to improve eventual outcomes, our literature search demonstrates the need for more targeted, well-designed studies.

Hormone Targets for the Treatment of Sleep Disorders in Postmenopausal Women with Schizophrenia: A Narrative Review.

While the early identification of insomnia in patients with schizophrenia is of clinical relevance, the use of specific compounds to treat insomnia has been studied less in postmenopausal women with schizophrenia. We aimed to explore the effects of melatonin, sex hormones, and raloxifene for the treatment of insomnia in these populations. Although melatonin treatment improved the quality and efficiency of the sleep of patients with schizophrenia, few studies have explored its use in postmenopausal women with schizophrenia. The estrogen and progesterone pathways are dysregulated in major psychiatric disorders, such as in schizophrenia. While, in the context of menopause, a high testosterone-to-estradiol ratio is associated with higher frequencies of depressive symptoms, the effects of estradiol and other sex hormones on sleep disorders in postmenopausal women with schizophrenia has not been sufficiently investigated. Raloxifene, a selective estrogen receptor modulator, has shown positive effects on sleep disorders in postmenopausal women. Future studies should investigate the effectiveness of hormonal compounds on insomnia in postmenopausal women with schizophrenia.