To investigate the relationship between social exclusion and outcomes of mentally ill patients with substance abuse problems receiving assertive outreach treatment in London.

Analysis was conducted on data on 580 patients from the “Pan-London Assertive Outreach Study (PLAO)”. Data were collected using clinician-rated scales of alcohol and drug abuse in the last six months before baseline. Outcomes “voluntary and compulsorily hospitalisation” were assessed over a 9-month follow-up period.

The analysis identified a group of patients with substance abuse who suffer from social exclusion and forensic problems (n=77, 15.8%), and had poorer outcomes than the rest of the patients in terms of voluntary (52% vs. 36% respectively) and compulsorily (39% vs. 22% respectively) hospitalisation.

There is a surprisingly low prevalence rate of substance abuse in AO teams in London. However, there is in these teams a distinct group of patients with substance abuse and social exclusion characteristics who could benefit from specific interventions in dual diagnosis and forensic mental health. The question that poses itself is whether or not we should re-think models of care and types of interventions provided for dual diagnosis patients receiving AO care.

The use of alcohol and other drugs among medical students has been a theme of growing interest and concern on the part of researchers, teaching institutions and medical associations since the decade of the 1960's. Objective: Recent use of alcohol, tobacco, tranquillisers, amphetamines, cannabis, organic solvents, and cocaine among 456 medical students was surveyed.

Assessment was done by means of a self-report questionnaire according to World Health Organisation guidelines.

Among medical students, after alcohol and tobacco, cannabis and solvents are the most frequently used psychoactive substances. As such, they were the most deeply analysed drugs in this study. Factors associated with the recent use of cannabis and solvents were established by logistic regression. Living with parents or a companion appeared as a protective factor for the use of cannabis. However, being male and regularly participating in the activities at the campus Sports Association showed as risk factors for the use of both cannabis and solvents.

Concepts and misconceptions concerning protective and risk factors must be discussed in the light of cultural and circumstantial interferences. Harm reduction strategies should be seriously considered.

To ascertain factors associated with adherence and relapse among alcohol dependents.

Three hundred alcoholic patients were interviewed at hospitalization and again 3 and 6 months thereafter. Assessment included the SCID-I to check for the presence of Axis I mental disorders, a questionnaire focusing on patient relationship with AA groups, and specific questions about participation in psychotherapy. A logistic regression analysis was performed to determine predictive variables for relapse and adherence.

Previous treatment for alcohol dependence (OR=3.65; CI:1.77-7.05) and being single (OR=2.39; CI:1.06-5.42) proved to be associated with relapse, whereas adherence to AA mutual-help groups (OR=0.31; CI:0.15-0.66), presence of a co-morbid depressive disorder (OR=0.46; CI:0.23-0.92), and probably adherence to psychotherapy (OR=0.52; CI:0.26-1.04) could be associated with abstinence. Higher educational level was predictive of adherence to AA (OR = 2.19; IC 1.08-4.41). Besides higher educational background (OR = 3.60; CI 1.6-7.9), the presence of a co-morbid depressive disorder (OR = 3.47; CI 1.8-6.5), the use of other drugs together with alcohol (OR = 3.08; CI 1.5-6.19), and having been previously treated (OR = 2.87; CI 1.29-6.40) were related to adherence to psychotherapy. The presence of a substance-induced anxiety disorder emerged as a factor of non-adherence to psychotherapy (OR = 0.27; CI 0.63-0.003).

These findings reinforce the importance of psychotherapy and AA groups as strategies for alcoholics to remain abstinent for longer periods. The identification of predictors of adherence and relapse are important to guide clinicians in the choice of the treatment strategies more likely to be successful.

Evidence suggests that persons with psychiatric diagnosis born in late 1940s and 1950s are at higher risk for violent behavior than other psychiatric patients from two reasons: 1/ these generations received inappropriate mental health care associated with deinstitutionalization; 2/ their individual characteristics may have differed because of factors, which affected their prenatal and perinatal period. The fact that between 1949 and 1989 Czech socialist health care system ignored the deinstitutionalization policy provides the opportunity for us to test this theory.

During our previous work we collected data on prevalence of violence in four cohorts of schizophrenic in years: 1949,1969, 1989 and 2000. Using the chart records all 572 patients were re-diagnosed. Only those patients (N=404) meeting the DSM IV criteria for schizophrenia were included in the study. For the purposes of this study we divided all 404 patients to the three groups: Patients born before 1946 (N=249), patients born in late 1940s and 1950s - between 1946 and 1959 - (N=84), and patient born after 1959 (N=71).

We tested the association of categorical year of birth (< 1946, 1946-1959, > 1959) and found no association (unadjusted and adjusted for cohort, observation years and gender) of year of birth and violent behavior (Pearson chi2 = 0.2798, Pr = 0.869).

Our findings suggest that only organizational changes are responsible for increase risk of violence.

To determine whether a differential state specific intervention in the initial prodromal state is effective for preventing progression to psychosis.

128 patients in the early initial prodromal state (EIPS) were randomized to receive either a comprehensive cognitive behavior therapy (CBT) intervention or supportive counseling (SC) for 12 months. 124 patients in a putatively late initial prodromal state (LIPS) were randomly assigned to a needs-focused inter-vention (NFI) or to NFI plus amisulpride.

In the EIPS trial Kaplan-Meier estimates of the risks of transitions to LIPS (5.3% vs. 18.5%, p=0.032), psychosis (1.6% vs. 13.8%, p=0.020) and schizophrenia (none vs. 13.8%, p=0.005) at month 12 were statistically significant lower in the CBT group than in the SC group. In the LIPS trial Amisul-pride+NFI produced superior effects to NFI alone on attenuated and full-blown psychotic symptoms, basic, depressive and negative symptoms and global functioning at week 12.

First results indicate that a differential intervention to the initial prodromal state is effective for preventing progression to psychosis.

Only a few randomized clinical trials have tested the effect on transition rates of intervention programs for patients with sub-threshold psychosis-like symptoms.

To examine whether integrated treatment reduced transition to psychosis for first-contact patients diagnosed with schizotypal disorder.

Seventy-nine patients were randomized to integrated treatment or standard treatment. Survival analysis with multivariate Cox-regression was used to identify factors determinant for transition to psychotic disorder.

In the multivariate model, male gender increased risk for transition to psychotic disorder (relative risk = 4.47, (confidence interval 1.30-15.33)), while integrated treatment reduced the risk (relative risk = 0.36 (confidence interval 0.16-0.85)). At two-year follow-up, the proportion diagnosed with a psychotic disorder was 25.0 percent for patients randomized to integrated treatment compared to 48.3 percent for patients randomized to standard treatment.

Integrated treatment postponed or inhibited onset of psychosis in significantly more cases than standard treatment.

After a first episode in schizophrenia, maintenance treatment is recommended for at least 1 year. In addition to maintenance treatment or particularly in case of drug discontinuation prodrome based early intervention is a recommended (supplemental) long-term treatment strategy to prevent relapse. Drug discontinuation, although inferior to maintenance treatment in multiple-episode patients, showed comparable relapse preventing results in first-episode patients (Gaebel et al. 2002), However, more empirical data is strongly needed, to evaluate this treatment strategy in first-episode patients.

Accordingly, a 2-years long-term trial in first-episode schizophrenia was conducted within the GRNS. In the first treatment year, maintenance treatment with risperidone was compared to treatment with (low-dose) haloperidol (randomized double-blind design). In the second treatment year, continued neuroleptic treatment was compared with stepwise drug withdrawal (randomized design) both supplemented by prodrome-based early intervention.

From the 96 patients after 1-year maintenance treatment, about 50% were not eligible for both treatment strategies due to doctors concerns (particularly to discontinue drug treatment) or to patients decision. Likewise to the first treatment year, relapse rate is very low, and preliminary results seems to indicate a higher risk for relapse and deterioration after drug discontinuation. Early recognition of relapse based on prodromal symptoms and other early warning signs showed satisfactory results with the highest relapse predictive validity for a composite score of unspecific prodromes.

The results emphasizes the need to evaluate and provide various effective long-term treatment strategies to take patients conditions and circumstances into account.

Objective is to compare the consequences of guided discontinuation strategy and maintenance treatment in remitted first episode psychosis in terms of relapse, symptomatic and social remission and recovery.

The study was conducted in seven mental health care organizations, covering a catchment area of 3.1 million inhabitants. A sample of 131 remitted first episode patients, aged 18 to 45 years, with a diagnosis of schizophrenia or related psychotic disorder was included. After six months of positive symptom remission they were randomly and openly assigned to discontinuation strategy or maintenance treatment. Maintenance treatment was carried out according to APA-guidelines, preferably using low dose atypical antipsychotics. Discontinuation strategy was carried out by gradual symptom-guided tapering of dosage and discontinuation if feasible. Follow-up was eighteen months.

Twice as many relapses occurred in discontinuation strategy (43% vs. 21%, P = 0.007). Of patients who received the strategy 20% were successfully discontinued. Recurrent symptoms caused another 30% to restart antipsychotic treatment, while in the remaining patients discontinuation was not feasible at all. Although no advantages of discontinuation strategy regarding functional outcome at follow-up, remission and recovery status over the last nine months were better.

A limited number of patients can be successfully discontinued. Although high relapse rates do not allow discontinuation strategy to be universal practice, it has nevertheless a favourable influence on remission and recovery during follow-up. Further research is needed to find predictors of successful discontinuation.

Psychiatry in Europe is undergoing a period of rapid and significant change. This includes changes in training, changes in the role of psychiatrists, and changes in the delivery and structure of mental health services. These changes have major implications for the future job satisfaction of trainees and young psychiatrists. This presentation aims to examine common themes across Europe and discuss possible approaches to meeting these challenges.

This paper uses data collected from trainees and young psychiatrists in 23 European countries via the European Federation of Psychiatric Trainees and the Association of European Psychiatrists networks of young psychiatrists and trainees to determine common issues and approaches towards resolving these.

Major changes currently affecting young psychiatrists and trainees include:

• • changes in training content and duration

• • increasing roles of other professions impacting on psychotherapy and prescribing

• • reconfiguration of mental health services

These changes lead to both challenges and opportunities for young psychiatrists and trainees. Sharing experience across Europe will contribute to improving morale and enhancing job satisfaction. Some specific ideas will be discussed interactively with the audience.

A first psychotic episode includes a wide range of disorders with different outcomes.

To study all patients with their first psychotic episode longitudinally in a circumscribed area in UAE.

The charts of all patients admitted to the psychiatric department of Al-Ain Hospital, in their first psychotic episode, and in their subsequent admissions – if applicable – were studied for 5 years starting from September 1997. Diagnoses of 161 patients were made using ICD-10 diagnostic criteria.

Of total of 161 patients, during their first admission: 69 were diagnosed as “acute psychotic disorder”, 35 as “manic episode”, 31 as “schizophrenia”, 16 were diagnosed as “depression with psychotic symptoms”, 3 as “drug induced psychosis”, one as “delusional disorder”, and 6 with no psychiatric diagnosis. Of the total 161 patients 42 were subsequently relapsed and re-admitted. Analysis of the diagnosis of these 42 patients revealed extensive change of diagnosis in most categories.

In the studied population, the majority of patients presenting in their first episode psychosis seemed to have a favorable outcome, whereas only a minority of them continued to have a relapsing illness.

To identify factors associated with delayed access of FEP to psychiatric care and possible measures that could help facilitate access and shorten duration of untreated psychosis (DUP)

FEP studies show that average time between onset of symptoms & first effective treatment is often one year or more1. Long DUP is undesirable as early treatment can reduce suffering and helps minimise risk of serious consequences due to changes in mental state & behaviour2,3,4. Early results suggested that early intervention in psychosis (EIP) service is more cost effective than generic services5.

Most FEP studies have been conducted in developed countries. This study aims to address the question of FEP delayed access to care in a rural Egyptian setting.

FEP cases who presented to Psychiatric Department at Mansoura General Hospital over a period of 6 months, were interviewed, together with relevant others either at first contact or after recovering from acute stage using a semistructured interview.

Main results:

1. 1. Total cases 40: Schizophrenia 14, Affective disorders: 15, Postpartum disorders: 5 and others: 6.

2. 2. On average FEP have first contact with Psychiatric service about 7 months from onset: Schizophrenia: 11 months and Affective within 3 months. No significant gender difference.

3. 3. Main factors associated with delayed access to Psychiatric care:

   1. • Cultural factors (36%): Jinn “Spirit” (16%), preference to traditional healers (10%), female gender (10%).

   2. • Lack of knowledge about Mental Illness and about service (28%).

   3. • Stigma (14%)

   4. • Financial factors (14%)

   5. • Effect of Mental Illness (7.4)

   6. • Unsuitable service (0.6%)

Study results indicate that cultural factors, lack of knowledge about mental illness & service, stigma and financial factors may play a significant role in delayed access of FEP to care in rural areas of Egypt. Programs to improve public awareness of mental illness & available service and address stigma are likely to help.