Franco Veltro

Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled, multicentric, real-world study

BACKGROUND This study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to bipolar I disorder. The efficacy of the intervention was evaluated in terms of improvement of patients׳ social functioning and reduction of family burden. METHODS This was a multicentre, real-world, controlled, outpatient trial carried out in 11 randomly recruited Italian mental health centres. Enroled patients and key-relatives were consecutively allocated either to receive PFI and Treatment As Usual (TAU) or to a waiting list receiving TAU alone. The efficacy of the intervention was evaluated in terms of improvement in patients׳ social functioning (primary outcome) and reduction of family burden (secondary outcome). RESULTS Of the 137 recruited families, 70 were allocated to the experimental group and 67 to the control group. At the end of the intervention, significant improvements in patients׳ social functioning and in relatives׳ burden were found in the treated group compared to TAU. This effect of the intervention remained also after controlling for several confounding patient׳s socio-demographic and clinical factors. The experimental intervention had an impact also on other outcome measures, such as patients׳ clinical status and personal burden. LIMITATIONS Lack of an active control group. CONCLUSIONS The results of this study clearly show that the psychoeducational family intervention according to the Falloon model is effective in improving the social outcome of patients with bipolar I disorder.

Baclofen-induced growth hormone secretion is blunted in chronic schizophrenics: neuroendocrine evidence for a GABA disturbance in schizophrenia

To substantiate a previously reported disturbance of gamma-aminobutyric acid (GABA) in chronic schizophrenia, plasma growth hormone (GH) response to a direct GABA agonist (baclofen, 10 mg) was assessed in 12 unmedicated chronic schizophrenic males and 10 sex- and age-matched healthy controls. Baclofen and placebo were administered orally, in a double-blind design, and blood samples were collected before and 30, 60, 90, 120, 180, and 240 min after drug or placebo administration. Baclofen induced a clear-cut rise in plasma GH levels over baseline values, but the GH increase observed in the patients was significantly smaller than that in controls. These results support the idea that GABA mechanisms may be impaired in chronic schizophrenia.

Effectiveness and efficiency of cognitive-behavioral group therapy for inpatients: 4-year follow-up study.

Objectives. The goals of this study were to evaluate the effectiveness of manualized cognitive-behavioral group therapy (CBGT) integrated into routine care on a psychiatric inpatient unit and to compare the impact of the intervention on patients with the following diagnoses: schizophrenia, major depression, bipolar disorder, or personality disorders. The results presented here expand on those presented in a previous publication by including 2 more years of data and additional analyses concerning diagnosis and economic outcomes. Method. A pre-post design was used to measure voluntary and compulsory readmissions, ward atmosphere, patient satisfaction, mean length of stay, and cost-income in the year before CBGT was introduced (2001) compared with the next 4 years. Results. In the years 2001-2005, percentage of total readmissions declined from 38% to 24% (p < 0.02); of those readmissions, 17% were compulsory in 2001 compared with 0 in 2005 (p < 0.02). A progressive improvement in ward atmosphere was observed from baseline to the following 4 years (p < 0.001). There was also statistically significant improvement in patient satisfaction compared with baseline, mainly observed during the first 2 years of the intervention (p < 0.001). The reduction in readmissions was statistically significant only for patients with schizophrenia (p < 0.001) and bipolar disorder (p < 0.04). Conclusions. These results are promising and indicate that CBGT may contribute added benefit to treatment on an inpatient psychiatric ward.

Feasibility of a psychoeducational family intervention for people with bipolar I disorder and their relatives: Results from an Italian real-world multicentre study

BACKGROUND Despite several guidelines recommend the use of psychoeducational family interventions (PFIs) as add-on in the treatment of patients with bipolar I disorder, their implementation on a large scale remains limited. The aim of the present study is to identify obstacles for the feasibility of PFIs in routine care. METHODS This was a multicentre, real-world, controlled, outpatient trial, carried out in 11 randomly recruited Italian mental health centres. Two mental health professionals from each center attended a modular training course on PFI and provided the intervention. Difficulties and benefits experienced by mental health professionals in implementing the intervention were assessed through the Family Intervention Schedule (FIS-R), which was administered six times. RESULTS Sixteen out of the 22 recruited professionals completed the training and administered the PFI to 70 patients with bipolar I disorder and their relatives. The retention rate of families receiving the intervention was 93%. Mental health professionals reported high levels of organizational difficulties, several benefits in their daily clinical work and low levels of intervention-related difficulties. The most important organizational obstacles were related to the need to integrate the intervention with other work responsibilities and to the lack of time to carry out the intervention. These difficulties did not decrease over time. Intervention-related difficulties were rated as less problematic since the first time assessment and tended to improve over time. LIMITATIONS Low number of recruited professionals; use of a not previously validated assessment instrument. CONCLUSIONS PFIs are feasible in routine care for the treatment of patients with bipolar I disorder and their relatives, and main obstacles are related to the organization/structure of mental health centres, and not to the characteristics of the intervention itself.

VADO approach efficacy in psychiatric rehabilitation: a controlled study

Aims – Assessment of the efficacy of the rehabilitation approach that is recommended by the manual VADO (AAOS in English: Abilities Assessment and Objectives Setting) in schizophrenic syndromes. Methods – Controlled trial, partly with individual randomisation. Centres were invited to recruit 10 patients who in most centres were randomly allocated either to the VADO approach or to usual rehabilitation practice. At least two professionals for each centre attended a brief intensive training course. Patients were assessed at baseline and six months later with a) the FPS scale, which is an improvement on the DSMIV SOFAS; b) the BPRS 4.0; c) AR, a clinical tool that is contained in VADO. Results – 55 patients received the experimental interventions and 40 the control one. Six months later greater significant improvements were observed in the experimental group, both in social functioning and in psychopathology. Conclusions – The dissemination of structured rehabilitation approaches that are based on personalized definition of objective, intensive progress monitoring, patients therapeutic education and validated strategies and do not imply additional costs, may be warranted. A longer follow–up is under way. Declaration of Interest : this work was partly funded by the National Mental Health Project (PNSM) of the Istituto Superiore della Sanita.

Development and Validation of a Self-Reported Questionnaire On Users’ Opinions About Schizophrenia: a Participatory Research

Background: Although users’ involvement in mental health research has repeatedly been acknowledged as having a positive influence on research quality, this rarely happens. Aims: To develop and validate a Questionnaire on Users’ Opinions (QOU) about schizophrenia, in close collaboration with 279 persons affected by this disorder. Methods: A preliminary list of items concerning the opinions of users with schizophrenia regarding causes, treatments and psychosocial consequences of the disorder was developed by 38 users with schizophrenia and 40 professionals who attended a workshop. Psychometric properties of the QOU were tested on 241 users with schizophrenia, 149 of whom were randomly assigned to a test—retest study and 92 to a face-validity study. Content and construct validity were explored in the whole sample. Results: The final version of the QOU contains: (1) 24 items on the psychosocial consequences of schizophrenia, grouped into six subscales, whose Cronbach’s alpha ranged between 0.55 and 0.74; (2) five multiple choice items on the Italian psychiatric law; (3) 12 open questions; and (4) four yes/no skipping items. Items’ reliability, measured by Cohen’s kappa coefficient, ranged between 0.55 and 0.92. Conclusion: This questionnaire may be useful to assess patients’ beliefs about schizophrenia and to target psychosocial interventions for this mental disorder.

[Randomised controlled trial of a behavioural family intervention: 1 year and 11-years follow-up].

AIM To test the efficacy of a Behavioural Family Therapy (BFT) in a routine setting, both short and long term, of a community mental health service (CMHS). METHODS In a randomised clinical trial 24 patients with a diagnosis of schizophrenia, as confirmed by PSE-IX, were assigned to the BFT according to Falloon (n = 12) or to individual usual treatment (n = 12). They were assessed before and at the end of the active treatment (after one year), and after an 11-years follow-up with compared on basic indicators (hospitalisations, length of stay, drop-out rate) and standardised instruments of psychopathological symptoms, social functioning, family burden. RESULTS At one-year follow-up clinical important and statistically significant differences were observed for psychotic positive symptoms (p<0.01), self-care (p<0.01), autonomy in daily life (p<0.001), subjective/objective family burden (p<0.001). Other psychosocial variables showed positive outcomes non reaching statistical significance. At the 11-year follow-up, marked differences were observed only in hospitalisations and drop-outs. CONCLUSIONS The BFT was rather easy to implement in a CMHS and very cost effective. However, as it has been shown in other studies, to keep all the benefits a consistent program of monitoring with booster sessions is essential.

The Development of Cognitive-Behavioral Therapies Within Italian Mental Health Services

The past two decades have seen unprecedented advances in the treatment of major mental disorders, and well-controlled research has demonstrated the efficacy of various combinations of biomedical and psychosocial strategies [1]. Prominent among the latter have been those based on psychological principles of learning and education that have become known as cognitive-behavioral psychotherapies [2]. For six years the authors were engaged in a systematic attempt to provide training and consultation in an effort to develop widespread application of evidence-based strategies throughout Italy. These included the following core strategies:

Positive screening and risk factors of postpartum depression in women who attended antenatal courses

AIM This study was designed to evaluate the prevalence of women screened positive for postpartum depression (PPD) and to investigate the main risk factors for PPD, in a large sample of Italian women. METHOD The sample (N=567) was recruited as part of 91 antenatal courses. Women were screened between the 6th and 12th week after birth, by filling the EPDS (Edinburg Postnatal Depression Scale). The validated cut-off score of ≥12 was used. Socio-demographic and clinical variables were investigated. RESULTS Out of the 567 screened women, 42 (7.4%) were positive. A higher risk was found in women who, during pregnancy, had a depressed mood (OR=3.2) or suffered from anxiety (OR=6.3), had little (OR=4.8) or no (OR=6.5) psychological support from friends or family, or their partner (OR=4.4), had a baby given to crying (OR=7.8), had a low self-esteem (OR=4.8), or had had, as children, a mother that was often (OR=4.6) or always (OR=12.5) critical of them. DISCUSSIONS AND CONCLUSIONS The results of the study are in agreement with the literature considering social and family support and the presence of anxiety and/or depression during pregnancy as main risk factors for PPD. In disagreement with previous studies on risk factors for depressive disorders, we found that the economic status was not associated to PPD.AIM This study was designed to evaluate the prevalence of women screened positive for postpartum depression (PPD) and to investigate the main risk factors for PPD, in a large sample of Italian women. METHOD The sample (N=567) was recruited as part of 91 antenatal courses. Women were screened between the 6th and 12th week after birth, by filling the EPDS (Edinburg Postnatal Depression Scale). The validated cut-off score of ≥12 was used. Socio-demographic and clinical variables were investigated. RESULTS Out of the 567 screened women, 42 (7.4%) were positive. A higher risk was found in women who, during pregnancy, had a depressed mood (OR=3.2) or suffered from anxiety (OR=6.3), had little (OR=4.8) or no (OR=6.5) psychological support from friends or family, or their partner (OR=4.4), had a baby given to crying (OR=7.8), had a low self-esteem (OR=4.8), or had had, as children, a mother that was often (OR=4.6) or always (OR=12.5) critical of them. DISCUSSIONS AND CONCLUSIONS The results of the study are in agreement with the literature considering social and family support and the presence of anxiety and/or depression during pregnancy as main risk factors for PPD. In disagreement with previous studies on risk factors for depressive disorders, we found that the economic status was not associated to PPD.

The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study

Background Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients’ personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives’ coping strategies in BD. Methods A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania “Luigi Vanvitelli” has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group. Results The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as “maintenance of social interests” (odds ratio [OR]=0.309, CI=0.04–0.57; p=0.023), “positive communication with the patient” (OR=0.295, CI=0.13–0.46; p=0.001), and “searching for information” (OR=0.443, CI=0.12–0.76; p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt “resignation” (OR=−0.380, CI=−0.68 to −0.08; p=0.014) and “coercion” (OR=−0.268, CI=−0.46 to −0.08; p=0.006) strategies, compared to TAU relatives. Conclusion PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention.