Substance Use/Dependence in Psychiatric Emergency Setting Leading to Hospitalization: Predictors of Continuity of Care

Background: Poor adherence to treatment is a common clinical problem in individuals affected by mental illness and substance use/dependence. In Italy, mental care is organized in a psychiatric service and addiction unit (SERD), characterized by dual independent assets of treatment. This difference, in the Emergency Room setting, leads to a risk of discontinuity of treatment in case of hospitalization. In this study we clinically characterized individuals who decided to attend hospital post-discharge appointments at SERD, in accordance with medical advice. Methods: This is a retrospective study, based on two years of discharged records of patients entering “Versilia Hospital” (Viareggio, Italy) emergency room, with urinalyses testing positive for substance use, and hospitalization after psychiatric consultation. The sample was divided according to the presence or absence of SERD consultation after discharge. Results: In the 2-year period of the present study, 1005 individuals were hospitalized. Considering the inclusion criterion of the study, the sample consisted of 264 individuals. Of these, 128 patients attended post-discharge appointments at SERD showing urinalyses positive to cocaine, opiates, and poly use; they were more frequently diagnosed as personality disorder and less frequently as bipolar disorder. The prediction was higher for patients that had already been treated at SERD, for patients who received SERD consultation during hospitalization, and for patients with positive urinalyses to cocaine and opiates at treatment entry. Conversely, patients who did not attend SERD consultation after discharge were affected by bipolar disorders. Limitations: Small sample size. Demographical data are limited to gender and age due to paucity of data in hospital information systems. SERD is located far from the hospital and is open only on weekdays; thus, it cannot ensure a consultation with all inpatients. Conclusions: Mental illness diagnosis, the set of substance use positivity at hospitalization, and having received SERD consultation during hospitalization appeared to have a critical role in promoting continuity of care. Moreover, to reduce the gap between the need and the provision of the treatment, a more effective personalized individual program of care should be implemented.

Attempted Suicide in the Older Adults: A Case Series From the Psychiatry Ward of the University Hospital Maggiore Della Carità, Novara, Italy

Introduction: As suicide rates increase with age, it is mandatory to carefully assess old age suicidal behaviors. Our aim was to describe the main socio-demographic and clinical features of a sample of suicide attempters aged 65 years and older, and to assess differences within the sample (men vs. women; patients with vs. without a previous history of suicide attempt; patients with vs. without a previous psychiatric history).Methods: Retrospective study conducted at the Maggiore della Carità University Hospital, Novara, Italy.Results: A higher percentage of female patients in our sample were treated by or referred to mental health services, while a greater percentage of male patients required a prolonged clinical observation in the Emergency Room (ER) or in non-psychiatric wards before psychiatric admission. The percentage of patients without previous psychiatric history taking anxiolytic and sedative medications was 25%.Conclusion: It is likely that different clusters and types of suicide attempters exist. Women in our sample appeared more proactive in asking for help, and more likely to be already treated by or referred to a psychiatric service, suggesting the need to facilitate the access to psychiatric services for the male population aged 65 years and older, or to offer support and care for the non-psychiatric reasons (comorbidities, pain, and loss of autonomy) possibly underlying suicidal behavior in this specific group. The use of medications deserves more attention considering the possible critical diagnostic issues in this age group.

Validity of the patient health questionnaire 9-item in autistic youths: a pilot study

Background Autistic adolescents have greater predisposition to depression and suicidality than neurotypical adolescents. Early detection is essential for timely treatment. The Patient Health Questionnaire 9-item (PHQ-9) is a brief screen for depression. The study examines the validity of the PHQ-9 for detecting major depressive disorder (MDD) in autistic youths. Methods English speaking youths aged 10–18 years, with DSM-IV/DSM-5/ICD-10 diagnosis of Autism Spectrum Disorder (ASD), and their parents presenting to a child psychiatric service were invited to participate between May 2018 to August 2020. Participants completed the respective self- and parent-rated PHQ-9 independently. MDD was verified using the MINI-Kid (Mini-International Neuropsychiatric Interview, Kid version). Results One hundred one youth, mean (SD) age 14.6 (2.3), were enrolled. 27 (27%) met criteria for current MDD. Mean total PHQ-9 scores, percentage ratings for severity of symptoms of depression, functional impairment, dysthymia and suicidality were compared. Areas under the ROC curve and statistically optimal cutoffs were determined. Parents rated depressive symptoms severity lower than their children. The PHQ-9 displayed low sensitivity with high false negative rates at conventional, adjusted and proposed cutoffs. Conclusions Future studies should improve on the validity and reliability of existing depression screening tools, or develop more appropriate screening methods of depression, for autistic youths.

Ekbom’s syndrome in a bipolar disorder patient: a case report

Introduction: Ekbom syndrome is a rare condition in which the patient believes that his or her body is infested by worms or other parasites.This condition is associated to mental ilness in 81% of cases. There is not a final statement about the best psychofarmacological treatment of this condition. Objective: The present study presents a case report on which an elderly woman with bipolar disorder has shown Ekbom syndrome. Method: This study lists a case report of a 69 yerar-old woman with bipolar disorder. This patient had presented the belief that worms were walking under her skin during the past few months. She had a previous diagnosis of bipolar disorder. Depressive symptoms were intense. The patient was followed up in an outpatient psychiatric service for 120 days. Lurasidone was introduced and some drugs were discontinued. Result: One month after starting treatment with lurasidone, there was a significant improvement of delusional beliefs of Ekbom syndrome. Such improvement was associated with the improvement of the bipolar depressive condition in this case. Conclusion: Ekbom syndrome is a rare kind of delusion. Its etiology is not fully understood. We presented a case of an elderly woman with previous diagnosis of bipolar disorder with Ekbom syndrome. To our knowledge, there are no other case reports informing the use of lurasidone in bipolar depression associated with Ekbom syndrome.

Microdose induction of buprenorphine-naloxone in a patient using high dose methadone: A case report

Background Buprenorphine is a partial mu-opioid receptor agonist approved for the treatment of opioid dependence. The risk of withdrawal symptoms and wait time required to safely initiate buprenorphine provides challenges to both patients and providers. Microdose induction is proposed as a possible solution to ease the transition to buprenorphine; however, little data has been published to date on patients stabilized on methadone doses greater than 100 mg. Case Report A 29-year-old patient stabilized on methadone 105 mg was successfully transitioned to sublingual buprenorphine-naloxone using a 7-day microdose protocol on an inpatient psychiatric service. During the transition, the patient reported only minimal symptoms. Conclusion This report adds to the growing literature supporting the use of a microdose induction to initiate buprenorphine-naloxone. Additionally, this approach may be significant for patients stabilized on high doses of methadone who may not be able to tolerate a traditional buprenorphine induction.

An acute change? Does treatment within a therapeutic community for personality disorders affect local acute service use

Purpose The intensive 18-month treatment in the personality disorder (PD) therapeutic community (TC) is felt to offer improvement in many aspects of patients’ lives. This study aims to understand if the use of acute services was also affected via a service evaluation project. Design/methodology/approach The authors collected data from electronic records on the use of local services in the two years before, during and the two years after treatment in the TC. Specifically, the authors counted inpatient bed days, Emergency department (ED) presentations and days under home treatment team and liaison psychiatry; the authors used ANOVA to analyse the data. Findings The study included 25 adult service users, 17 female and 8 male, with an average age of 40. Whilst there were reductions in the use of inpatient beds and ED presentations, on analysis, these were not found statistically significant. The small size of the study is a limitation and may limit the generalisability of the findings. The study concludes there may be reductions in acute psychiatric service use during and after treatment in the TC. The findings were not statistically significant; the authors suggest larger multi-centre studies may be able to demonstrate statistical significance. Originality/value PD patients have a relatively high use of acute psychiatric services compared to other patient groups. The authors are not aware of any similar studies in the published literature.

Pathway to Service and Duration of Untreated Attention Deficit, Hyperactivity Disorder among Children Presented to a Governmental, Mental Health Hospital in Egypt

Background ADHD is one of the most common neurodevelopmental disorders. Despite the presence of evidence based approved diagnosing and treatment tools for ADHD, there still is an underdiagnoses and underutilization of these services. Untreated ADHD, unlike what some families may believe, doesn’t go away on its own, in fact, the condition may get worse with age, affecting more domains of the child’s life as an adolescent and later on as an adult. In addition, untreated ADHD impacts not only the patient, but also the family and the society as a whole. Objective to investigate different routes that parents take before reaching the child and adolescence psychiatric services. And to further explore various reasons for any delay in seeking psychiatric help. In addition we aimed to estimate the duration of untreated ADHD before patients receive proper psychiatric service and treatment. Patients and Methods A total of 350 cases were recruited in a cross sectional study that took place at the Child and Adolescence outpatient clinic at Abbassia mental health hospital in Cairo, Egypt. Results Results showed that the average delay in seeking Child and Adolescence psychiatric service and the duration of untreated ADHD was 3±2 years. The majority of parents, 27.1%, first consulted pediatricians as regards to their child’s symptoms. The most commonly reported source of referral was school teachers in 23.1%. The most distressing symptom stated by 28.1% of parents was impulsivity. Stigma of mental illness was the most frequently reported reason for delay in reaching out for psychiatric service. Conclusion we concluded that parents tend to take other routes through different professions before reaching Child and Adolescence Mental Health Services, this causes subsequent delay in receiving diagnosis and treatment for ADHD. In Addition, it was concluded that sociocultural beliefs affected parent’s pattern of help seeking.

The Structure of Social Support: A Multilevel Analysis of the Personal Networks of People with Severe Mental Disorders

Background. For psychiatric service users suffering from severe mental disorders, the social support provided by personal social networks is essential for living a meaningful life within the community. However, the importance of the support received depend on the relations between the providers of social support. Yet this hasn’t been addressed in the literature so far for people with severe mental disorders. This article seeks to investigate how characteristics of service users with severe mental disorders, their social contacts, and the pattern of relationships between those contacts influence the distribution and provision of social support to people with severe mental disorders. Methods. We collected personal network data relating to 380 psychiatric service users from a random sample of health care providers in Belgium. We computed various measures of the structure of those neworks and of the position of support persons within those networks. We conducted a multilevel analysis of the importance of the support provided by each support persons.Results. The results show that the more central a support person was in the network of a service user, the more important his or her support was considered to be by the service user. Also, the denser the network in which a support person was embedded, the less important was the support he or she offers, but only for hospitalised service users. Conclusions. These finding highlight the collective dimension of social support. We discuss the implications for the organisation of mental health care.

Socio-Demographic and Clinical Characteristics of Psychiatric Patients Who Have Committed Suicide: Analysis of Bulgarian Regional Suicidal Registry for 10 Years

Introduction: Suicide is a major public health problem but factors determining suicide risk are still unclear. Studies in this field in Bulgaria are limited, especially on a regional level.Methods: By a cross-sectional design, we accessed the medical records of all psychiatric patients committed suicide over a 10-year period (2009–2018) in one major administrative region of Bulgaria. A statistical analysis was performed of the association between age of suicide as an indirect yet measurable expression of the underlying suicidal diathesis and a number of socio-demographic and clinical characteristics.Results: Seventy-seven of 281 suicides (28%) had psychiatric records. Most common diagnoses were mood disorders (44%), followed by schizophrenia (27%), anxiety disorders (10%), substance use disorders (9%) and organic conditions (8%). Male gender, single/divorced marital status, early illness onset, co-occurring substance misuse and lower educational attainment (for patients aged below 70) were significantly associated with earlier age of suicide whereas past suicide attempts and psychiatric hospitalizations, comorbid somatic conditions and unemployment showed insignificant association. Substantial proportion of patients (60%) had contacted psychiatric service in the year preceding suicide, with nearly half of these encounters being within 30 days of the accident.Conclusion: Severe mental disorders are major suicide risk factor with additional contribution of certain socio-demographic and illness-related characteristics. Monitoring for suicidality must be constant in chronic psychiatric patients. Registration of suicide cases in Bulgaria needs improvement in terms of information concerning mental health. More studies with larger samples and longitudinal design are needed to further elucidate distal and proximal suicide risk factors.

Modern approaches to the diagnosis and treatment of anxiety disorders associated with a new coronavirus infection

The article systematizes information on the diagnosis and treatment of anxiety disorders, the frequency of which has increased significantly at the present time, in connection with the COVID-19 pandemic. The characteristic of stressful factors affecting the human psyche in the conditions of forced self-isolation and after it is given. Many people experience anxiety due to lockdown, social isolation, unemployment, and a high probability of illness and death. Uncertainty in the future, anxiety during the period of uncertainty caused by the spread of the “new coronavirus”, are a trigger for emotional exhaustion, suppress the immune system, which negatively affects the human nervous system and provokes an exacerbation of chronic ailments. The psychological consequences of a person’s stay in quarantine are considered. In the structure of mental health disorders associated with the COVID-19 epidemic, there is a large range of adaptation disorders: fear, frustration, a sense of hopelessness, expectation of threat, loneliness, social isolation and alienation. In the situation of COVID-19, there is often a depletion of mental resources and maladaptation, a disorder of adaptive reactions. Anxiety disorders occur in the form of adaptation disorders, generalized anxiety disorder, somatoform disorders, including panic attacks. Timely diagnosis of these disorders is possible not only by the psychiatric service, but also with the involvement of internists who possess screening diagnostic tools with automated conclusions (scales, mobile applications to smartphones, etc.). A brief review of domestic and foreign studies on the assessment of methods for the diagnosis and treatment of anxiety disorders is presented. Diagnostic methods and therapeutic tactics, the use of various traditional drugs in psychosomatic pathology are discussed. To correct the identified disorders, there is a choice of anti-anxiety drugs, including antidepressants (primarily selective serotonin reuptake inhibitors), tranquilizers, among which tofizopam occupies a worthy place.