Assessing the Trajectory of Bipolar Disorder Effectively in Order to Treat Effectively.

Accurate diagnosis of mood disorders, particularly depression and bipolar disorder, is essential for effective treatment planning and patient management. This article emphasizes the need for systematic symptom assessment and longitudinal analysis in facilitating the precise diagnosis and planning appropriate treatment interventions. By meticulously evaluating the symptomatology and delineating the longitudinal trajectory of the illness, clinicians can distinguish between unipolar depression and bipolar disorder, and therefore optimise patient outcomes. The article describes the inherent complexities in diagnosing mood disorders. It describes the overlapping symptomatology and diagnostic challenges. Through a comprehensive review of literature and clinical insights, it argues for a structured approach to symptom assessment, focusing on both the current presentation and also retrospective evaluation of illness progression. By elucidating the longitudinal trajectory of the illness, including the presence of episodes of high mood suggestive of bipolar disorder, clinicians can differentiate between mood disorders accurately. The article discusses the implications of accurate diagnosis on treatment planning and patient prognosis. A precise diagnosis enables clinicians to plan treatment strategies to the specific needs of the individual, including pharmacotherapy, psychotherapy, or both. By addressing the underlying mechanisms and trajectory of the illness, clinicians can implement targeted interventions which reduce the risk of misdiagnosis and which optimize therapeutic outcomes.

Assessing the Trajectory of Schizophrenia Effectively in Order to Treat Effectively.

INTRODUCTION: Schizophrenia is a complex psychiatric disorder characterized by heterogeneous symptom trajectories that significantly impact patient outcomes. We believe that the study of the trajectories of Schizophrenia is useful in assessing treatment options and outcomes. While the Positive and Negative Syndrome scale is usually used on one occasion to measure symptoms at a single time, if measured repeatedly , the PANSS is also useful in measuring trajectories. In order to illustrate and promote this serial use, we have reviewed papers which describe the delineation of Trajectories of Symptoms in Schizophrenia based on PANSS scores. This review integrates findings from longitudinal studies focusing on the trajectories of positive symptoms, negative symptoms, the relation between positive and negative symptoms and cognition, soft neurological signs, and treatment response in schizophrenia. METHODS: Studies were identified from the PUBMED database .Studies included in this review employed diverse methodologies such as trajectory analyses, longitudinal assessments, and clinical trials. Data were extracted from a range of patient cohorts, including those with first-episode psychosis and chronic schizophrenia. RESULTS: Longitudinal studies consistently demonstrate variability in the trajectories of positive symptoms, with most patients experiencing early stable remission, though a subgroup exhibits persistent or fluctuating symptomatology. Negative symptoms, on the other hand, often show poor improvement over time, correlating with impaired social and neurocognitive functioning. Cognitive deficits also vary, with some domains showing improvement while others, such as logical memory, deteriorate in certain patient subgroups. The relationship between positive and negative symptom trajectories highlights their complex relationship, influencing overall functioning and treatment outcomes. Antipsychotic medications demonstrate varied responses across patient cohorts, with distinct trajectory patterns observed based on medication type and patient-specific factors such as co-morbid substance abuse and duration of untreated psychosis. CONCLUSION: Understanding the longitudinal trajectories of symptoms in schizophrenia is crucial for optimizing therapeutic strategies and improving patient outcomes. Personalised interventions tailored to individual symptom profiles and early clinical responses are recommended to enhance treatment efficacy and promote recovery. The PANSS scale can be used to delineate Trajectories of various symptom Groups in Schizophrenia.

The Concept of Staging in Schizophrenia; 13 Years After the 'Agius Concept of Staging' Was Published.

We review the development of clinical staging models of schizophrenia, which has developed as a logical extension of the Neuro-developmental theory of Schizophrenia. The staging approach, which involves assessing a disorder based on its severity, scope, progression, and characteristics, is gaining growing recognition in the fields of clinical psychology and psychiatry. We review the development of clinical staging models of schizophrenia, which has developed as a logical extension of the Neuro-developmental theory of Schizophrenia. The development of these clinical staging models should be based also on the neuroimaging dana, since this implies actual changes within the brain. There still are some difficulties with these models, but they are gradually providing both more logical ways of understanding the development of psychotic illness and more effective ways of treatment. The Models have contributed to research in several areas of psychiatry.

Audio-visual Technology and Its Impact on Mental Wellbeing.

Audio-visual technology can have a significant impact on a person's metal wellbeing to the extent that research shows that it can cause structural brain changes. In this paper we explore some of the associations between this technology and mental wellbeing. Audio-visual technology can help in fulfilling the need of human beings for connectedness, but it can be doing this inadequately. It is saturating the brain with information, and can lead to misinformation, misinterpretation, misrepresentation of such information. The impact of the media platforms on the mental wellbeing of their audience relies on an interaction between the platform and the viewer. We explore how this impact can be influenced by the viewer's age or psychiatric conditions. We advocate that if the right balance of utilisation of television and social media platforms is found, they can be a positive and crucial part of society's lifestyle.

A Prospective Study of Short-term Outcomes of a Residential Programme for the Morbidly Obese in Malta.

Obesity is a worldwide problem, and Malta is no exception. In Malta, a Foundation was established to address weight problems amongst the population, and this initiative included the opening in 2014 of an 8-week residential programme for morbidly obese patients. This multidisciplinary programme is managed and coordinated by a team consisting of doctors, psychiatrists, nurses, physiotherapist, psychologists, dietitian, nutritionists and occupational therapists. This team guides residents towards adopting a healthier lifestyle, rather than focusing solely on food intake. In this study, the first 163 residents admitted to the programme, (65 males and 98 females), were assessed at the point of admission and discharge against several physical parameters. The effectiveness of the programme in the short term was validated since at the point of discharge these patients had a statistically significant reduction in weight, BMI, cholesterol levels, glucose levels and HBA1C. They were also more mobile, and this difference was also statistically significant.

Epidemiology of Serious Mental Illness in Malta - Consequences for developing a new psychiatric hospital and community psychiatry.

Mental Health Services in Malta are presently at crossroads, because they are in the stage of increasing and strengthening the community services and considering closing the main psychiatric inpatient facility and replacing it with a new hospital. For proper planning of such changes, and ideal approach is that of basing these plans on results of population based epidemiological findings on rate of mental illness and required care. Such studies are strongly recommended, and this approach has already been used in Malta a couple of years ago prior to establishing inpatient care for Eating Disorders. In absence of such studies, this paper proposes ways how to use findings from available research and data to use as basis for such proper service plans.

Stigma in Malta; A Mediterranean Perspective.

The aim of this paper to describe what Transcultural Psychiatry is. It attempts to describe stigma in Malta and how it comes about that the Mental Hospital in Malta is named for Our Lady of Mount Carmel and finally attempt to put Mount Carmel Hospital and its dedication within Maltese Culture and the culture of the Mediterranean. The paper demonstrates that to understand this, it is necessary to employ History, Anthropology, Theology, among other issues. Doing this also suggests that Malta has undergone a process of 'normalisation' regarding treatment of Mental Health Problems.

A National Snapshot of Substance Misuse among Child and Adolescent Psychiatric Inpatients in Malta.

This paper reports on a patient record survey that was undertaken with the central aim of establishing reliable, baseline information to inform strategic planning and organisation of future CAMHS in Malta. The records of the total population of children and adolescents admitted into the psychatric hospital over a five year period were surveyed. Results showed that the characteristics and circumstances of children and adolescents with mental disorder and comorbid substance misuse in Malta are similar to those described in international studies. The survey emphasised the pressing need for further research into this sub group and also highlighted gaps in reliable data systems locally.

'Dar Kenn Ghal Sahhtek'--an eating disorder and obesity service in Malta.

This paper will describe the incidence of eating disorders, with particular focus on obesity and binge eating, within the Island of Malta. The development of and 'Dar Kenn Ghal Sahhtek', the first centre for eating disorders in Malta will then be recounted, and the effective therapeutic interventions provided in it will be described. One important function of this unit is the treatment of excessive obesity. Some epidemiological data on the Obese Patients in DKS, relating to the incidence of Binge Eating Disorder in the DKS patient group will be given. This data was collected during a collaboritive research project between the Psychiatry Department of Cambridge University and 'Dar Kenn Ghal Sahhtek'.

The multidisciplinary approach to mood disorders.

This article outlines the use of the multidisciplinary approach to mood disorders in the Short Stay Psychiatric Unit (SSPU) in Mater Dei Hospital, Msida, Malta. An audit was carried out on all patients whose first admission to SSPU was in 2008 and who were diagnosed with having a mood disorder. The aim was to see whether the use of a multidisciplinary approach is in actual fact affecting patient outcome or not. The latter was measured by recording whether the patients needed any further admission and if this was the case, the length in days leading to their 2nd admission.

Eating disorders in Malta.

In the beginning of 2014 a new service (residential and non residential) for eating disorders is being planned to open in Malta. A telephone based survey was conducted between 30 May and 11 June 2012. A randomized sample of 6000 of the population between 15 and 50 years old was chosen. 2.9 per cent of respondents have suffered from an eating disorder at some point in time. 2.0 percent of these had suffered from an eating disorder in the past, while the remaining (0.9 per cent) were suffering from an eating disorder at the time of study. Out of these 2,008 individuals participated in the study. Binge Eating was the most common eating disorder, with 55.8 per cent of respondents having this condition, followed by Anorexia (34.3 per cent) and Bulimia (13.3 per cent). These results were comparable to those of other European countries. Awareness of these conditions in the general population was generally good, higher in females and in those with a higher educational level.

The mental health of newly graduated doctors in Malta.

BACKGROUND: Several studies have shown high rates of psychiatric morbidity in young doctors at various stages of their training (Paice, et al. 2002, Levine et al. 2006). Migration is also known to have an impact on emotional wellbeing (Bhugra 2004). Foreign doctors in Malta now make up over 30% of the junior doctor cohort. This is a new situation for trainers here.This study was carried out in part fulfillment of the requirements for the completion of Specialist Training in Psychiatry in Malta. This article focuses on the first part of the study: the quantitative analysis aimed to answer the following questions: 1. What are the rates of mental health problems amongst recently qualified doctors? 2. What are the factors associated with the increased rates of mental distress? SUBJECTS AND METHODS: A quantitative cross-sectional analysis was carried out by means of self-report questionnaire including demographic details and the General Health Questionnaire-28 (GHQ-28) (Goldberg 1972). This study was approved by the Health Ethics Committee (HEC23/12). RESULTS: 117 (78.5%) of junior doctors participated in this study. 70.9% were Maltese. 49.4% were found to have GHQ-28 scores of more than 6, indicating significant psychological distress. Further analyses revealed that lack of leisure time (p<0.001), uncertainty (p=0.009), migration (p=0.03) and being female (p=0.04) were significantly related to caseness. CONCLUSION: As trainers and supervisors in medical education, it is important to be aware of the difficulties that young doctors face. These may include psychological distress, significant enough to reach caseness. Lack of leisure time seems to be an important factor which is possibly an area that can be easily tackled.

A Retrospective Longitudinal Analysis of Mental Health Admissions: Measuring the Fallout of the Pandemic.

BACKGROUND: In this research article, we review the infrequently considered long-term impact of the pandemic on inpatient mental health, by reviewing the clinical parameters of all psychiatric admissions to Mount Carmel Hospital, our region's main psychiatric healthcare facility, from 2019-2021. METHODS: 4292 patients were admitted during the research period of this retrospective longitudinal analysis. Taking 2019 as the pre-COVID reference year, we compared mean monthly admissions from 2020 and 2021, looking at patient demographics, status under the Mental Health Act, diagnosis, and self-injurious behaviour. RESULTS: While the pandemic was reflected in a moderate increase in mean monthly presentations with suicidal ideation and suicidal self-injury, presentations in 2020 otherwise remained largely stable. This contrasted with a surge in presentations in 2021 with mood disorders, schizophrenia, anxiety, personality disorders, and autism spectrum disorders. Furthermore, presentations involving self-injurious behaviour continued to grow. Involuntary admissions also increased significantly in 2021. CONCLUSIONS: This paper highlights the pernicious long-term impact of the pandemic on mental health presentations, demonstrated by an increase in hospital admissions and more serious presentations. These findings should be considered in the guidance for responses to any future pandemic, giving attention to the evidence of the impact of restrictive measures on mental health.

The interplay between pharmacogenetics, concomitant drugs and blood levels of amitriptyline and its main metabolites.

Background: The research considers the impact of genotype-inferred variability on blood levels of amitriptyline and its main metabolites, as may be moderated by phenocopying. Patients & methods:CYP2D6 and CYP2C19 genotypes, and serum concentrations of amitriptyline, nortriptyline and hydroxymetabolites, were determined in 33 outpatients. Co-medications were reviewed to identify CYP inhibition risk. Results: CYP2C19 metabolizer status explained interpatient variation in nortriptyline to amitriptyline concentration ratios. The hydroxymetabolite to parent ratios increased with higher CYP2D6 activity scores and lower CYP2D6 inhibition risk. In patients at high CYP2D6 inhibition risk, the amitriptyline + nortriptyline concentration was, on average, 52% above the higher end of expected ranges. Conclusion: Practical construal of pharmacogenetics and drug interactions tantamount to aberrant metabolism can facilitate patient-tailored use of the established drug.

Amitriptyline is an established drug in managing depression and neuropathic pain. Body exposure to amitriptyline and its by-products is influenced by enzymes activities, which are subject to genetic variation, whereas other medications in a patient's treatment regimen may alter drug breakdown. To study these implications, genetic testing was conducted in 33 outpatients on amitriptyline therapy, alongside measurement of drug concentrations in blood and consideration of any co-administered medications. Breakdown of amitriptyline to nortriptyline was associated with the genetically determined status of patients. Subjects at high risk of having their rate for further breakdown delayed by other drugs had higher blood levels than expected in normal cases. A proportion of variation observed in blood drug concentrations across individuals with same genetic results could be explained by actions of drugs received concurrently. Supportive evidence is provided on the integration of drug interaction information with insights from genetic testing for patient-tailored pharmacotherapy that attempts to mitigate the possibility of missing an intended benefit or the risk of adverse events due to altered blood levels.

Developing the 2020-2030 mental health strategy for Malta: Addressing the needs of a small island state undergoing rapid socioeconomic transition.

Malta has embarked on a renewed national endeavour to reform the mental health sector, prioritising mental health in the context of the national health strategy post 2020. Past attempts at reforming this sector were stifled due to insufficient and unsustained political commitment, leaving it direly under-resourced. An interplay of factors over recent years has rekindled political and public interest in mental health. These include: the establishment of a mental health commissioner; indictment from a National Audit Office report; and coordinated public pressure from local media, non-governmental organisations and professionals. Government responded by publishing a mental health strategy to address both long-standing and new challenges arising from rapid socioeconomic changes which have put further strain on an already overstretched system, demanding urgent action. The concept of strengthening resilience is put forward as a central tenet in the strategy and a combination of initiatives were proposed for the prevention of mental illness, investment in physical and human resources and the creation of a new service framework. Successful implementation of this strategy is dependent on continued political commitment, visible leadership, ongoing investment commitment, and meaningful engagement by key stakeholders. Ongoing stakeholder advocacy appears to be crucial to ensure that mental health continues to be considered as a national priority.

Effect of COVID-19 pandemic on mental health hospital admissions: comparative population-based study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) global pandemic caused mental health services to be downscaled to abide by the public health restrictions issued. AIMS: The aim of this study was to investigate whether the pandemic and resultant restrictions had an impact on Malta's admissions to hospital for mental health issues by assessing the number and nature of psychiatric admissions to our only national mental health hospital. METHOD: Data collection was carried out retrospectively for the 13-week period between 7 March 2020 and 4 June 2020, compared with the equivalent in 2019. Demographic data was obtained and descriptive statistical analysis through the use of the χ²-test, z-test and logistic regression model were used to compare both data-sets, using a P-value of 0.05. RESULTS: An overall reduction in admissions to hospital was noted in 2020 when compared with 2019, recorded to be lowest in March 2020 with a steady acceleration of admissions up until May 2020 (χ2(3) = 22.573, P < 0.001). This coincided with a decelerated rate of positive COVID-19 cases locally. In 2020, there were significantly higher female admissions (χ2(1) = 10.197, P < 0.001), increased presentations of self-harm/suicidal ideation (P < 0.001) and higher involuntary admissions using the Mental Health Act (χ2(1) = 4.904, P = 0.027). The logistic regression model identified total length of stay in hospital, primary mental health diagnosis, gender and month of admission as variables significantly associated with an admission. CONCLUSIONS: Our first population-wide study confirms that the COVID-19 pandemic and subsequent public health restrictions had an impact on the population's hospital admissions for mental health issues.

WITHDRAWN: The way in which COVID-19 changed behaviour on social media in Malta.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Evidence That the Urban Environment Moderates the Level of Familial Clustering of Positive Psychotic Symptoms.

If the shared familial risk factors that predispose to psychotic disorder interact with early-life exposures in the urban environment, familial correlations of psychosis proneness measures should be higher in the exposed environment. We tested the hypothesis that in sib-pairs with one member affected by psychotic disorder, the familial correlation of psychotic experiences, but not depression, negative symptoms, or intelligence quotient (IQ), would be higher if the nonaffected sibling was raised in an urban environment until age 15 years. The sample analyzed consisted of 959 sib-pairs of whom one was affected with psychotic disorder. Lifetime self-reported psychotic and depressive experiences were measured using the self-reported "Community Assessment of Psychic Experiences" (CAPE). In the unadjusted model of the sibling-patient association in CAPE positive symptoms, there was a significant interaction by urban environment (B interaction = 0.079, 95% CI: 0.021 to 0.137, P = .007, n = 828). Stratified analyses revealed a strong sib-pair association in the urban environment (B = 0.077, 95% CI: 0.037 to 0.117, P < .001) and absence of association in the rural environment (B = −0.002, 95% CI: −0.044 to 0.039, P = .920). Associations were not affected after taking into account confounders and outliers, and there was no evidence that sibling associations in IQ, depression, or negative symptoms were moderated by the urban environment. The results agree with previous work indicating that the effects of the genetic and environmental factors that occasion familial clustering of psychotic disorder depend on whether or not an individual spends his early life in an urban environment.

The mental health services for detained asylum seekers in Malta.

Approximately 17 000 individuals have claimed asylum in Malta over the past 10 years. Maltese law stipulates mandatory detention. Here, we review Malta's asylum procedures and detention policy, and explore the impact of detention on mental health. We review the current mental health services and make recommendations to help fill the gaps.

Cannabis use and outcome of recent onset psychosis.

PURPOSE: To test the hypothesis that recent onset psychotic patients who use cannabis will have psychotic symptoms that are more severe and more persistent than those who do not use cannabis. SUBJECTS AND METHODS: We carried out a 4-year follow-up study of a cohort of 119 patients with recent onset of psychosis. The patients were divided into four groups according to duration of cannabis use, taking index admission and follow-up as reference points. RESULTS: Those subjects who persisted in the use of cannabis had more positive (but not negative) symptoms and a more continuous illness at follow-up. LIMITATIONS: The main limitations of the study were: the relatively small sample size, and that the excess of male subjects and the presence of cannabis induced psychosis could have a confusing impact on the interpretation of the results. CONCLUSION: It is possible that psychotic patients who use cannabis are at a greater risk of a more continuous illness with more positive symptoms than those who do not.