The current state of mental health care in Italy: problems,perspectives, and lessons to learn

After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants—one of Europe’s currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients’ families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.     

A commentary on methodological issues in stroke caregiver research: lessons learned from three RESCUE intervention studies

Stroke caregivers represent a distinct population and require unique considerations when conducting intervention research. Unfortunately, there are few published recommendations for conducting intervention trials with stroke caregivers. Thus, the goal of this paper is to provide foundational guidance for stroke caregiving researchers. We describe lessons learned from three trials of the RESCUE intervention to illustrate methodological issues in stroke caregiver research. We identify challenges encountered while conducting a clinical demonstration project, pilot study, and multi-site randomized controlled trial of a problem-solving and skills-building stroke caregiver intervention. We use our research experiences to exemplify or enhance understanding of each issue and describe the strategies we employed to overcome these obstacles. We present issues related to and recommendations for study design, theoretical frameworks, eligibility criteria, recruitment and retention, human subjects protection, intervention design, treatment fidelity, outcome measures, and qualitative methods. Identifying approaches to circumvent methodological challenges can help advance research on and implementation of stroke caregiver programs.     

The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam

OBJECTIVE: To examine long-term outcome of late-life anxiety disorders and utilization of mental health care services. METHOD: A cohort of subjects (aged > or = 55 years) with an anxiety disorder (n = 112) was identified in the Longitudinal Aging Study Amsterdam (n = 3107). At 6 year follow-up, the rate of persistence and prognostic factors for persistence of anxiety were established. RESULTS: Six years after baseline 23% of our sample met the criteria for an anxiety disorder. Another 47% suffered from subclinical anxiety symptoms. Persistence of anxiety was associated with a high score on neuroticism at baseline. Use of benzodiazepines was high (43%), while use of mental health care facilities (14%) and anti-depressants (7%) remained low in those with persistent anxiety. CONCLUSION: Results indicate that those high in neuroticism are at greater risk for persistence of anxiety. Efforts to enhance appropriate referral of anxious older adults do not seem to have had the desired effect.     

Studying the neuropsychological sequelae of SARS-CoV-2: lessons learned from 35 years of neuroHIV research

Journal of NeuroVirology - The virology of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the human immune response to the virus are under vigorous investigation. There are now...     

Pathway to psychiatric care of the elderly with depression

Goldberg and Huxley describe a pathway to psychiatric care which has five levels and four filters. To explore the application of this pathway to the elderly with depression we searched the relevant literature to estimate median annual rates of moderate-severe depression at each level of the pathway. Among 27 elderly per thousand each year who had depression, 22 consulted a family physician who detected the disorder in 5.3. Of these, 2.8 were referred to psychiatric services and 1.3 were ultimately admitted to psychiatric units. Thus, only 10% of the elderly with moderate-severe depression were assessed or treated by a psychiatrist. If confirmed, these findings have implications for geriatric psychiatry services and research.     

Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression

Abstract

Supervision of psychotherapists and counselors, especially in the early years of practice, is widely accepted as being important for professional development and to ensure optimal client outcomes. Although the process of clinical supervision has been extensively studied, less is known about the impact of supervision on psychotherapy practice and client symptom outcome. This study evaluated the impact of clinical supervision on client working alliance and symptom reduction in the brief treatment of major depression. The authors randomly assigned 127 clients with a diagnosis of major depression to 127 supervised or unsupervised therapists to receive eight sessions of problems-solving treatment. Supervised therapists were randomly assigned to either alliance skill– or alliance process–focused supervision and received eight supervision sessions. Before beginning treatment, therapists received one supervision session for brief training in the working alliance supervision approach and in specific characteristics of each case. Standard measures of therapeutic alliance and symptom change were used as dependent variables. The results showed a significant effect for both supervision conditions on working alliance from the first session of therapy, symptom reduction, and treatment retention and evaluation but no effect differences between supervision conditions. It was not possible to separate the effects of supervision from the single pretreatment session and is possible that allegiance effects might have inflated results. The scientific and clinical relevance of these findings is discussed.

Zusammenfassung

Klinische Supervision: Ihr Einfluss auf Klienten-Einschätzungen der Arbeitsbeziehung und die Symptomreduktion in Kurzzeittherapie von schwerer Depression

Supervision von Psychotherapeuten und Beratern, besonders in frühen Jahren ihres Praktizierens, wird weithin als wichtig für die professionelle Entwicklung und das Erreichen optimaler Therapieergebnisse angesehen. Obwohl der Prozess der klinischen Supervision ausführlich untersucht wurde, ist weniger über ihren Einfluss auf die psychotherapeutisch Praxis und die Reduktion von Symptomen bekannt. Diese Untersuchung bewertete den Einfluss von klinischer Supervision auf die Arbeitsbeziehung der Klienten und die Symptomreduktion bei Kurzzeittherapie von schwerer Depression. Die Autoren haben 127 Klienten mit schwerer Depression dem Zufall nach 127 supervisierten oder nicht supervisierten Therapeuten zugewiesen für eine Problemlösungsbehandlung mit acht Sitzungen. Supervisierte Therapeuten wurden dem Zufall nach einer Allianzfähigkeits-Supervision oder einer Allianzprozess-Supervision zugewiesen und erhielten acht Supervisionstrainings. Vor Beginn der Behandlung bekamen die Therapeuten eine Supervisions-Sitzung mit einem kurzen Training des Arbeitsbeziehungs-Supervisions-Zugangs und den spezifischen Charakteristika aller Klienten. Standardmasse der therapeutischen Allianz und der Symptomveränderungen wurden als abhängige Variablen verwendet. Die Ergebnisse zeigten einen signifikanten Effekt für beide Supervisionsbedingungen auf die Arbeitsbeziehung von der ersten Therapiesitzung an, auf die Symptomreduktion, den Verbleib in der Therapie und die Bewertung, aber keinen Unterschied zwischen den Supervisionsbedingungen. Die Effekte der Supervision und der kurzen Einführung zum Vorgehen der Behandlung waren nicht zu trennen und es ist möglich, dass Loyalitätseffekte die Ergebnisse verstärkt haben. Die wissenschaftliche und klinische Relevanz der Ergebnisse wird diskutiert.

Résumé

La supervision clinique?: son influence sur l'alliance de travail évaluée par les clients et la réduction des symptômes dans le traitement bref de la dépression majeure

La supervision des psychothérapeutes et conseillers, surtout dans les premières années de leur pratique, est largement acceptée dans son importance pour le développement professionnel et pour assurer un effet clinique optimal pour les clients. Bien que le processus de la supervision clinique ait été largement étudié, on a moins de connaissance sur l'impact de la supervision sur la pratique psychothérapeutique et les résultats cliniques des clients. Cette étude a évalué l'impact de la supervision clinique sur l'alliance de travail des clients et la réduction des symptômes dans le traitement bref de la dépression majeure. Les auteurs ont attribué au hasard 127 clients avec un diagnostic de dépression majeure à 127 thérapeutes supervisés ou non supervisés pour un traitement de 8 séances d'un traitement de solution de problèmes. Les thérapeutes supervisés étaient assignés au hasard à une supervision focalisée soit sur l'habileté soit sur le processus au sujet de l'alliance et ils recevaient 8 séances de supervision. Avant de commencer le traitement, les thérapeutes recevaient une séance de supervision pour une formation brève dans l'approche de la supervision de l'alliance de travail et pour des caractéristiques spécifiques de chaque cas. Des mesures standard de l'alliance thérapeutique et du changement de symptômes étaient appliques en tant que variables dépendantes. Les résultats montraient un effet significatif pour les deux conditions de supervision sur l'alliance de travail de la première séance thérapeutique, la réduction des symptômes ainsi que l'adhésion au et l’évaluation du traitement, mais pas de différence dans l'effet des deux conditions de supervision. Il n’était pas possible de séparer les effets de la supervision des la séance unique de pré-traitement et il est possible que des effets d'allégeance aient dilaté les résultats. L'importance scientifique et clinique de ces résultats est discutée.

Resumen

Supervisión clínica: su influencia sobre la alianza de trabajo evaluada por el cliente y la reducción sintomática en la terapia breve de la depresión mayor

La supervisión de psicoterapeutas y consejeros, especialmente en los primeros años de práctica, está ampliamente aceptada como importante para el desarrollo profesional y para asegurar resultados óptimos para el cliente. Si bien el proceso de supervisión clínica ha sido extensamente estudiado, menos se conoce acerca del impacto de la supervisión sobre la práctica psicoterapéutica y el resultado de los síntomas del cliente. Este studio evaluó el impacto de la supervisión clínica sobre la alianza de trabajo del cliente y la reducción del síntoma en la terapia breve de la depresión mayor. Los autores asignaron al azar ciento veintisiente clientes con diagnóstico de depresión mayor a ciento veintisiete terapeutas supervisados o no, que recibirían ocho sesiones de terapia para resolver problemas. Los terapeutas supervisados fueron asignados al azar para una supervisión focalizada en el desarrollo de la habilidad para hacer alianza (alliance skill) o en el proceso de la alianza (alliance process) y recibieron ocho sesiones de supervisión. Antes de comenzar el tratamiento, los terapeutas recibieron una sesión de supervisión para entrenamiento breve en la supervisión para la alianza de trabajo y para características específicas de cada caso. Como variables dependientes se utilizaron medidas estándar de alianza terapéutica y de cambio sintomático. Los resultados mostraron un efecto significativo para ambos tipos de supervisión de la alianza de trabajo desde las primeras sesiones de terapia, reducción sintomática, retención en el tratamiento y evaluación pero sin diferencia entre el efecto de las condiciones de supervisión. No fue possible separar los efectos de la supervisión de los de la sesión previa al tratamiento y es posible que los efectos de la adhesión haya iinflado los resultados. Se debate sobre la relevancia científica y clínica de estos hallazgos.

Resumo

Supervisão clínica: a sua influência nas avaliações da aliança terapeutica pelos clientes e na redução sintomática em tratamento breve da depressão major

A supervisão de psicoterapeutas e conselheiros, em especial durante os primeiros anos de prática, tem sido consensualmente aceite como sendo importante para o desenvolvimento profissional e para assegurar a optimização resultados terapêuticos. Embora os processos de supervisão clínica tenham sido amplamente estudados, pouco se conhece sobre o impacto da supervisão na prática psicoterapêutica e nas melhorias sintomáticas do cliente. Este estudo avaliou o impacto da supervisão clínica na aliança terapêutica e na redução sintomática em terapia breve da depressão major. Os autores distribuíram aleatoriamente 127 clientes, diagnosticados com depressão major, a 127 terapeutas com e sem supervisão, para receberem oito sessões de tratamento de resolução de problemas. Os terapeutas supervisionados foram aleatoriamente distribuídos por duas condições de supervisão, focadas nas competências de aliança terapêutica ou focadas no processo da aliança, recebendo oito sessões de supervisão. Antes do início do tratamento, os terapeutas receberam uma sessão de supervisão como treino breve na abordagem de supervisão da aliança terapêutica e informação sobre as características específicas de cada caso. Foram usadas medidas estandardizadas da aliança terapêutica e da mudança sintomática como variáveis dependentes. Os resultados demonstraram um efeito significativo, em ambas as condições de supervisão, na aliança terapêutica, na redução sintomática, manutenção dos ganhos terapêuticos e avaliação do tratamento, mas não se verificaram diferenças entre as condições de supervisão. Não foi possível separar os efeitos da supervisão da sessão única de treino no pré-tratamento e é possível que os efeitos do comprometimento tenham inflacionado os resultados. São discutidos os resultados em relação à sua relevância científica e clínica.

     

Genetics of anxiety disorders: the complex road from DSM to DNA

Anxiety disorders are among the most common psychiatric disorders, affecting one in four individuals over a lifetime. Although our understanding of the etiology of these disorders is incomplete, familial and genetic factors are established risk factors. However, identifying the specific casual genes has been difficult. Within the past several years, advances in molecular and statistical genetic methods have made the genetic dissection of complex disorders a feasible project. Here we provide an overview of these developments, with a focus on their implications for genetic studies of anxiety disorders. Although the genetic and phenotypic complexity of the anxiety disorders present formidable challenges, advances in neuroimaging and experimental animal models of anxiety and fear offer important opportunities for discovery. Real progress in identifying the genetic basis of anxiety disorders will require integrative approaches that make use of these biologic tools as well as larger‐scale genomic studies. If successful, such efforts may yield novel and more effective approaches for the prevention and treatment of these common and costly disorders. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.     

Suicidality in children and adolescents: lessons to be learned from the COVID-19 crisis

European Child & Adolescent Psychiatry -     

Oral health,anxiety symptoms and depressive symptoms: findings from the survey of health,ageing and retirement in Europe

Background

There is limited knowledge regarding the association between oral health and mental health in terms of depressive symptoms and particularly anxiety symptoms. Therefore, our aim was to close this gap in knowledge.

Methods

Cross-sectional data were used from wave 5 of the pan-European Survey of Health Ageing, and Retirement in Europe (SHARE) (n = 62 358 observations). The Beck Anxiety Inventory was used to quantify anxiety symptoms and the Euro-D was used to measure depressive symptoms. Oral health was quantified based on the presence of missing natural teeth, the number of missing natural teeth and the extent of replaced teeth. It was adjusted for several covariates in regression analysis.

Results

Multiple linear regressions revealed that the presence of missing natural teeth was associated with higher anxiety symptoms (β = 0.11, P < 0.001) and higher depressive symptoms (β = 0.22, P < 0.001) among the total sample. Among individuals with at least one missing natural tooth, the number of missing natural teeth was positively associated with higher anxiety symptoms (β = 0.02, P < 0.001) and higher depressive symptoms (β = 0.02, P < 0.001) – and fully replaced teeth (compared to not at all replaced teeth) were associated with lower anxiety symptoms (β = −0.35, P < 0.001) and lower depressive symptoms (β = −0.36, P < 0.001).

Conclusion

Our study stresses the association between lower oral health and lower mental health among older adults in Europe. Future studies based on longitudinal data are required.     

Anger problems across the anxiety disorders: findings from a population-based study

Background: Previous research examining anger problems among the anxiety disorders has been limited by the use of nonrepresentative samples, univariate analyses, as well as low sample size. The current study examined the association between posttraumatic stress disorder (PTSD), panic disorder (PD), social anxiety disorder, specific phobia (SP), and generalized anxiety disorder (GAD) and anger experience and expression. We hypothesized that greater anger experience and expression would be associated with all anxiety disorders, but that it would be most consistently associated with PTSD and PD diagnoses, and that these relationships would remain significant after controlling for demographics (i.e. age, gender, ethnicity, marital status, and income) and comorbid disorders. Methods: Participants included 5,692 (54% female) adults from the National Comorbidity Survey—Replication, a large, nationally representative survey. Results: Our data suggest that there are unique relationships between multiple anxiety disorders and various indices of anger experience and expression that are not better accounted for by psychiatric comorbidity. Contrary to predictions, PTSD and PD were not consistently associated with anger experience and expression. Conclusions: Overall, these findings lend support to the emerging literature demonstrating a potentially important relationship between anxiety disorders and anger problems. Depression and Anxiety, 2011.© 2010 Wiley‐Liss, Inc.