Search

We examined whether excess chronic medical comorbidity mediated excess COVID-19 inpatient mortality among people with mental disorders in the early phase of the pandemic, a question with important implications for public health and clinical decision-making. Using records of 2599 COVID-19 hospitalized patients, we conducted a formal causal mediation analysis to estimate the extent to which chronic comorbidity mediates the association between mental disorders and COVID-19 mortality. The Odds Ratio (95% CI) for Natural Indirect Effect and Controlled Direct Effect were 1.07(1.02, 1.14) and 1.40 (1.00, 1.95), respectively, suggesting that a large proportion of excess COVID-19 mortality among people with mental disorders may be explained by factors other than comorbidity.

Objetivo: evaluar la efectividad de la introducción del instrumento de feedback formal PCOMS en psicoterapia en el sistema nacional de salud español. Método: se trató de un estudio clínico aleatorizado y controlado simple ciego en cuatro centros de salud mental y atención primaria del Hospital Universitario La Paz, España. Los pacientes asignados al grupo experimental completaron junto con su terapeuta las medidas del instrumento PCOMS durante cada sesión, mientras que los pacientes asignados al grupo control recibieron el tratamiento habitual. Un total de 58 pacientes completaron el estudio. La variable principal fue el resultado terapéutico, medida a través de la escala ORS. Las variables secundarias fueron la sintomatología, a través de la escala GSI (SCL-90), satisfacción, a través de la escala CRES-4, y abandono prematuro. Resultado: se encontraron diferencias entre el grupo experimental y control en el resultado terapéutico. El número necesario a tratar indicó que por cada siete pacientes tratados en la condición experimental se evitaría el empeoramiento o estancamiento de un paciente. No se obtuvieron diferencias en sintomatología, satisfacción o abandono prematuro. Conclusiones: el instrumento PCOMS puede incrementar la efectividad de la psicoterapia en contextos de salud mental del sistema nacional de salud español.

Introduction Paediatric and adult psychiatric emergency department (ED) visits decreased during the initial COVID-19 outbreak. Long-term consequences of the COVID-19 pandemic will include increases in mental healthcare needs, especially among vulnerable groups such as children and adolescents. Aim This study examined changes in the number of overall and diagnosis-specific mental health ED visits among patients aged Methods Using clinical records from all psychiatric ED visits at a major teaching hospital between October 2018 and April 2021, we conducted interrupted time-series analyses and compared trends before and after the day of the first ED COVID-19 case (1st March 2020). Results A total of 663 patients were included. In March 2020, there was a marked initial decrease of -12.8 (95% CI -21.9, - 7.9) less monthly mental health ED visits. After April 2020, there was a subsequent increasing trend of 3.4 (95% CI 2.6, 4.2) additional monthly mental health ED visits. Conclusion After the onset of the COVID-19 pandemic, there was an increase in paediatric psychiatric ED visits, especially due to suicide-related reasons. These data reinforce the crucial role of the ED in the management of acute mental health problems among youth and highlight the need for renovated efforts to enhance access to care outside of and during acute crises during the pandemic and its aftermath.

Objective This study explores whether social cognition and social functioning improve after a mindfulness-based social cognition training (SocialMIND). Methods Thirty-eight outpatients with psychosis completed an assessment with social cognition (Eyes Test, Ambiguous Intentions and Hostility Questionnaire [AIHQ], and Hinting Task) and social functioning tasks (Personal and Social Performance [PSP] scale) before and after eight SocialMIND weekly sessions. Mean differences between timepoints were standardized and 95% confidence intervals were obtained with a paired samples t-test. Results The scores of the Eyes Test (95% CI [.43, 3.32], d = .48), the Hostility Bias subscale (AIHQ) (95% CI [-.29, -.01], d = .44), and the self-care difficulties subscale (PSP) (95% CI [-.77, -.09], d = .45) improved after the intervention. Conclusions and Implications for practice: The results of SocialMIND-8 are very promising in terms of developing comprehensive rehabilitation programs. Further trials must address its effectiveness against a control group during longer follow-up periods. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background During the initial COVID-19 outbreak, organizational changes were required to ensure adequate staffing in healthcare facilities. The extent to which organizational changes impacted the mental wellbeing of healthcare workers (HCWs) remains unexplored. Here we analyzed the association between three work-related stressors (reported access to protective equipment, change in job functions, and patient prioritization decision-making) and mental health outcomes (depression symptoms, psychological distress, suicidal thoughts, and fear of infection) in a large sample of Spanish HCWs during the initial COVID-19 outbreak. Methods We conducted a cross-sectional study including HCWs from three regions of Spain between April 24th and June 22nd, 2020. An online survey measured sociodemographic characteristics, work-related stressors, fear of infection, and mental health outcomes (depression [PHQ-9], psychological distress [GHQ-12], death wishes [C-SSRS]). We conducted mixed-effects regression models to adjust all associations for relevant individual- and region-level sources of confounding. Results We recruited 2,370 HCWs. Twenty-seven percent screened positive for depression and 74% for psychological distress. Seven percent reported death wishes. Respondents were more afraid of infecting their loved ones than of getting infected themselves. All work-related stressors were associated with depression symptoms and psychological distress in adjusted models. Limitations Non-probabilistic sampling, potential reverse causation. Conclusions Modifiable work-related stressors are associated with worse mental health among HCWs. Our results suggest that workplace prevention strategies for HCWs should provide sufficient protective equipment, minimize changes in job functions, favor the implementation of criteria for patient triage and on-call bioethics committees, and facilitate access to stepped-care, evidence-based mental health treatment.

Objective: To characterize the evolution of healthcare workers’ mental health status over the 1-year period following the initial COVID-19 pandemic outbreak and to examine baseline characteristics associated with resolution or persistence of mental health problems over time.Methods: We conducted an 8-month follow-up cohort study. Eligible participants were healthcare workers working in Spain. Baseline data were collected during the initial pandemic outbreak. Survey-based self-reported measures included COVID-19-related exposures, sociodemographic characteristics, and three mental health outcomes (psychological distress, depression symptoms, and posttraumatic stress disorder symptoms). We examined three longitudinal trajectories in mental health outcomes between baseline and follow-up assessments (namely asymptomatic/stable, recovering, and persistently symptomatic/worsening).Results: We recruited 1,807 participants. Between baseline and follow-up assessments, the proportion of respondents screening positive for psychological distress and probable depression decreased, respectively, from 74% to 56% and from 28% to 21%. Two-thirds remained asymptomatic/stable in terms of depression symptoms and 56% remained symptomatic or worsened over time in terms of psychological distress.Conclusion: Poor mental health outcomes among healthcare workers persisted over time. Occupational programs and mental health strategies should be put in place.

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were “conceptual disorganization”, “emotional withdrawal”, “lack of spontaneity and flow of conversation”, “delusions”, “unusual thought content”, “dealing with strangers” and “poor rapport”. Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population, This work was supported by the Madrid Regional Government (R&D activities in Biomedicine (grant number S2017/BMD-3740 - AGES-CM 2-CM)) and Structural Funds of the European Union. Ana Izquierdo’s work is supported by the PFIS predoctoral program (FI17/00138) from the Instituto de Salud Carlos III (Spain) and co-funded by the European Union (ERDF/ESF, "A way to make Europe”/ “Investing in your future”) and The Biomedical Research Foundation of La Princesa University Hospital. Angela Ib´a˜nez thanks the support of CIBERSAM and of the Spanish Ministry of Science, Innovation and Universities. Instituto de Salud Carlos III (PI16/00834 and PI19/01295) co-financed by ERDF Funds from the European Commission. Covadonga M. Díaz-Caneja holds a Juan Rod´es Grant from Instituto de Salud Carlos III (JR19/00024). Celso Arango was supported by the Spanish Ministry of Science and Innovation. Instituto de Salud Carlos III (SAM16PE07CP1, PI16/02012, PI19/ 024), co-financed by ERDF Funds from the European Commission, “A way of making Europe”, CIBERSAM. Madrid Regional Government (B2017/BMD-3740 AGES-CM-2), European Union Structural Funds. European Union Seventh Framework Program under grant agreements FP7-4-HEALTH-2009-2.2.1-2-241909 (Project EU-GEI), FP7- HEALTH- 2013-2.2.1-2-603196 (Project PSYSCAN) and FP7- HEALTH-2013- 2.2.1-2-602478 (Project METSY); and European Union H2020 Program under the Innovative Medicines Initiative 2 Joint Undertaking (grant agreement No 115916, Project PRISM, and grant agreement No 777394, Project AIMS-2-TRIALS), Fundaci´on Familia Alonso, Fundaci´on Alicia Koplowitz and Fundaci´on Mutua Madrile˜na

BackgroundHealthcare workers (HCWs) from COVID-19 hotspots worldwide have reported poor mental health outcomes since the pandemic's beginning. The virulence of the initial COVID-19 surge in Spain and the urgency for rapid evidence constrained early studies in their capacity to inform mental health programs accurately. Here, we used a qualitative research design to describe relevant mental health problems among frontline HCWs and explore their association with determinants and consequences and their implications for the design and implementation of mental health programs.Materials and methodsFollowing the Programme Design, Implementation, Monitoring, and Evaluation (DIME) protocol, we used a two-step qualitative research design to interview frontline HCWs, mental health experts, administrators, and service planners in Spain. We used Free List (FL) interviews to identify problems experienced by frontline HCWs and Key informant (KI) interviews to describe them and explore their determinants and consequences, as well as the strategies considered useful to overcome these problems. We used a thematic analysis approach to analyze the interview outputs and framed our results into a five-level social-ecological model (intrapersonal, interpersonal, organizational, community, and public health).ResultsWe recruited 75 FL and 22 KI interviewees, roughly balanced in age and gender. We detected 56 themes during the FL interviews and explored the following themes in the KI interviews: fear of infection, psychological distress, stress, moral distress, and interpersonal conflicts among coworkers. We found that interviewees reported perceived causes and consequences across problems at all levels (intrapersonal to public health). Although several mental health strategies were implemented (especially at an intrapersonal and interpersonal level), most mental health needs remained unmet, especially at the organizational, community, and public policy levels.ConclusionsIn keeping with available quantitative evidence, our findings show that mental health problems are still relevant for frontline HCWs 1 year after the COVID-19 pandemic and that many reported causes of these problems are modifiable. Based on this, we offer specific recommendations to design and implement mental health strategies and recommend using transdiagnostic, low-intensity, scalable psychological interventions contextually adapted and tailored for HCWs.

Objective: To examine any prospective association between neutrophil-to-lymphocyte ratio (NLR) at hospital admission and subsequent delirium in older COVID-19 hospitalized patients comparing by sex and age groups.Methods: The sample consisted of 1,785 COVID-19 adult inpatients (minimum sample size required of 635 participants) admitted to a public general hospital in Madrid (Spain) between March 16th and April 15th, 2020. Variables were obtained from electronic health records. Binary logistic regression models were performed between baseline NLR and delirium adjusting for age, sex, medical comorbidity, current illness severity, serious mental illness history and use of chloroquine and dexamethasone. An NLR cut-off was identified, and stratified analyses were performed by age and sex. Also, another biomarker was tested as an exposure (the systemic immune-inflammation index –SII).Results: 55.3% of the patients were men, with a mean age of 66.8 years. Roughly 13% of the patients had delirium during hospitalization. NLR on admission predicted subsequent delirium development (adjusted OR = 1.02, 95 percent CI: 1.00–1.04, p = 0.024). Patients between 69 and 80 years with NLR values > 6.3 presented a twofold increased risk for delirium (p = 0.004). There were no sex differences in the association between baseline NLR and delirium (p > 0.05) nor SII predicted delirium development (p = 0.341).Conclusion: NLR is a good predictor of delirium during hospitalization, especially among older adults, independently of medical comorbidity, illness severity, and other covariates. Routine blood tests on admission might provide valuable information to guide the decision-making process to be followed with these especially vulnerable patients.

Objective According to randomized trials, contact after a suicide attempt lowers relapse risk. However, effectiveness studies based on real clinical data can provide additional external validity. Method We conducted an observational study to determine if an emergency department (ED)-initiated intervention for suicide attempt risk reduction, consisting on scheduling a single added appointment within 7 days after discharge following a suicide attempt, can reduce the risk of relapse. The study included 1,775 patients who had been treated at a general hospital ED due to a suicide attempt. The principal outcome measure was ED return after a new attempt. We obtained Kaplan-Meier survival functions and used Cox proportional hazard regression models to estimate unadjusted and adjusted risks of relapse by treatment phase. Covariates included: age, gender, history of suicide attempts, history of psychiatric disorders, concurrent alcohol/drug abuse, number of attempts during follow-up, admission as an inpatient and family support. Results A total of 497 (22.5%) attempts were followed by a relapse. Subjects exposed to the studied intervention had a lower risk of relapse after a suicide attempt, with a 24% adjusted risk reduction estimate. Conclusion Our real-world results suggest that an additional early appointment, scheduled before discharging suicide attempters, reduces suicide reattempt risk.

Background During the initial COVID-19 outbreak, health systems faced unprecedented organizational stress. Meanwhile, reports of episodes of discrimination and violence towards healthcare workers increased globally. This study explores the association between perceived discrimination and mental health outcomes in a large sample of healthcare workers in Spain. Materials and methods Healthcare workers from inpatient and outpatient facilities (N = 2,053) filled an on-line questionnaire in May or June 2020. Mental health outcomes included depression symptoms (Patient Health Questionnaire [PHQ-9]), psychological distress (General Health Questionnaire [GHQ-12]) and death thoughts (Columbia Suicide Severity Rating Scale [C-SSRS]). We also measured perceived discrimination and/or stigmatization due to being a healthcare worker since pandemic onset. Regression models adjusted for potential confounding sources (age, sex, history of a mental health diagnosis and type of job) were fitted. Results Thirty percent of the respondents reported discrimination and/or stigmatization. Perceived discrimination was associated with higher depression (B = 2.4, 95 percent CI: 1.8, 2.9) and psychological distress (B = 1.1, 95 percent CI: 0.7, 1.4) scores, and with a 2-fold increase in risk of reporting death thoughts (OR = 2.0, 95 percent CI: 1.4, 3.1). Conclusions Perceived discrimination is a modifiable driver of mental health problems among healthcare workers. Mass media, legislators, and healthcare institutions must put in place prevention and restoration strategies to limit discrimination towards healthcare workers and reduce its mental health impact.

To compare the effect of a mindfulness-based mobile application versus an in-person mindfulness-based training program in terms of reducing anxiety and increasing empathy, self-compassion, and mindfulness in a population of healthcare students.The authors conducted a single-blind, randomised controlled trial with three parallel groups. Participants were allocated to the mobile app, the in-person mindfulness-based program (IMBP), or a control group. Assessments at baseline and postintervention (8 weeks) included measures of anxiety, empathy, self-compassion, and mindfulness.Of 168 students randomised, 84 were analysed on an intention-to-treat basis (app:A mobile app can be as effective as an IMBP in reducing anxiety and increasing self-compassion and mindfulness among healthcare students.

RESUMEN La sujeción mecánica en psiquiatría es un procedimiento permitido en España que despierta importantes conflictos éticos. Diversos estudios sostienen que su uso depende de factores no clínicos, como las experiencias de los profesionales y las influencias del contexto, más que de factores clínicos (diagnósticos o síntomas). El objetivo del estudio es comprender las experiencias de profesionales de salud mental en formación en relación con el uso de sujeciones en la red de salud mental de Madrid. Es un estudio cualitativo de tipo fenomenológico mediante grupos focales, realizados en 2017. Las entrevistas fueron transcritas para su discusión y análisis temático mediante Atlas.ti. Los resultados descriptivos sugieren que estas medidas producen malestar y conflicto con relación al rol de cuidador y se observan estrategias de adaptación a los mismos. A partir de los hallazgos, se reflexiona acerca de aspectos de sus experiencias y del contexto que influyen en su uso, así como de las contradicciones del cuidado en la práctica clínica ABSTRACT Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals’ experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid’s mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice

Objective: To determine the cost-effectiveness of 2 strategies for post-discharge suicide prevention, an Enhanced Contact intervention based on repeated in-person and telephone contacts, and an individual 2-month long problem-solving Psychotherapy program, in comparison to facilitated access to outpatient care following a suicide attempt. Methods: We conducted a cost-effectiveness analysis based on a decision tree between January and December 2019. Comparative effectiveness estimates were obtained from an observational study conducted between 2013 and 2017 in Madrid, Spain. Electronic health care records documented resource use (including extra-hospital emergency care, mortality, inpatient admission, and disability leave). Direct cost data were derived from Madrid’s official list of public health care prices. Indirect cost data were derived from Spain’s National Institute of Statistics. Results: Both augmentation strategies were more cost-effective than a single priority outpatient appointment considering reasonable thresholds of willingness to pay. Under the base-case scenario, Enhanced Contact and Psychotherapy incurred, respectively, €2,340 and 6,260 per averted attempt, compared to a single priority appointment. Deterministic and probabilistic sensitivity analyses showed both augmentation strategies to remain cost-effective under several scenarios. Enhanced Contact was slightly cost minimizing in comparison to Psychotherapy (base-case scenario: €−196 per averted attempt). Conclusions: Two post-discharge suicide prevention strategies based on Enhanced Contact and Psychotherapy were cost-effective in comparison to a single priority appointment. Increasing contacts between suicide attempters and mental health-care providers was slightly cost minimizing compared to psychotherapy.

The links between psychosis and socio-economic disadvantage have been widely studied. No previous study has analysed the interrelationships and mutual influences between functioning dimensions in first episode of psychosis (FEP) according to their neighbourhood household income, using a multidimensional and transdiagnostic perspective. 170 patients and 129 controls, participants in an observational study (AGES-CM), comprised the study sample. The WHO Disability Assessment Schedule (WHODAS 2.0) was used to assess functioning, whereas participants' postcodes were used to obtain the average household income for each neighbourhood, collected by the Spanish National Statistics Institute (INE). Network analyses were conducted with the aim of defining the interrelationships between the different dimensions of functioning according to the neighbourhood household income. Our results show that lower neighbourhood socioeconomic level is associated with lower functioning in patients with FEP. Moreover, our findings suggest that “household responsibilities” plays a central role in the disability of patients who live in low-income neighbourhoods, whereas “dealing with strangers” is the most important node in the network of patients who live in high-income neighbourhoods. These results could help to personalize treatments, by allowing the identification of potential functioning areas to be prioritized in the treatment of FEP according to the patient's neighbourhood characteristics.

The measures to contain the spread of the COVID-19 outbreak have no precedent in the recent history of many countries. Around 2,000 million people in the world are in isolation or quarantine, and gatherings of people have been expressly banned in many countries. In Spain, this prohibition affects workplaces, schools, and the national health system, where most of the healthcare is being provided either on the phone or online.

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.La sujeción mecánica en psiquiatría es un procedimiento permitido en España que despierta importantes conflictos éticos. Diversos estudios sostienen que su uso depende de factores no clínicos, como las experiencias de los profesionales y las influencias del contexto, más que de factores clínicos (diagnósticos o síntomas). El objetivo del estudio es comprender las experiencias de profesionales de salud mental en formación en relación con el uso de sujeciones en la red de salud mental de Madrid. Es un estudio cualitativo de tipo fenomenológico mediante grupos focales, realizados en 2017. Las entrevistas fueron transcritas para su discusión y análisis temático mediante Atlas.ti. Los resultados descriptivos sugieren que estas medidas producen malestar y conflicto con relación al rol de cuidador y se observan estrategias de adaptación a los mismos. A partir de los hallazgos, se reflexiona acerca de aspectos de sus experiencias y del contexto que influyen en su uso, así como de las contradicciones del cuidado en la práctica clínica.

Introduction: The COVID-19 outbreak is having an impact on the well-being of healthcare workers. Mindfulness-based interventions have shown effectiveness in reducing stress and fostering resilience and recovery in healthcare workers. There are no studies examining the feasibility of brief mindfulness-based interventions during the COVID-19 outbreak. Materials and Methods: This is an exploratory study with a post intervention assessment. We describe an on-site brief mindfulness intervention and evaluate its helpfulness, safety, and feasibility. Results: One thousand out of 7,000 (14%) healthcare workers from La Paz University Hospital in Madrid (Spain) participated in at least one session. One hundred and fifty out of 1,000 (15%) participants filled out a self-report questionnaire evaluating the helpfulness of the intervention for on-site stress reduction. Ninety two subjects (61%) participated in more than one session. Most of the participants were women (80%) with a mean age of 38.6 years. Almost half of the sample were nurses (46%). Sessions were perceived as being helpful with a mean rating of 8.4 on a scale from 0 to 10. Only 3 people (2%) reported a minor adverse effect (increased anxiety or dizziness). Discussion: Our data supports the utility, safety and feasibility of an on-site, brief mindfulness-based intervention designed to reduce stress for frontline health workers during a crisis. There is a need to continue testing this type of interventions, and to integrate emotion regulation strategies as an essential part of health workers' general training. Clinical Trial Registration number: NCT04555005.

Resumen Introduccion Varios estudios estadounidenses han investigado la conducta delictiva en las personas sin hogar con trastorno mental grave. Pero hasta la fecha ninguno se ha realizado en Espana. Metodologia Estudio observacional retrospectivo, en una muestra de 118 pacientes, seleccionados de un programa de atencion psiquiatrica para personas sin hogar con trastorno mental grave. Se analizaron los factores asociados a la conducta delictiva mediante la comparacion de 2 grupos, con y sin antecedentes penales. Resultados El 24,6% de la muestra tenia algun antecedente penal y el 58,6% de este grupo habia ingresado en prision. Se encontraron diferencias significativas entre ambos grupos para las variables: sexo, condenas pendientes, duracion del sinhogarismo, comorbilidad con politoxicomania, conciencia de enfermedad y gravedad de los sintomas psicoticos. Conclusiones En la poblacion de personas sin hogar con trastorno mental grave, con independencia del sexo, la coexistencia de comorbilidad con politoxicomania y una duracion prolongada del sinhogarismo, constituyen el factor de riesgo mas importante para la conducta delictiva.

Introduction Several US studies have investigated the criminal behaviour among homeless individuals with severe mental illness. But to date, no studies have been carried out in Spain. Method A retrospective observational study was conducted on a sample of 118 patients selected from a psychiatric care programme for homeless individuals with severe mental illness. Factors associated with criminal behaviour were analysed by comparing 2 groups, with and without criminal records. Results Of the total sample studied, 24.6% had a criminal record, and 58.6% of them had entered prison. Significant differences between groups were found for the variables of gender, pending sentences, duration of homelessness, multiple substance use, disease awareness, and severity of psychotic symptoms. Conclusions In the population of homeless individuals with severe mental illness, regardless of gender, the co-existence of comorbidity with multiple substance use, and a prolonged duration of homelessness, is the most important risk factor for criminal behaviour.

Schizophrenia is a clinically heterogeneous syndrome affecting multiple dimensions of patients’ life. Therefore, its treatment might require a multidimensional approach that should take into account the efficacy (the ability of an intervention to get the desired result under ideal conditions), the effectiveness (the degree to which the intended effect is obtained under routine clinical practice conditions or settings) and the efficiency (value of the intervention as relative to its cost to the individual or society) of any therapeutic intervention. In a first step of the process, a group of 90 national experts from different areas of health-care and with a multidimensional and multidisciplinary perspective of the disease, defined the concepts of efficacy, effectiveness and efficiency of established therapeutic interventions within 7 key dimensions of the illness: symptomatology; comorbidity; relapse and adherence; insight and subjective experience; cognition; quality of life, autonomy and functional capacity; and social inclusion and associated factors. The main conclusions and recommendations of this stage of the work are presented herein.

Background People who suffer a first episode of psychosis experience higher levels of distress and suffering. Early intervention programs combine pharmacological and psychosocial strategies that include different components, such as cognitive-behavioural therapy, psychosocial interventions, medication adherence, family psychoeducation, counselling, etc. Among the complementary approaches, mindfulness-based interventions help participants to cultivate a radical acceptance of their psychotic experiences within a person-centered framework. They show promising results for people with longer duration of psychosis, but there is still no evidence for people who have recently experienced their first episode of psychosis. Methods The present parallel-group, single-blind (evaluator), randomised (1:1 ratio), controlled (versus active comparator), superiority, clinical trial will compare the effectiveness of SocialMIND on social functioning as measured by the Personal and Social Performance (PSP) scale. The active comparator will be a psychoeducational multicomponent intervention (PMI) that incorporates elements of early intervention programs that are effective for people who have suffered a first episode of psychosis. Both SocialMIND and PMI encompass eight weekly sessions, four bi-weekly sessions, and five monthly sessions. Changes in primary and secondary outcomes will be measured after weekly (8th week), bi-weekly (16th week) and monthly sessions (56th week), and 3 months after completing the intervention (68th week). Secondary outcomes include symptoms of psychosis, anxiety and depression, as well as indicators of general functioning. Tertiary outcomes are measures of social cognition, neurocognition, mindfulness, and indicators of inflammation and oxidative stress. A final sample of 80 participants is proposed to detect clinically significant differences in social functioning. Discussion This is the first mindfulness-based social cognition training for people with psychosis. SocialMIND aims to generate changes in the real-life functioning of people who have experienced a first episode of psychosis, and to be at least as effective as a psychoeducational multicomponent program. Adherence to the interventions is a common problem among young people with psychosis, so several difficulties are anticipated, and some methodological issues are discussed. Trial registration The trial was registered in ClinicalTrials.gov in October 2018 (NCT03309475).

Introduction Two statistical sources provide data on hospital stays and discharges for all Spanish hospitals: Hospital Morbidity Survey (acronym in Spanish: EMH) and Statistics of Health Establishments providing Inpatient Care (acronym in Spanish: EESCRI). Our aim is to contrast these two statistical sources to define their accuracy and relevance in psychiatric epidemiology studies. Material and methodology The analysis is based on two aspects: (1) Compare the number of psychiatric stays and hospital discharges from 1990 to 2009. (2) Analyse and compare how the average stay is provided. Results The differences between the two statistical sources are significant and increase over time. In 2005–2009 the EMH records 121% of hospitalisations (577,078 vs 475,414) and 46% (14,239,527 vs 30,821,412) of psychiatric stays, compared with EESCRI. Moreover, the average stay estimated by EESCRI shows serious methodological problems, particularly in settings of prolonged hospitalisation (psychiatric hospitals); the estimations are potentially below the real value. Conclusions Surprisingly, the questionnaires completed by hospitals to develop the EESCRI provide data on assisted morbidity quite different from that provided by the EMH, despite both statistical sources having the same inpatient records for data processing. It is difficult to attribute these differences to sampling error, as the EMH has a very high sampling fraction, which minimises the sampling error. Given the mismatch between sources, we recommend using the EMH, as it offers more reliable data and allows an accurate determination of the length of stays.

Resumen Introduccion Dos fuentes estadisticas sanitarias proporcionan datos sobre altas y estancias en todos los hospitales espanoles: la Encuesta de Morbilidad Hospitalaria (EMH) y la Estadistica de Establecimientos Sanitarios con Regimen de Internado (EESCRI). Nuestro objetivo es contrastar ambas fuentes para definir su precision y pertinencia en estudios de epidemiologia psiquiatrica. Material y metodos Se focaliza el analisis en 2 aspectos: 1.- comparar el numero de altas y estancias psiquiatricas recogidas entre 1990-2009; 2.- analizar y comparar el modo en que se proporciona la estancia media. Resultados Las diferencias entre ambas fuentes son profundas y aumentan con el tiempo. En 2005-2009 la EMH registro un 121% mas de altas (577.078 vs. 475.414) y un 46% (14.239.527 vs. 30.821.412) menos de estancias psiquiatricas que la EESCRI. Por otra parte, la estancia media estimada a traves de la EESCRI presenta serios problemas metodologicos, particularmente en entornos con hospitalizaciones prolongadas (hospitales psiquiatricos), siendo la estimacion de la EESCRI potencialmente inferior al valor real. Conclusiones Sorprende que los cuestionarios cumplimentados por los hospitales para elaborar la EESCRI proporcionen una morbilidad asistida tan alejada de la que recoge la EMH, cuando ambas fuentes disponen de los mismos registros de pacientes hospitalizados para su elaboracion. Resulta dificil atribuir esas diferencias a errores de muestreo, ya que la EMH posee una fraccion de muestreo muy elevada, lo que minimiza el error muestral. Ante la discordancia entre fuentes se aconseja utilizar la EMH que ofrece datos mas fiables y permite determinar con precision la duracion de las hospitalizaciones.

Objective: To determine the comparative effectiveness of 3 real-practice preventive programs aimed at lowering the relapse risk following a suicide attempt: a single priority appointment with an outpatient psychiatrist, an enhanced contact intervention, and an individual psychotherapy program. Methods: This observational study was conducted in a sample of 1,492 suicide attempters from 3 catchment areas in Madrid, Spain, between 2013 and 2017. Relapse was defined as an emergency department return after a new attempt within a 1-year follow-up. Kaplan-Meier survival functions were obtained by intervention, and Cox proportional hazard regression models were used to estimate unadjusted and adjusted risks of relapse by intervention. Sex- and age-stratified analyses were also conducted. Covariates were age, sex, history of suicide attempts, history of psychiatric disorders, main ICD-10 psychiatric diagnostic groups, medical comorbidities, and family support. Results: A total of 133 subjects (8.9%) relapsed. The psychotherapy group had a lower presence of known risk factors for suicide attempt. Individual psychotherapy and enhanced contact were more effective than a single priority appointment at reducing suicide reattempt, with a 40% lower relapse risk in adjusted models. Results did not differ after sex and age stratification. Conclusions: In a naturalistic clinical setting, patients exposed to individual psychotherapy or an enhanced contact intervention had a similar, lower relapse risk than the single priority appointment group.

Schizophrenia is a clinically heterogeneous syndrome affecting multiple dimensions of patients' life. Therefore, its treatment might require a multidimensional approach that should take into account the efficacy (the ability of an intervention to get the desired result under ideal conditions), the effectiveness (the degree to which the intended effect is obtained under routine clinical practice conditions or settings) and the efficiency (value of the intervention as relative to its cost to the individual or society) of any therapeutic intervention. In a first step of the process, a group of 90 national experts from different areas of health-care and with a multidimensional and multidisciplinary perspective of the disease, defined the concepts of efficacy, effectiveness and efficiency of established therapeutic interventions within 7 key dimensions of the illness: symptomatology; comorbidity; relapse and adherence; insight and subjective experience; cognition; quality of life, autonomy and functional capacity; and social inclusion and associated factors. The main conclusions and recommendations of this stage of the work are presented herein.

Aims.To assess the impact of the Continuity-of-Care Program (CCP; a clinical case management model) on hospital use of persons with schizophrenia in three Community Mental Health Services in Madrid (Spain).Methods.Using data provided by the Psychiatric Case Register, we analyzed the use of hospitalization in 250 individuals before and after the date of inclusion in this program.Results.During the first year after launching the program, there was a 40–69% reduction in the number of admissions, length of each hospital stay, proportion of admitted patients, total number of days in-hospital, proportion of patients visiting the emergency room, and emergency room visits. This drop was maintained over the subsequent 3 years of program functioning.Conclusions.These results encourage the development and implementation of such programs, even though more studies evaluating the effectiveness of these programs for other endpoints are needed.

This study aimed to investigate quality of life and burden on caregivers in Spanish outpatients with schizophrenia, treated with different antipsychotics.Sociodemographic and clinical data were collected for 1865 patients diagnosed with schizophrenia. Patients answered the EuroQol-5D questionnaire and caregivers answered questionnaires assessing caregiver burden. Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression of Severity (CGI-S), and clinician's satisfaction were also recorded. The same data were also collected at months 3 and 6.According to EQ-5D results, usual activities (29.6%) and anxiety/depression (31.1%) were the most relevant reported problems. Good overall scores (5-7) on EQ-5D were reported by 47/118 (39.8%) of risperidone long-acting injectable (LAI) patients compared to 52/218 (23.9%) for oral conventional antipsychotics, 51/194 (26.2%) for injectable conventional antipsychotics, and 332/1110 (29.9%) for oral atypical antipsychotics. Significant benefits of risperidone LAI vs. other types of antipsychotic were also found in caregiver burden and clinician-derived outcome measures. At months 3 and 6, retention was85%, and score on the EQ5D improved for the overall sample.In Spanish patients with schizophrenia, activities of daily living and anxiety/depression were more relevant reported problems. Risperidone LAI was associated with better quality-of-life outcomes and lower caregiver burden compared to other types of antipsychotic.

Introduction Primary Insomnia is difficulty in initiating, or maintaining sleep, waking up too early, or sleep that is chronically nonrestorative or of poor quality (AASM, 2005) that can not be explained by another mental disorder, medical illness or substance abuse disorder. Psychological factors, such as depression, anxiety and excessive worry, can strongly influence insomnia (Kales and Vgontzas, 1992). Moreover, the personality profiles of insomniacs may differ from those of normal controls (de Saint Hilaire et al., 2005), suggesting that personality traits may also influence the severity of insomnia. Both depression and anxiety have been suggested to be the underlying link between personality and insomnia (Harvey and Greenall, 2003; Ongur et al., 2005; Carney et al., 2010), though the precise mechanism of this influence is unclear at the moment. Traditional studies using the MMPI and found higher scores in patients insomniacs: Traits of neuroticism, anxiety, worry (Freedman and Sattler, 1982), Personality styles aimed at internalizing the concerns and increased psychological and physiological activation (Kales, Caldwell, Preston, Healey and Kales, 1976). According to these results, it is found more anxiety, both psychic and somatic, in patients suffering from insomnia (Lundh, Broman and Hetta, 1995). Studies applying the Temperament and Character Inventory (TCI-R) Clonninger consistently show higher Harm Avoidance in insomniac patients than in control and less self- direction (De Saint Hilaire, Straub & Pelissolo, 2005). Severity of insomnia correlates (Park, An, Jang and Chung, 2012): Positively with Harm Avoidance; Negatively with Novelty Seeking, Cooperation and Reward Dependence Objectives: Analyze temperamental and characterological features of a group of patients diagnosed with primary insomnia To study the relationship between the severity of insomnia and anxiety and depression symptoms. Materials and methods Sample: 25 patients diagnosed with primary insomnia Instruments: Beck Depression Inventory (BDI), Hamilton Anxiety Scale, Temperament and Character Inventory- Revised (TCI-R), Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale, the Horne and Ostberg morning/evening questionnaire (MEQ), and actigraphy. Statistical Analysis: Raw scores on TCI-R were standardized and transformed into Z scores following normative data (Gutierrez- Zotes et al., 2003), compared with population mean using a Student t test for one sample (comparison value=0 ). We used Pearson correlation between BDI, Hamilton and ISI. Results The scores on the Harm Avoidance scale are significantly above average in patients with primary insomnia ( t =4.51, p t =−2.51, p =0.02) The measures of anxiety and depression correlated with each other ( r =0.71, p r =0.22 and r =0.02, respectively). Conclusion The results are consistent with the literature reviewed in a greater tendency to harm avoidance and lower self-direction in patients with insomnia The present study found no relationship between the severity of insomnia and anxiety and depression symptoms In light of the results are proposed therapeutic interventions aimed at increasing active coping and improving emotional regulation. Acknowledgement Sara Izquierdo and Ana Alcon, clinical psychological trainees, who also collaborated in the studio and of course patients.

En el presente trabajo se revisan los distintos modelos de Programas de Seguimiento y Cuidado de enfermos mentales graves y cronicos en la comunidad (Modelo de agencia, «case management» clinico, «case management» intensivo, tratamiento asertivo comunitario, modelo de competencias y modelo rehabilitador) y se analizan sus caracteristicas diferenciales. Asi mismo se describen los programas de estas caracteristicas que se han desarrollado en el estado espanol en las ultimas decadas y se presentan los resultados preliminares del estudio IPSE («Impacto de los Programas de Seguimiento y Cuidados en personas con trastornos Esquizofrenicos en la Comunidad») en cuanto a: la valoracion cualitativa de los programas por parte de los usuarios y familiares, las caracteristicas que contribuyen al adecuado funcionamiento del programa y a la consecucion de los objetivos, y los obstaculos comunes a su adecuada implementacion.