Andrzej Kiejna

The Quality Indicator for Rehabilitative Care (QuIRC) is an international, standardised quality tool for the evaluation of mental health facilities that provide longer term care. Completed by the service manager, it comprises 145 items that assess seven domains of care: living environment; treatments and interventions; therapeutic environment; self-management and autonomy; social interface; human rights; and recovery based practice. We used the QuIRC to investigate associations between characteristics of longer term mental health facilities across Europe and the quality of care they delivered to service patients. QuIRC assessments were completed for 213 longer term mental health units in ten countries that were at various stages of deinstitutionalisation of their mental health services. Associations between QuIRC domain scores and unit descriptive variables were explored using simple and multiple linear regression that took into account clustering at the unit and country level. We found wide variation in QuIRC domain scores between individual units, but across countries, fewer than a quarter scored below 50 % on any domains. The quality of care was higher in units that were smaller, of mixed sex, that had a defined expected maximum length of stay and in which not all patients were severely disabled. This is the first time longer term mental health units across a number of European countries have been compared using a standardised measure. Further use of the QuIRC will allow greater understanding of the quality of care in these units across Europe and provide an opportunity to monitor pan-European quality standards of care for this vulnerable patient group.

Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Currently, the use of first generation antipsychotics (FGA) is strongly limited. On the other hand, treatment with second generation antipsychotics (SGA) can not be applied in every patient. Therefore, there is an urgent necessity to obtain information about the knowledge and experience of clinicians with regard to safety and efficacy of pernazine, which represents the most widely used FGA in Poland. Due to a striking scarcity of studies on pernazine, authors designed and performed the study, which should provide physicians knowledge arising from daily practice of clinicians included in this study. Analysis was performed basing on 142 opinions of 26 physicians who were experienced in the treatment with pernazine. The Delphi method, which relies on concluding from expert opinions was adopted in this study. A three-round Delphi was used in order to yield final conclusions. According to clinicians, pernazine is one of the most cost-effective and well-tolerated FGA. Furthermore, its different profiles of action (anxiolytic and sedative) enable to use pernazine in various indications, as well as in polypharmacotherapy. Referring to a long-term experience, clinicians emphasised the efficacy of pernazine and a high compliance with medication. Psychiatric treatment should be individualised taking into account not only clinical indices but also patient's preferences and expectations. According to clinicians pernazine is a safe and versatile medication for schizophrenia or other mental disorders and serves as the alternative for SGA.

The study aimed to analyse the bipolarity features between patients with treatment-resistant depression and patients with remission of a depressive episode. The population studied included patients aged 18-65 who had a diagnosis of first or recurrent major depressive disorder. Each psychiatrist included 5 consecutive patients, from all the patients he is treating, where the depressive episode was assessed as treatment-resistant (TR) and 5 consecutive patients with a depressive episode in remission (RE). One thousand and fifty-one patients entered the study: 570 in the treatment-resistant depression group and 481 in the remission group. All patients were assessed using the Mood Disorder Questionnaire (MDQ) and Hypomania Checklist (HCL-32). The assessment of current depressive symptoms was done by means of a 17-item Hamilton Depression Rating Scale. The percentage of patients screened positive by MDQ was significantly higher in TR than in RE (13.7 vs. 5.6% p < 0.001). Also, the percentage of patients having positive response to 14 or more items of the HCL-32 was significantly higher in TR than in RE (43.9% vs. 30.0%, respectively, p < 0.001). The multiple logistic regression model showed that independent risk factors for treatment resistance were: bipolar features in HCL-32 scale, scoring 6 or higher on MDQ, age at first onset < or = 20 years, more than three previous depressive episodes and partial remission after the previous depressive episode. Identified independent risk factors for treatment resistance suggest possible association between bipolarity and worse response to antidepressant drugs in patients with mood disorders.

Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts.

In current diagnostic classifications such as the International Classification of Diseases (ICD-10) and the American Diagnostic and Statistical Manual (DSM-IV), unipolar and bipolar mood disorders are mentioned, where the differentiating factor is occurrence of mania or hypomania. In DSM-IV, bipolar mood disorder type I (bipolar I), with the episodes of mania, and bipolar mood disorder type II (bipolar II) with hypomania, have been separated. Clinical and epidemiological studies performed in recent decades using more sensitive measures of the assessment of hypomania suggest a marked prevalence of bipolar disorders of not-bipolar I type, amounting to about 3-5% of population. In 2005, Angst and collaborators introduced the Hypomania Check List-32 scale (HCL-32) aimed at a better identification of the occurrence of hypomania symptoms in patients with affective disorders. The studies carried out in many countries have demonstrated a significant sensitivity and specificity of the scale and its usefulness for the assessment of bipolar affective disorders. In the present paper, the Polish version of HCL-32 scale is presented. This version has been already employed in the all-country Polish project TRES-DEP where the features of bipolarity were assessed in depressive patients in whom treatment with antidepressant drugs was unsuccessful.

The aim of the study was the assessment of types and incidence of aggressive behaviours amongst psychiatric patients with violent acts marked in the referrals. 107 patients with aggressive or autoaggressive behaviours admitted to the General Hospital of Mental Disorders in Lubiaz and 37 controls without aggressive acts in referrals were examined. Two-way data analysis of the qualified individuals was performed. Firstly, the group was divided into 3 subgroups depending on marked or not marked aggressive behaviours in referrals as well as violent acts reported during index admission. Subsequently the group was divided into 2 subgroups consisting of individuals with aggressive behaviours during hospitalization and patients without reported violent acts, both regardless of aggressive behaviours marked or not in the referrals. In each group, The Brief Psychiatric Rating Scale (BPRS) was used. The type, gravity and number of aggressive behaviours were assessed with the "Overt Aggression Scale" (OAS). During the study, 34% of the participants presented aggressive behaviours. Over 80 % of aggressive acts were observed during the first week of hospitalization. 84% of the patients with aggressive behaviours during index admission presented similar behaviours during previous hospitalizations. The study corroborates the hypothesis that aggressive behaviours among patients admitted to the psychiatric hospital due to aggression are very frequent and predominantly observed in the early stages of hospitalizations. Identified important and predictive factors of possible aggressive behaviours are: violent acts marked in the referrals, treatment in the psychiatric hospital without consent and aggressive behaviours during previous hospitalizations conformed in the medical reports.

In view of the fact that schizophrenia is a disorder increasing the risk of mortality and development of somatic disturbances, the presented study was undertaken with the aim to analyse to what extent psychiatrists assess the somatic condition of their patients diagnosed with schizophrenia. The participants of a nationwide study ordered by Bristol-Myers Squibb and carried out by a survey agency were 404 physicians. The study was based on a specially devised questionnaire, administered to doctors in June and July 2009. Responses from 184 psychiatry specialists were obtained during the conference "Psychiatry 2009" held in Krak6w, whereas the remaining respondents were questioned at their workplaces. The questionnaire consisted of ten questions concerning various aspects of somatic health, control of health parameters and effects of pharmacological treatment on the condition of schizophrenic patients. The majority (73.05%) of the respondents were found to consider the somatic condition of their patients as important or very important. In the opinion of 70.54% of the physicians, metabolic disturbances were the most significant aspect of somatic health. Doctors in private practice paid more attention to sexual and endocrine system dysfunctions than those employed in hospital wards. Most psychiatrists performed physical examinations and checked laboratory parameters "almost on every visit". The questioned physicians appreciate the importance of somatic condition assessment in schizophrenic patients and check the important laboratory parameters regularly. Taking into account the essence of the problem, establishing closer cooperation in this area with first-contact physicians should be considered. In view of definitely positive opinions expressed by psychiatrists, concerning their involvement in the evaluation of the somatic condition of schizophrenic patients, asking the patients themselves whether that meets their needs in this respect would render the obtained results more objective.

Long-term mental illnesses such as schizophrenia or affective disorders often impose a burden on the patients who suffer from it, as well as on their carers (relatives or friends). There are many instruments measuring family or caregiver burden. One of these instruments is the Involvement Evaluation Questionnaire (IEQ). The IEQ is a 31-item questionnaire which is completed by the caregiver. The IEQ contains 27 items that can be divided into four subscales (domains): tension (nine items), worrying (six items), supervision (six items) and urging (eight items). Two items appear in more than one domain. The items are scored on a 5-point Likert scale (never, sometimes, regularly, often and always). There is no full Polish adaptation of IEQ so far. The psychometric properties of the IEQ and its culture-profiled versions are satisfying and comparable. The IEQ, as a self-assessment instrument, is easy to administer and not time-consuming. The IEQ proved to be a reliable instrument for measuring caregiver consequences in mental healthcare.