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Background: In mental health, transition refers to the pathway of young people from child and adolescent to adult services. Training of mental health psychiatrists on transition-related topics offers the opportunity to improve clinical practice and experiences of young people reaching the upper age limit of child and adolescent care., Methods: National psychiatrist's organizations or experts from 21 European countries were surveyed 1/ to describe the status of transition in adult psychiatry (AP) and child and adolescent psychiatry (CAP) postgraduate training in Europe; 2/ to explore the amount of cross-training between both specialties. This survey was a part of the MILESTONE project aiming to study and improve the transition process of young people at the service boundary., Results: Transition was a mandatory topic in the AP curriculum of 1/19 countries (5%) and in the CAP curriculum of 4/17 countries (24%). Most topics relevant for transition planning were addressed during AP training in 7/17 countries (41%) to 10/17 countries (59%), and during CAP training in 9/11 countries (82%) to 13/13 countries (100%). Depending on the training models, theoretical education in CAP was mandatory during AP training in 94% (15/16) to 100% of the countries (3/3); and in AP during CAP training in 81% (13/16) to 100% of the countries (3/3). Placements were mandatory in CAP during AP training in 67% (2/3) to 71% of the countries (12/17); and in AP during CAP training in 87% (13/15) to 100% of the countries (3/3)., Discussion and Conclusion: Specific training about transition is limited during CAP and AP postgraduate training in Europe. Cross-training between both specialties offers a basis for improved communication between child and adult services but efforts should be sustained in practical training. Recommendations are provided to foster further development and meet the specific needs of young people transitioning to adult services., Competing Interests: SP is employed by HealthTracker Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Russet, Humbertclaude, Davidovic Vrljicak, Dieleman, Dodig-Ćurković, Franic, Gerritsen, de Girolamo, Hendrickx, Kerbage, McNicholas, Maras, Paramala, Paul, Schandrin, Schulze, Street, Tuomainen, Wolke, Singh, Tremmery and Purper-Ouakil.)

Purpose: The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports., Participants: Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at., Findings to Date: This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year., Future Plans: Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared., Trial Registration Number: NCT03013595., Competing Interests: Competing interests: SPS is part-funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West Midlands (NIHR CLAHRC WM), now recommissioned as NIHR Applied Research Collaboration West Midlands. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. PS is the co-inventor of the HealthTrackerTM and is the Chief Executive Officer and shareholder in HealthTracker Ltd. FF is a Chief Technical Officer and AK is the Chief Finance Officer employed by HealthTracker Ltd respectively. FCV publishes the Dutch translations of ASEBA, from which he receives remuneration. AM was a speaker and advisor for Neurim, Shire, Infectopharm and Lilly (all not related to transition research)., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Locus of control (LOC) is a modifiable mediator of symptoms of posttraumatic stress disorder (PTSD) among traumatized individuals and a potential target of intervention. Compared with studies involving adults, the potential mediation effect of LOC on PTSD symptoms among trauma-exposed children and adolescents is relatively under-explored. This study, therefore, assessed the mediation effects of LOC on the association between lifetime cumulative trauma and PTSD symptoms among a large cohort of adolescents from different cultural background., Cross-sectional study., LOC was determined using the Multi-Dimension Locus of Control Scale; Posttraumatic stress symptoms using the UCLA PTSD Reaction Index; and other significant negative life events using the Life Events Checklist., Among 3826 adolescents who completed the study, external LOC explained 24% of variance ( R 2  = .24; F 2,3823  = 619.01; p  < .01) in PTSD symptoms and had significant indirect effect on the relationship between self-reported cumulative traumatic event exposure and PTSD symptoms (ß = .14; 95% BC CI [.10, .20]). Moderated mediation results showed significant potentiation of the moderation effects among older adolescents; boys; and those from more affluent families., The study further strengthened the hitherto limited evidence that external LOC partially mediate the relationship between cumulative trauma exposure and PTSD symptoms among adolescents.

Background: Given the high prevalence of internalizing disorders among adolescents, it is necessary to define the factors affecting the development and course of psychopathology. Nolen Hoeksema demonstrated the effect of rumination on the development of various forms of psychopathology in adults, while recent data suggest that cognitive control may be a factor underlying this relationship. The aim of this study is to investigate the relation between cognitive control impairments and symptoms of depression through rumination in adolescents suffering from internalizing psychiatric disorders., Subjects and Methods: The study included 100 adolescents of both genders diagnosed with internalizing psychiatric disorders at the Unit for Child and Adolescent Psychiatry at University Hospital Center Osijek. During psychodiagnostic assessment, subjects completed Youth self report, CANTAB Intra-dimensional/extra-dimensional (IED) task, The Ruminative Response Scale, and Beck Depression Inventory-II., Results: The results indicate a clinically significant level of internalizing symptoms and a clinically and subclinically high level of depressive symptoms. The results also show a high positive correlation between internalizing symptoms, rumination, and depressive symptoms, as well as a positive correlation between female gender and internalizing symptoms, rumination, and depressive symptoms. Significant predictors of depression are female gender and rumination while cognitive control has not been detected as a significant predictor., Conclusion: The results of the study emphasize the importance of rumination in the prediction of depressive symptoms in internalizing psychiatric disorders among adolescents and, accordingly, the importance of rumination as a clinical variable in terms of implications in the prevention and treatment of internalizing psychopathology.

Objective: Young people moving from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) are faced with significant challenges. To improve this state of affairs, there needs to be a recognition of the problem and initiatives and an urgent requirement for appropriate tools for measuring readiness and outcomes at the transfer boundary (16-18 years of age in Europe). The objective of this study was to develop and validate the Transition Readiness and Appropriateness Measure (TRAM) for assessing a young person's readiness for transition, and their outcomes at the transfer boundary., Design: MILESTONE prospective study., Setting: Eight European Union (EU) countries participating in the EU-funded MILESTONE study., Participants: The first phase (MILESTONE validation study) involved 100 adolescents (pre-transition), young adults (post-transition), parents/carers and both CAMHS and AMHS clinicians. The second phase (MILESTONE cohort study and nested cluster randomised trial) involved over 1000 young people., Results: The development of the TRAM began with a literature review on transitioning and a review of important items regarding transition by a panel of 34 mental health experts. A list of 64 items of potential importance were identified, which together comprised the TRAM. The psychometric properties of the different versions of the TRAM were evaluated and showed that the TRAM had good reliability for all versions and low-to-moderate correlations when compared with other established instruments and a well-defined factor structure. The main results of the cohort study with the nested cluster randomised trial are not reported., Conclusion: The TRAM is a reliable instrument for assessing transition readiness and appropriateness. It highlighted the barriers to a successful transition and informed clinicians, identifying areas which clinicians on both sides of the transfer boundary can work on to ease the transition for the young person., Trial Registration Number: ISRCTN83240263 (Registered 23 July 2015), NCT03013595 (Registered 6 January 2017); Pre-results., Competing Interests: Competing interests: PS is the co-inventor of the HealthTracker and is the Chief Executive Officer and shareholder in HealthTracker. FF is a Chief Technical Officer and KL is a Project Manager employed by HealthTracker. FV is the Dutch distributor of ASEBA from which he receives remuneration. SPS is part-funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care WM (NIHR CLAHRC WM)., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Adolescent non-suicidal self-injurious behavior (NSSI) is a major public health concern. Although widespread, it is yet often a hidden problem. The purpose of this study was to explore the characteristics of self-injurious behavior in youth treated in an in-patient psychiatric unit., Subjects and Methods: The study included 105 adolescents with a history of NSSI (mean age 15 years, 80% females) that underwent inpatient psychiatric treatment at a specialized facility. The factors assessed were sociodemographic data, frequency and type of NSSI, history of psychiatric disorder in family, existence of past traumatic event, alcohol, cigarettes and drug dependance and clinical psychiatric diagnosis. Retrospective-chart review study., Results: Of all assessed, patients with NSSI were predominantly female adolescents. Mean age onset of NSSI in the sample was 15 years. Equal number of patients showed occasional and repetitive NSSI, using self-cutting as a most common mean of self-injury. Approximately ¼ of adolescents met criteria for an adjustment disorder and ¼ for a mixed disorder of conduct and emotions. A low 7.8% met the criterion for borderline personality disorder. We found a statistically significant correlation between alcohol consumption and frequency of self-injurious behavior., Conclusions: Our study points to the fact that there has been an increase in prevalence of NSSI. Also, NSSI showed to be associated with female gender, alcohol consumption and a broad spectrum of comorbidities. Future research should focus not only on adolescents being hospitalized and treated, but should be representative of the whole young population because there are no national statistics on NSSI among young people in Croatia. Furthermore, future studies should focus on the origin of NSSI as opposed to its characteristics, in order for professionals to be able to prevent the issue.

Background: Profound clinical, conceptual and ideological differences between child and adult mental health service models contribute to transition-related discontinuity of care. Many of these may be related to psychiatry training., Methods: A systematic review on General Adult Psychiatry (GAP) and Child and Adult Psychiatry (CAP) training in Europe, with a particular focus on transition as a theme in GAP and CAP training., Results: Thirty-four full-papers, six abstracts and seven additional full text documents were identified. Important variations between countries were found across several domains including assessment of trainees, clinical and educational supervision, psychotherapy training and continuing medical education. Three models of training were identified: i) a generalist common training programme; ii) totally separate training programmes; iii) mixed types. Only two national training programs (UK and Ireland) were identified to have addressed transition as a topic, both involving CAP exclusively., Conclusion: Three models of training in GAP and CAP across Europe are identified, suggesting that the harmonization is not yet realised and a possible barrier to improving transitional care. Training in transition has only recently been considered. It is timely, topical and important to develop evidence-based training approaches on transitional care across Europe into both CAP and GAP training.

The original version of this article contained an error in Table 1. The correct table is presented below.

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

The WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Suicide and mood disorders (especially major depressive disorder (MDD) and bipolar affective disorder (BD)) represent a significant global health burden. Major depressive disorder and bipolar affective disorder have been associated with increased risk for suicide. Some specific suicide risk factors might be found in underlying individual personality traits. Specific personality features may predispose an individual to mood disorders (MDD or BD) hence increased suicide risk. The specificity of this research is in the assessment of personality features during the acute phase of illness immediately after suicide attempt which resulted in psychiatric inpatient treatment., Subjects and Methods: The study included 119 unrelated Caucasian participants with MDD-severe depressive episode without psychotic symptoms (MDD) and BD-severe depressive episode without psychotic symptoms (BD-sDE). Both groups of patients with MDD and BD-sDE were divided into the suicide attempters and non-suicidal group. The diagnoses of the severe depressive episode without psychotic symptoms in major depressive disorder (MDD; F32.2) and bipolar disorder (BD-sDE; F31.4) were made according to ICD-10 (WHO 1992) diagnostic criteria. Methods of suicide attempts were also assessed according to ICD-10 and a self-report questionnaire, the Temperament and Character Inventory (TCI) was applied., Results: The participants who exhibited suicide attempt had significantly higher scores on harm-avoidance (HA) (p<0.001), significantly lower score on persistence (PS) (p=0.037) and lower score, however not statistically significant, on novelty-seeking (NS) (p=0.319) regarding temperament dimensions. In character dimensions, the patients with suicidal attempt had significantly lower scores on self-directedness (SD) (p<0.001) and significantly lower scores on cooperativeness (CO) (p=0.001)., Conclusion: Patients who had suicide attempt may have some significantly different personality traits than non-suicidal patients with mood disorders. The combination of high harm-avoidance (HA) and low self-directedness (SD) may be specific for depressive episode while the combination of high HA, novelty-seeking (NS), and self-transcendence (ST) with low SD may be related to suicide attempts during the depressive episode in bipolar disorder. The novelty-seeking (NS), self-transcendence (ST) and self-directedness (SD) may be specific for suicidal group of bipolar patients.

Background: Prevalence of prescribing psychotropic medications, particularly inappropriate prescription, is widespread in older adults, both in nursing home residents as well as community-dwelling older adults. This review describes prevalence and prevention of inappropriate prescribing and risk factors associated with psychotropic medications., Methods: MEDLINE and GOOGLE SCHOLAR data base were searched for the key words "older adults", "psychotropic drugs", "inappropriate prescribing", "nursing home residents", "community-dwelling older adults". The study was limited to the articles published in English in the period from 2007 to 2014. The list of references includes additional articles that were searched manually., Results: The utilization of different psychotropic medications is prevalent among older adults worldwide, regardless of whether they live in nursing homes or in the community. Among older adults, nursing home residents are the most vulnerable individuals for potentially inappropriate drug prescription. The most common potentially inappropriate prescribed medications in the elderly are benzodiazepines, particularly long-acting, antipsychotics and antidepressants, particularly SSRIs. All classes of listed medications have been associated with different adverse events, particularly falls and falls-related fractures and increased risk for mortality. Many different pharmacological and non-pharmacological interventions, such as monitoring polypharmacy, reviewing medications, spending more time in the institution by a physician, reducing the number of prescribers in the institution as well as greater involvement of geriatricians, general practitioners and pharmacists should be implemented to reduce this health issue., Conclusion: The prevalence of prescribing psychotropic medications to older adults is high. Inappropriate prescribing of psychotropic drugs and polypharmacy are present in institutionalized and non-institutionalized older adults and can cause adverse health events, and can significantly reduce the quality of life of these vulnerable groups. Multidisciplinary approach is needed in addressing widespread problem of prevalence of psychotropic medications in older adults.

Abstract Using inductively-coupled plasma mass spectrometry (ICP-MS), we measured the concentrations of thallium and uranium in local water resources from three villages (Ćelije, Draž, and Potnjani) in eastern Croatia, with the aim to determine if they were associated with the levels of these same elements in the serum, urine, and hair collected from the residents of this area. The exposure of the local population to thallium and uranium through drinking water was generally low. ICP-MS was capable of measuring the levels of both of the elements in almost all of the analysed samples. Although there were differences in the concentrations of both elements in water samples and biological specimens taken from the residents, they did not reach the maximum contaminant level in any of the four sample types studied. Although hair was previously reported as an excellent indicator of occupational and environmental exposure to various elements, our study did not confirm it as a reliable biological material for tracing thallium and uranium levels, mainly due to the very low concentrations of these elements, often well below the detection limit. However, our results have shown that the concentration of thallium and uranium in drinking water can be effectively traced in urine samples.

Background: A large increase in the use of atypical antipsychotics (AAPs) in the Western developed countries has been reported. Patterns of antipsychotic therapy and the extent of use of AAPs for youth outside of the developed world are lacking., Aims: To evaluate patterns of antipsychotic treatment of pediatric outpatients in Croatia, including the rate of AAP use., Material and Methods: Retrospective analysis of outpatient visits to child psychiatrists by persons aged 18 and younger that included prescription of antipsychotics. Antipsychotic treatment data were identified by frequency, medication class, subclass and drug entity and were analyzed in relation to age group, gender and psychiatric diagnosis., Results: Overall, 1.3% (106/7953) of pediatric outpatients received antipsychotic therapy during the study period. Antipsychotic treatment was significantly more common in boys and in adolescents. AAPs (80.1%) were significantly more often prescribed than typical antipsychotics (19.9%) (t = 7.76; P < 0.01). In all diagnostic categories (behavior disorders, pervasive developmental disorders and mental retardation, psychotic disorders, mood and tic disorders), the treatment with AAPs was more frequent than typical antipsychotics (χ(2) = 9.92, df = 4, P < 0.05). AAPs were used as monotherapy in 62.2% of outpatients. Off-label prescribing was found in 52.9% of young patients who had received AAPs., Conclusions: AAPs comprise most of the antipsychotic medications prescribed to pediatric outpatients in Croatia in all diagnostic categories, reflecting trends in other countries. Unfortunately, such practice occurs in the absence of supporting data about long-term safety and in spite of the lack of evidence regarding their efficacy in some indications.

Objective: Change in cognitive function is one of the well-known consequences of the end-stage renal disease (ESRD). The aim of this study was to determine the effect of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) on cognitive and motor functions., Methods: In this cross-sectional study, cognitive and motor functions were investigated in a selected population of 42 patients with ESRD (22 patients on chronic HD and 20 patients on CAPD, aged 50.31 ± 11.07 years). Assessment of cognitive and motor functions was performed by Symbol Digit Modalities Test (SDMT) and Complex Reactiometer Drenovac (CRD-series), a battery of computer-generated psychological tests to measure simple visual discrimination of signal location, short-term memory, simple convergent visual orientation, and convergent thinking., Results: The statistically significant difference in cognitive-motor functions between HD and CAPD patients was not found in any of the time-related parameters in all CRD-series tests or SDMT score. Higher serum levels of albumin, creatinine, and calcium were correlated with better cognitive-motor performance among all patients regardless of dialysis modality. The significant correlation between ultrafiltration rate per HD and short-term memory actualization test score (CRD-324 MT) among HD patients was found (r = 0.434, p = 0.025)., Conclusion: This study has demonstrated that well-nourished and medically stable HD and CAPD patients without clinical signs of dementia or cognitive impairment and without significant difference in age and level of education performed all tests of cognitive-motor abilities without statistically significant difference.

Background: Kidney failure is believed to have a negative impact on cognitive function, and cognitive impairment is common among maintenance hemodialysis (HD) patients. Previous studies have shown a beneficial effect of kidney transplantation in certain cognitive tests but not across all cognitive domains assessed. But, most of these studies performed a cross-sectional analysis, suffered from lack of standardization of adequate dialysis dose, hemoglobin level, and insufficient sensitivity of neuropsychological tests. The aim of this study was to evaluate the effect of successful kidney transplantation on cognitive and psychomotor function in adequately dialyzed HD patients without severe anemia, using sensitive neuropsychological tests., Methods: Twenty-one medically stable patients (aged 45.1 ± 7.9 years) on maintenance HD (7.6 ± 4.2 years) were investigated before and 20.5 ± 8.5 months after successful kidney transplantation using Complex Reactiometer Drenovac, a battery of computer-generated psychological tests which measure a simple visual discrimination of signal location, short-term memory, simple convergent visual orientation and convergent thinking., Results: Our findings indicated significantly better cognitive and psychomotor performance after transplantation on tests that assess processing speed, attention, short time memory, convergent thinking and executive functioning. Also, significant negative correlation between follow-up time after transplantation and cognitive and psychomotor performance in minimum time of solving test of convergent thinking was found., Conclusion: We conclude that cognitive and psychomotor functions are superior after successful kidney transplantation compared with HD, and that early beneficial effects of transplantation are not transient and cognitive and psychomotor performance might be even improved in time following successful transplantation., (Copyright © 2011 S. Karger AG, Basel.)