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Objective: This paper illustrates the process of constructing, selecting and applying simple measures in order to empirically derive patterns of course of psychotic episodes in schizophrenia. Method: Data were collected with a composite instrument constructed for a multi-centre, follow-up randomized controlled trial of adherence therapy for people with schizophrenia. The instrument included a retrospective weekly assessment of psychotic/non-psychotic status, which was used to derive the measures, and the DSM-IV course specifiers. Results: The measures discriminated well between different course patterns and identified homogeneous clusters of subjects which correlated with the groups derived from the DSM-IV course specifiers. Conclusions: The new measures provide an empirical basis to identify specific patterns of course and to differentiate patients according to pre-defined criteria. They can be used in follow-up studies as measures of outcome, to investigate correlations between variables and to identify potential predictors of outcome. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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Inter- and intra-hemispheric connectivity disturbances have been suggested to play a major role in schizophrenia. To this extent, diffusion weighted imaging (DWI) is a relatively new technique examining subtle white matter microstructure organization. DWI studies in schizophrenia strongly suggest that white matter communication is disrupted. This supports the hypothesis that there is a cortico-cortical and transcallosal altered connectivity in schizophrenia, which may be relevant for the pathophysiology and the cognitive disturbances of the disorder. Future longitudinal diffusion and functional imaging studies targeting brain communication together with genetic investigations should further characterize white matter pathology in schizophrenia and its relevance for the development of the illness. [ABSTRACT FROM AUTHOR]

A new type of magnetic resonance imaging analysis, based on fusion of three-dimensional reconstructions of time-to-peak parametric maps and high-resolution T1-weighted images, is proposed in order to evaluate the perfusion of selected volumes of interest. Because in recent years a wealth of data have suggested the crucial involvement of vascular alterations in mental diseases, we tested our new method on a restricted sample of schizophrenic patients and matched healthy controls. The perfusion of the whole brain was compared with that of the caudate nucleus by means of intrasubject analysis. As expected, owing to the encephalic vascular pattern, a significantly lower time-to-peak was observed in the caudate nucleus than in the whole brain in all healthy controls, indicating that the suggested method has enough sensitivity to detect subtle perfusion changes even in small volumes of interest. Interestingly, a less uniform pattern was observed in the schizophrenic patients. The latter finding needs to be replicated in an adequate number of subjects. In summary, the three-dimensional analysis method we propose has been shown to be a feasible tool for revealing subtle vascular changes both in normal subjects and in pathological conditions. [ABSTRACT FROM AUTHOR]

Aim: This cross-sectional study attempted to identify factors associated with clinicians' dispositions of patients after the first visit in an out-patient psychiatric department.Methods: Over a 33-month period, all new episodes of care with the department were included in the study. For each patient, socio-demographic, clinical information and contact characteristics were prospectively collected in relation to the first visit, as was information on case disposition. Factors associated with clinicians' disposition were analysed.Results: Of the 1,138 patients who met the study criteria, 848 (75%) were followed up by the department, 150 (13%) were referred to other services and 140 (12%) were discharged. Suffering from a major psychiatric disorder, being younger and not living in an institution influenced clinicians' disposition to follow-up patients. Older age increased the chances of being referred to other services rather than discharged.Conclusions: Examining decision-making behaviour in out-patient psychiatric departments is a worthwhile endeavour because this setting represents the main entry point of modern and accessible community-based systems of care. The findings confirmed the importance of psychiatric determinants in the dispositional process and contribute to make clinicians more aware of other factors related to their decision-making. [ABSTRACT FROM AUTHOR]

Background: There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.Aims: To provide an evidence base for this debate, and present a stepped care model.Method: Cochrane systematic reviews and other reviews were summarised.Results: The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.Conclusions: Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here. [ABSTRACT FROM AUTHOR]

Background:. Schizophrenia as a chronic mental disorder not only has far-reaching consequences for patients, but also for their family members or other informal caregivers. In this study, we investigated whether needs for care of patients with schizophrenia are related to (negative) consequences for their informal caregivers. Method:. A total of 287 patients with schizophrenia and their informal caregivers participated in the EPSILON study of schizophrenia in five European countries. Caregiver consequences were measured by the Involvement Evaluation Questionnaire (IEQ) and needs for care by the Camberwell Assessment of Need (CAN). Results:. Total number of needs for care as well as specific areas of needs for care of patients appeared to be only weak predictors of caregiver consequences in terms of explained variance. Conclusion:. Subjective needs for care as measured by the CAN are not a good indicator for consequences experienced by the informal care system of patients with schizophrenia. [ABSTRACT FROM AUTHOR]

Background: Few studies have investigated factors which predict inappropriate terminations (drop-out) of clinical contact with mental health services.Aims: To identify patient and treatment characteristics associated with dropping out of contact with community-based psychiatric services (CPS).Method: A 3-month cohort of patients attending the CPS was followed up for 2 years, to identify drop-outs.Results: We identified 495 patients who had had at least one psychiatric contact of whom 261 had complete ratings for the Global Assessment of Functioning and the Verona Service Satisfaction Scale. In the year after the index contact, 70 terminated contact with the CPS; of these, 44 were rated as having inappropriate terminations (the "drop-out" group) and 26 had appropriate terminations of contact. Drop-outs were younger, less likely to be married and their previous length of contact with services was shorter. No drop-outs had a diagnosis of schizophrenia. Multivariate analysis revealed predictors of dropping out.Conclusions: In a CPS targeted to patients with severe mental illnesses, those who drop out of care are younger patients without psychoses who are generally satisfied with their treatment. [ABSTRACT FROM AUTHOR]

Background: There is little consistency in how severe mental illness (SMI) is defined in practice, and no operational definitions.Aims: To test two operationalized definitions, based on the National Institute of Mental Health (1987) definition: the first uses three criteria (diagnosis of psychosis; duration of service contact > or = 2 years; GAF score < or = 50), the second only the last two.Method: Annual prevalence rates of SMI in two European catchment areas for each criterion and the criteria combined were calculated.Results: The first definition produced rates of 2.55 and 1.34/1000 in London and Verona, respectively; the second permitted an additional 0.98/1000 non-psychotic disorders to be included in Verona.Conclusions: The three-dimensional definition selects a small group of patients with SMI who have psychotic disorders. The two-dimensional approach allows estimates of SMI prevalence rates which include all forms of mental disorder. [ABSTRACT FROM AUTHOR]

Background. Most studies which showed an excess mortality in psychiatric patients have been conducted on hospitalised samples. Method. This was a case register study. All South Verona patients with an lCD diagnosis who had psychiatric contacts with specialist services in 1982-1991 were included. Mortality was studied in relation to sex, age, diagnosis, pattern of care and interval from registration. Standardised Mortality Rates (SMRs) and Poisson regression analysis were calculated. Results. The overall SMR was 1.63 (95% Cl = 1.5-1.8), which is the lowest value reported so far. Mortality was higher among men (SMR = 2.24; 95% Cl = 1.9-2.6), among patients who were admitted to hospital (SMR = 2.23; 95% Cl = 1.9-2.6), among younger age groups (SMR=8.82; 95% Cl=4.9-14.6) and in the first year after registration (SMR=2.32; 95% Cl = 1.8-2.9). Higher mortality was found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87; 95% Cl = 3.0-4.9). The SMR for suicide was 17.41. Using a Poisson regression model, diagnosis, pattern of care and interval from registration were all found to be significantly associated with mortality. When all these variables were entered together in the model, each maintained its predictive role. Conclusions. The overall mortality of psychiatric patients treated in a community-based system of care was higher than expected, but lower than the mortality reported in other psychiatric settings. The highest mortality risk was found in the first year after registration. [ABSTRACT FROM AUTHOR]

Many service users and professionals are not satisfied with current hospital care: they call for a safer and more friendly environment, with greater freedom and less social distance between staff and patients. Phase 2 of the Alternatives Study was designed to improve the evidence base for such residential alternatives, Findings suggest that offering a more acceptable environment increases satisfaction with treatment, although it does not improve the clinical outcome. This set of coordinated studies also suggest that we should listen (and talk) more to our patients, and make our style of working in hospital and community facilities less paternalistic. [ABSTRACT FROM AUTHOR]

Comments on the issues concerning the emergence of antidepressant and antipsychotic drugs and the automatism of prescribing. Increase in therapeutic options available for patients suffering from psychiatric disorders; Efficacy of the drugs; Possibility of automatism of prescribing to induce a passive attitude among doctors.