Domenico Berardi

Subthreshold psychiatric disorders in primary care: prevalence and associated characteristics

BACKGROUND The authors analyse the prevalence of subthreshold psychiatric disorders in primary care and their association with the patients health perception, disability in daily activities and psychological distress. METHODS Five-hundred and fifty-four primary care patients who completed a two-phase study were administered the Composite International Interview for Primary Health Care (CIDI-PHC) and other self-report measures. Unweighted and weighted prevalence estimates were obtained for ICD-10 formal disorders and subthreshold disorders defined by specific operational criteria. The impact of subthreshold disorders on health perception, disability in daily activities and psychological distress was analysed by using multiple regression models. RESULTS The overall prevalence of subthreshold disorders exceeded that of ICD-10 disorders. Subjects with subthreshold disorders reported levels of psychological distress, disability in daily activities and perceived health comparable to those of patients with full-fledged ICD-10 disorders. When we analysed the associated health characteristics of individual subthreshold disorders, we found that each subthreshold disorder was characterized by poorer health perception, after adjusting for comorbidity with defined disorders and physical illness, age and gender. Disability in daily activities was increased in individuals with subthreshold depression and agoraphobia. LIMITATIONS The number of cases with subthreshold panic and somatization is very small and does not allow one to draw any definite conclusions on their associated characteristics. To reduce non-response bias related to sampling design and refusals, adjusted sampling weights were computed. Since the study design in Bologna and Verona was different and Bologna patients scoring <4 on the General Health Questionnaire were not interviewed, individuals with minimal distress come from the Verona sample alone. CONCLUSIONS Because of the prevalence and associated characteristics of subthreshold disorders, primary care physicians should attach adequate importance to the patients perceived poor health, distress and inability to fulfil daily tasks. The clinical relevance of subthreshold disorders has also potential implications for ongoing revisions of classification systems.

Mental, physical and functional status in primary care attenders.

Objective: The purpose of the present study was to analyze the association, in primary care attenders, between psychiatric disorders, medical comorbidity, and impairment in mental and physical function status. Methods: The study had a two-stage design. The GHQ-12 was used to screen 1647 patients, and 323 of them were then interviewed using the CIDI-PHC to obtain ICD-10 diagnoses. Severity of mental illness was assessed using the Hamilton scales for anxiety and depression. The DUSOI was used to evaluate the severity of physical illness. The MOS SF-36 was used to assess health related quality of life. Results: The estimated prevalence of ICD-10 psychiatric disorders and subthreshold disorders was 12.4 percent and 18 percent respectively. The most common psychiatric disorders were generalized anxiety, major depression, and neurasthenia. The severity of physical illness did not vary across diagnostic status categories. Significant impairment, both in physical and mental functioning was seen in patients suffering from ICD-10 full-fledged and subthreshold disorders. Severity of impairment increased from subthreshold cases to full-fledged cases, and among the latter according to the severity of depressive and anxious symptoms, assessed using Hamilton scales. The most frequent psychiatric disorders were associated with significant worsening in health related quality of life, with relevant differences between psychiatric diagnoses regarding the domains affected. Impairment associated with mental disorders was greater than that associated with physical illness. Conclusions: The results of the present study confirm that ICD-10 psychiatric disorders are common in general practice and are associated with relevant impairment in physical and mental functional status. Psychiatric morbidity is not related to severity of physical illness rated by general practitioner.

Atypical Neuroleptic Malignant Syndrome Associated with Clozapine Treatment

Clozapine is an atypical neuroleptic drug that was initially thought not to cause neuroleptic malignant syndrome (NMS). The authors report a case of NMS associated with clozapine use, developed in a patient without previous history of NMS. Considering that 13 such cases (including ours) have been reported so far, NMS should be considered in the differential diagnosis of a febrile patient treated with clozapine.

Clinical correlates of akathisia in acute psychiatric inpatients.

&NA; This study identified acute and chronic akathisia in acute psychiatric inpatients receiving conventional antipsychotic medication, and evaluated the clinical characteristics, risk factors and clinical implications of the condition. Akathisia and other movement disorders were systematically assessed in patients consecutively admitted to an acute psychiatric ward over one year. Akathisia was diagnosed in 15 (21%) of 72 patients. Akathisia, developing as an acute condition in seven patients, generally presented with the subjective experience of dysphoria and unease without restless movements. This acute akathisia developed during the first few days of hospitalization and was associated with both a higher average dose of antipsychotic medication and a greater increase in dosage. In the remaining eight cases, akathisia was already present on admission, and thus classified as chronic. Those patients with chronic akathisia exhibited both subjective restlessness and the characteristic restless movements. Chronic akathisia was unrelated to antipsychotic dosage. The proportion of patients with akathisia who discontinued drug treatment was significantly higher than that for patients without the condition. Patients with acute akathisia tended to drop‐out of treatment and those with the chronic form tended to have treatment withdrawn by the prescribing clinician. One interpretation is that the subjective distress of acute akathisia may be particularly difficult for patients to tolerate and leads them to stop medication, while patients with more chronic akathisia may have become more accepting of the experience. Repetitive movements of the legs were observed more commonly in those with chronic rather than acute akathisia, and may represent a way of achieving some limited respite.

The Bologna Primary Care Liaison Service: First Year Evaluation

Primary care and mental health were recently integrated by the Italian health authorities. The Bologna Primary Care Liaison Service (PCLS) is ideally suited to the Italian National Health Care System, because most primary care physicians practice individually and mental health services provide first level care. The distinctive features of the program are: 1) location within a mental health center; 2) comprehensive mental health assessment and intervention; 3) collaboration between primary care physicians and mental health services which is facilitated through committees and communication. First year results met expectations. Integrating a PCLS program within a mental health center can be a viable means of implementing national policy.

Extrapyramidal symptoms and residual psychopathology with low-dose neuroleptics

Residual psychopathology associated with EPS has been mainly assessed in experimental studies where neuroleptics were administered at standard, fixed dosages. The present study evaluates residual psychopathology in 69 schizophrenic patients treated with moderate, flexible doses of neuroleptics (430 mg eq. CPZ) at the out‐patient Community Mental Health Services (CMHSs) in Bologna. Akathisia was present in 27·5 per cent of patients and parkinsonism in 27·5 per cent. A more severe psychopathological state was associated with both side‐effects, as seen by significantly higher BPRS global scores. This severity was due to tension and anxiety–depression symptoms in patients with akathisia and to negative symptomatology in patients with parkinsonism, as shown by significant associations with BPRS subscales ANS‐DEP and NEG, respectively. In conclusion, the present study underlines that EPS are frequent even in an out‐patient setting where moderate neuroleptic doses are employed, and more importantly shows that in these conditions, the residual psychopathology resulting from EPS is clinically very significant. Copyright

Clozapine effectiveness in a psychiatric service in Italy

Clozapine was administered to 28 resistant schizophrenics at psychiatric services in Bologna. At 26 weeks 62% responded. Positive and negative symptoms improved, but decrease of negative symptoms partially depended upon improvement of positive and EPS. No cases of agranulocytosis were seen. Some drop-outs were related to difficulties with psychopathological improvement.