Andrea Fiorillo

Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS)

BackgroundThe aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff.MethodsA participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland).ResultsIn both patient and staff versions, the two CDMS subscales “Participation in Decision Making” and “Information” reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation.ConclusionsTogether with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) – “Clinical Decision Making in Routine Care” and “Clinical Decision Making Involvement and Satisfaction” – the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.

Psychoeducational family interventions for schizophrenia in the last decade: from explanatory to pragmatic trials

A number of explanatory RCT studies published since the 1980s have demonstrated the clinical efficacy of Psychoeducational Family Interventions (PFI) for schizophrenia when provided in combination with drug therapy. In recent years, there has been a shift from efficacy to effectiveness studies and great attention by the researchers in developing training programmes in these interventions for ordinary staff. In this paper, we will provide an overview of the studies on PFI for schizophrenia which have been carried out in the last decade in routine clinical settings or with at least a partial involvement of ordinary staff. These studies have been grouped into: (a) studies comparing PFI with standard care; (b) studies comparing PFI with individual integrated interventions; (c) studies comparing different PFI strategies; (d) implementation studies. The results of these studies reveal that, when provided in clinical settings, PFI have positive middle-term effects on patients clinical status and disability, and limited impact on family burden. From a methodological viewpoint, these studies had several similarities, such as homogeneity of PFI models and mid-term follow-up assessments, and several differences, mainly in the intensity and duration of the family exposure to the intervention. Future studies are needed to identify the best dose at which PFI can be provided in routine conditions at the most convenient cost-benefit ratio.

Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice.

More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review.

Desire for information of people with severe mental illness

PurposeTo assess (1) the desire of people with severe mental illness for information on their treatment and (2) whether the desire for information is associated with socio-demographic variables, diagnosis, illness duration, therapeutic relationship, needs and symptom severity.Methods588 outpatients with severe mental illness were recruited in six European countries (Germany, Denmark, Hungary, Italy, Switzerland, United Kingdom) during the “Clinical decision making and outcome in routine care of people with severe mental illness (CEDAR)” study (ISRCTN75841675). Desire for information was assessed by the Information subscale of the Clinical Decision Making Style Scale. Study participants with high desire for information were compared with those with moderate or low desire for information.Results80xa0% of study participants (nxa0=xa0462) wanted to receive information on all aspects of their treatment (management, prognosis, alternative options for care). Participants with a high desire for information had less severe symptoms (ORxa0=xa00.988, CIxa0=xa00.977–1.000) and a better self-rated therapeutic alliance (ORxa0=xa01.304, CIxa0=xa01.130–1.508) with their clinician.ConclusionsMost, but not all, people with severe mental illness have a high desire for information. Desire for information is associated with variables, such as therapeutic relationship and symptom severity, which are amenable to change during treatment.

A predictive model to allocate frequent service users of community-based Mental Health Services to different packages of care

AIMnTo develop predictive models to allocate patients into frequent and low service users groups within the Italian Community-based Mental Health Services (CMHSs). To allocate frequent users to different packages of care, identifying the costs of these packages.nnnMETHODSnSocio-demographic and clinical data and GAF scores at baseline were collected for 1250 users attending five CMHSs. All psychiatric contacts made by these patients during six months were recorded. A logistic regression identified frequent service users predictive variables. Multinomial logistic regression identified variables able to predict the most appropriate package of care. A cost function was utilised to estimate costs.nnnRESULTSnFrequent service users were 49%, using nearly 90% of all contacts. The model classified correctly 80% of users in the frequent and low users groups. Three packages of care were identified: Basic Community Treatment (4,133 Euro per six months); Intensive Community Treatment (6,180 Euro) and Rehabilitative Community Treatment (11,984 Euro) for 83%, 6% and 11% of frequent service users respectively. The model was found to be accurate for 85% of users.nnnCONCLUSIONnIt is possible to develop predictive models to identify frequent service users and to assign them to pre-defined packages of care, and to use these models to inform the funding of psychiatric care.

Effects of Clinical Decision Topic on Patients’ Involvement in and Satisfaction With Decisions and Their Subsequent Implementation

OBJECTIVEnClinical decision making is an important aspect of mental health care. Predictors of how patients experience decision making and whether decisions are implemented are underresearched. This study investigated the relationship between decision topic and involvement in the decision, satisfaction with it, and its subsequent implementation from both staff and patient perspectives.nnnMETHODSnAs part of the Clinical Decision Making and Outcome in Routine Care for People With Severe Mental Illness study, patients (N=588) and their providers (N=213) were recruited from community-based mental health services in six European countries. Both completed bimonthly assessments for one year using the Clinical Decision Making in Routine Care Scale to assess the decision topic and implementation; both also completed the Clinical Decision Making Involvement and Satisfaction Scale.nnnRESULTSnThree categories of decision topics were determined: treatment (most frequently cited), social, and financial. The topic identified as most important remained stable over the follow-up. Patients were more likely to rate their involvement as active rather than passive for social decisions (odds ratio [OR]=5.7, p<.001) and financial decisions (OR=9.5, p<.001). They were more likely to report higher levels of satisfaction rather than lower levels for social decisions (OR=1.5, p=.01) and financial decisions (OR=1.7, p=.01). Social decisions were more likely to be partly implemented (OR=3.0, p<.001) or fully implemented (OR=1.7, p=.03) than not implemented.nnnCONCLUSIONSnPatients reported poorer involvement, satisfaction, and implementation in regard to treatment-related decisions, compared with social and financial decisions. Clinicians may need to employ different interactional styles for different types of decisions to maximize satisfaction and decision implementation.

Violence and mental disorders. A retrospective study of people in charge of a community mental health center

BACKGROUNDnNumerous studies conducted in inpatient settings have highlighted how mental disorders are associated with an increased risk of violence, particularly during acute phases. However, to date a more limited number of studies have been performed to assess the risk of violence in outpatients, particularly in Italy. The present study aims to evaluate the prevalence of violent events in a sample of patients in charge of a community mental health center in Italy.nnnMETHODSnBased on data obtained from standardized clinical records, a retrospective study was undertaken to investigate acts of violence (physical aggression only) in a total of 678 patients (Males=308, 45.4%) in charge of a university mental health center; patients were mainly affected by anxiety disorders (30.7%), depressive disorder (17.2%), bipolar disorder (18.3%) and schizophrenia or other psychotic disorders (25.0%).nnnRESULTSn27.6% of the sample had committed at least one act of violence during their lifetime, 10.5% over the previous year. 56.7% of those who committed violence acts had acted violently twice or more during their lifetime. A significant association of lifetime violence was found with gender (male), younger age, low education, unemployment, living with parents. With regard to diagnosis, a significant association was found with schizophrenia and other psychotic disorders, personality disorders, mental retardation, and comorbidity between two or more psychiatric disorders. Violence was moreover associated with early age at onset and at first psychiatric treatment, longer duration of the disorder, previous hospital admissions, previous violent events.nnnCONCLUSIONnViolent behavior is relatively common among outpatients.

Urban insecurity and fear of crime in people suffering from patients with mental disorders: preliminary results of a multicentric italian study

Aims. To assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes. Methods. Twenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools. Results. The final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (±13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%). Discussion and conclusions. Our results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders. Language: itAIMSnTo assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes.nnnMETHODSnTwenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools.nnnRESULTSnThe final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (± 13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%).nnnDISCUSSION AND CONCLUSIONSnOur results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders.

Ripensare la pratica psichiatrica: riflessioni sul ruolo della psichiatria nella società moderna

In this paper we will describe cultural, social and scientific changes occurred in psychiatry in the last years, identifying the new target for mental health professionals. Groups of young psychiatrists from the Italian Psychiatric Association, the European Psychiatric Association and the World Psychiatric Association have established an international network that launched a debate on the future role of psychiatry. In a rapidly changing world, there is the need to: 1) adapt training in psychiatry to the modern world; 2) identify the new target of mental health professionals; 3) enhance the image of psychiatry in the society; 4) overcome stigma towards people with mental disorders. In recent years, socio-cultural and scientific changes have had a significant impact on the psychiatrists clinical practice. Mental health professionals should deal with these changes appropriately in order to overcome the current crisis of psychiatry, which should be considered as a developmental phase rather than a conceptual one. From time to time psychiatry is criticized both from inside and outside the profession. The current crisis was unavoidable due to the recent socio-cultural changes, but it should be considered an opportunity to adapt the profession to modern times.

[Urban insecurity and fear of crime in people suffering from mental disorders: a study in 24 Mental Health Centers in Italy].

Aims. To assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes. Methods. Twenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools. Results. The final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (±13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%). Discussion and conclusions. Our results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders. Language: itAIMSnTo assess in a sample of people with mental disorders: 1) fear of crime and perceived insecurity; 2) the association between fear of crime and insecurity; 3) the incidence of crimes.nnnMETHODSnTwenty-four Italian mental health centres have been invited to participate in the study from the network of the Early Career Psychiatrists Committee of the Italian Psychiatric Association. In each participating centre, the first 20 patients consecutively accessing the mental health centre between February and April 2011 have been recruited. All patients have been assessed using validated assessment tools.nnnRESULTSnThe final sample consists of 426 patients. They are mostly female (70.1%), with a mean age of 45 years (± 13.5), and with a good level of education. Fifty-two percent of patients have a diagnosis of mood disorders, and 37.8% on anxiety spectrum disorders. About half of the sample declares that the most prominent feeling toward life is uncertainty. Almost all patients report to have at least one big fear, with the most frequently report being: 1) loss or death of a loved one (41.2%); 2) financial constraint (28.4%); 3) physical or mental health problems (26.5%).nnnDISCUSSION AND CONCLUSIONSnOur results show the presence of a common sense of uncertainty among patients, probably as a result of the historical moment we are facing. It is reasonable that this attitude toward life can have a detrimental impact on patients psychological and physical wellbeing, contributing to high levels of distress. Further studies are needed in order to clarify the possible relationship between fears, uncertainty and mental disorders.