Symposium “ Family burden: dimensions, determinants and intervention”

Title of presentation: Determinants of the caregiving appraisal

Appraisal of caregiving and its relationship to family burden and experienced mental health problems in the relatives were investigated as part of a multi-centre study of the quality of mental health services in Sweden. The sample was drawn from relatives of involuntarily and voluntarily admitted patients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden, experience of mental health problems and appraisal of the caregiving situation.

The results showed a high proportion of relatives engaged in caregiving activities on a daily basis the month before the patient's admission to hospital and a high proportion of relatives appraising the caregiving activities negatively. The burden was more extensive if the relative and the patient were living together, had a longer duration of their relationship, if the relative was rendering caregiving on a daily basis and if the relative appraised caregiving negatively.

The relatives’ psychological distress was not related to their negative appraisal of caregiving, nor was patient characteristics, such as diagnosis and level of psychosocial functioning. The only factor found to influence the relatives’ psychological distress was the duration of relationship to the patient.

Interventions reducing psychological distress for relatives who have known the patients for more than 20 years, who live with the patient, who give care on a daily basis and who appraise their caregiving negatively are suggested.

In the past 30 years, research on Expressed Emotions and family burden, and the adoption of the stress-vulnerability model of schizophrenia, have led to the development of integrated treatments for this mental disorder combining pharmacological and family cognitive-behavioural interventions. The latter, called Psychoeducational Family Interventions (PFI), aim to: a) provide the family with information about the patient's disorder and its treatments; b) improve family communication patterns; c) enhance family's problem solving skills; d) encourage relatives’ involvement in social activities.

Since the 1980s, a number of RCT and several meta-analyses have demonstrated the efficacy of PFI on relapse and hospitalisation rates in schizophrenia.

In recent years, there has been a shift from efficacy to effectiveness studies and great attention by the researchers in developing training programmes in PFI for ordinary staff.

In this presentation, we will provide an overview of the studies on PFI for schizophrenia which have been carried out in the last decade in routine clinical settings or with at least partial involvement of ordinary staff. These studies have been grouped into: a) studies comparing PFI with standard care; b) studies comparing PFI with individual integrated interventions; c) studies comparing different PFI strategies; d) implementation studies.

The results of these studies reveal that, when provided in clinical settings, PFI have positive middle-term effects on patients’ clinical status and disability, and limited impact on family burden.

Future studies are needed to identify the “best dose” at which PFI can be provided in routine conditions at the most convenient cost-benefit ratio.

Sixty years ago, the concept of custodial inpatient treatment began to gradually change into that of an activating outpatient concept. Through this process, the number of in-patient beds today in all psychiatric hospitals in the western part of the world has been reduced to 10-20% of those at the beginning of the 20th century. Though outpatient services had expanded to a high degree, the main burden of the psychosocial treatment still fell upon relatives. Most of these nursing families were poorly informed regarding their new duties. Thus many families were overstrained and not able to fulfill their function as "co-therapists". Because of the prevalence of overstrained families with dysfunctional behaviour, the EE-concept was developed in the sixties (Brown et al 1964). With the introduction of family therapy and the emergence of self help groups for relatives, families obtained substantial support. Through family therapeutic interventions, relatives were systematically integrated into long term rehabilitation concepts. In this way, the stigma of the "HEE"- relatives was changed (Bebbington et al 1994; Schulze-Mönking 1994; Möller-Leimkühler 2008). In the meantime, the engagement of family members can be viewed as an important resource and not merely as a stress factor which is to be reduced (Pitschel-Walz, Bäuml et al 2001). According to the therapeutic guidelines it is now part of standard therapy to integrate relatives already in the beginning of the treatment. In this context, psychoeducation is a very effective measure to inform family members of the background of the illness and the most important treatment elements. During the course of time, many concepts have been developed, particularly concerning schizophrenic psychosis, to train relatives and their patients to have better communication with less stress and more helpful interactions. Through the establishment of a worldwide network, relatives are encouraged to use their knowhow not only alone at home but also in their interaction with professionals and politicians to improve the living conditions of their patients. In this lecture, the historical background and actual findings concerning the empowerment of the relatives will be presented.

The study was conducted in a tertiary care facility in Rawalpindi, Pakistan. The objective was establishment of a service delivery system in a tertiary care facility of Rawalpindi for screening, early diagnosis and prompt management of women with post natal depression. It also evaluated the effectiveness of the service and determined the frequency of Postnatal Depression cases presenting in the postnatal clinic of Rawalpindi General Hospital. This interventional study involved screening and confirmation of diagnosis for Postnatal depression of 908 mothers presenting in the postnatal clinic. The scales used were Edinburgh Postnatal Depression Scale (EPDS) and Hamilton Rating Scale. EPDS showed scores above cutoff of 10 for 318 (35%) mothers. When Hamilton scale was applied, 05 (1.57%) mothers had no confirmed diagnosis of Depression, however, all the remaining 313 mothers (98.42%) had Depression. The prevalence of the post natal depression was found to be 313 per 1000 or 31%. Statistically significant associations were observed on Chi Squared test, between PND and variables like mothers educational status, their working status, number of previous children, mode of last delivery, obstetrical complications during last pregnancy, age group, monthly family income, Effectiveness of the services rendered were evaluated by applying t-test by comparing the mean weekly turn over of PND patients over 35 wks study period and showed statistically significant difference in favor of interventional services with t-statistic of 16.263, p-value of 0.000.

Risk for emotional and behavioural problems are known to be high among children of depressed mothers, but little is known about the impact of antenatal and postnatal depression on the physical health of the infant. Our one-year prospective follow-up study of 320 mothers and their infants in rural Rawalpindi, Pakistan, shows that infants of antenatally depressed mothers have poorer growth than controls. The relative risk for being underweight (weight-for-age z-score < -2SD) is 4.0 (95%CI 2.1-7.7) at 6 months and 2.6 (95% CI 1.7-4.1) at 12 months, while the risks for stunting (length-for-age z-score < –2SD) is 4.4 (95%CI 1.7-11.4) at 6 months and 2.5 (95% CI 1.6-4.0) at 12 months. Relative risk for ≥5 diarrhoeal episodes per year is 2.4 (95% CI 1.7-3.3). Chronic depression carries a greater risk for poor outcome than episodic depression. The associations remain significant after adjustment for confounders by multivariate analyses. It is concluded that preventive and treatment strategies for maternal depression could benefit not only the mother's well-being but also the infant's physical health and development.

Previous studies have found maternal depression to be a major risk factor for poor growth in infants in Pakistan and south Asia. The mediating mechanisms between maternal depression and infant malnutrition are an important area for research.Studies have shown that maternal depression maybe associated with shorter duration of feeding however the evidence is equivocal. The quantity of breast milk could be another factor which has only been tested with relatively inaccurate methods of clinical scoring and test weighing till date. We aim to study the relationship of maternal depression with duration of breastfeeding and infant feeding practices. Moreover, we would also estimate the breast milk production and intake by the infant in depressed versus normal mothers, using the new technology of isotope dilution, in a rural community in Rawalpindi, Pakistan.

A random sample of 100 depressed and 100 non-depressed women will be recruited for the proposed prospective cohort study. The depressive disorder will be diagnosed antenatlly and 6 months postnatally using validated instruments. The duration of exclusive breastfeeding will be assessed prospectively and infant feeding practices will be assessed at 6 months with appropriate tools. Breast-milk intake will be measured in 30 mothers from each group, using the dose-to-the-mother deuterium oxide method also validated in Pakistan by the investigators. Differences in the two groups of mothers will be estimated using appropriate statistical techniques, while controlling for possible confounders.

The aim of study is to determine the maternal perception of inadequate breast feed and compare possible augmentation of breast milk with lactogouges (metclopromide) and structured counseling of mothers, using the new technology of isotope labeling in a community in Rawalpindi, Pakistan.A random sample of 200 lactating mothers having complaints of reduced breast milk production is being recruited from well baby clinic of participating hospitals. All should be practicing exclusive breastfeeding with infants from 2-3 months of age. Their perceptions regarding their breast milk production is assessed. They are randomized into four groups. Group one will be given oral metclopromide, groups 2 will be given structured counseling by trained health workers and group 3 will receive placebo whereas group 4 will receive CBT. Breast-milk production will be measured at completion of 4 weeks of intervention by using the dose-to-the-mother deuterium oxide method also validated in Pakistan by the investigators to a limited sample. Differences in the groups of mothers will be estimated using appropriate statistical techniques, while controlling for possible confounders. Outcome of the study would be able to demonstrate that lactogouges, or simple counselling may have an effect on increasing the breast milk quantity of mothers and also effect of interventions on their perceptions. The results of the study could have a major impact on the breastfeeding teachings and practices in our society which in turn has a potential to improve and have a significant impact on one of the main Millennium Development Goals i.e. child mortality and morbidity.

The aim of the TREAT-study (Treatment-systems Research on European Addiction Treatment) is the comparison of the course of predominantly opiate dependent patients from six European regions concerning severity of illness, health service use and heroin-use.

Over the last several years diagnostic research made significant conceptual and methodological advances but acute mental disorders still remain almost neglected from international classifications. This is becoming, however, an area of growing concern with considerable relevance to mental health policies: an increasing number of patients seek for acute/emergency treatment with atypical symptoms yet classic diagnostic categories do not adequately describe the multiple co-morbidities and unpredictable course of these disorders. To capture a number of exquisite clinical characteristics that may be a putative target of innovative treatment programs on the changing scene of emergency psychiatry and acute psychiatric treatment, this report will introduce the concept of “new acute mental patient” a condition at the crossroad of dissociative disorders, mood disorders and personality disorders among patients exposed to traumatic life events. The validity of this diagnostic construct and its relevance to outcome research will be further investigated utilizing the data basis from longitudinal studies.

Research on pathogenesis and treatment has long been concentrated on the problems involving abnormalities in the reward and motivational system. However, current research also looks at decision making, including both error detection and behavioral inhibition. It is assumed that compulsive use and relapse in patients with a substance use disorder or with pathological gambling are the result not only of excessive salience of drug related stimuli but also of impaired error detection and behavioral disinhibition.

In this presentation an overview will be given of the research on decision making in alcoholics, drug addicts and pathological gamblers. The data show that patients with both chemical and non-chemical addictions have serious problems with error detection and behavioral inhibition independent of the presence of antisocial or borderline personality disorders. Recent data also show that ex-addicts have fewer problems with behavioral inhibition, indicating either pre-existing normality or improvement after abstinence. The fact that patients with low levels of behavioral inhibition relapse more frequently supports the first explanation. It, therefore, seems important to improve decision making in patients with addictive behaviors, using pharmacological interventions (cognitive enhancers), neurophysiological techniques (biofeedback)or psychotherapeutic treatments(training).

In alcoholism, central serotonergic dysfunction may contribute to negative affect and impulsive aggression. In animal experiments and human studies, serotonin transporters and receptors interact with central processing of affectively negative stimuli. Monoamine effects on central processing of emotionally salient stimuli are genetically influenced, and besides single gene effect, gene-gene interactions have been postulated. Gene-gene effects are often assumed but difficult to test in behavioral genetics due to the small explained behavioral variance. Processing of unpleasant stimuli in the amygdala has been associated with a functional polymorphism (val158-met)in the catechol-O-methyltransferase (COMT) gene and independently with a functional polymorphism in the regulatory region of the serotonin transporter (5-HTT) gene. 5-HTT function may also be affected by a recently detected A/G exchange in the long allele (insertion)of the 5-HTT regulatory region. In individuals with more COMT met158 alleles and with more s or lG alleles of the 5-HTT regulatory region, aversive stimuli elicited greater neuronal activity in the bilateral amygdalae and hippocampi. These genotype effects were additional to amygdala and hippocampus activation by aversive versus neutral stimuli, indicating that COMT val158-met and 5-HTT genotype were additionally associated with increased processing of aversive stimuli in the amygdalae. Functional brain imaging may be used to assess the interaction of multiple genotypes with anxiety and impulsive aggressiveness in alcohol-dependent patients.

Decision making research continues to generate new approaches to understanding addiction, in relation to developing interconnected concepts of myopia, hypersensitivity to reward and hyposensitivity to punishment. Despite high levels of inter-subject variance in former studies, little progress has been made in describing how individuals differ in terms of their decision-making strategies and behaviours within these decision-making tasks. A study was undertaken to develop methods for analysing and describing adapting response behaviours within a decision-making task. In addition, the effect of task manipulations such as feedback, penalties and practice were examined. Substitute medication maintained adult males were recruited for this study.

Interesting behavioural traits appear to reflect the performance differences between individuals, perhaps offering an additional approach to understanding the idiosyncratic nature of response behaviour during these tasks. Some insight was also gained in how task design may relate to decision-making strategies / response behaviours.

Impulse-control disorders are characterized by the presence of irresistible urges or impulses. With regard to phenomenology and pathogenesis of these disorders two yet unsolved questions attracted researchers: do Impulse-Control Disorders represent disorders of impulses (are the urges so penetrating that the individuum is no longer able to control them) or are they primary disorders to control ubiquitary impulses, or both of them. An answer to these questions is essential for pharmacological and psychotherapeutic treatment planning. In ICD-10 and DSM-IV, however, these questions remain untouched. There, the diagnosis impulse (control) disorders should be used for kinds of persistently repeated maladaptive behaviour that are not secondary to a recognized psychiatric syndrome, and in which it appears that there is repeated failure to resist impulses to carry out the behaviour and the patients report a prodromal period of tension with a feeling of release at the time of the act. Pathological gambling, pyromania, kleptomania, and trichotillomania must be attributed to the rest-category named “Impulse Control Disorders” in DSM-IV or named “Habit and Impulse Disorders” in ICD-10. As we know from clinical praxis, patients suffering from pathological gambling show a much more complex psychopathology quite similar to substance-related disorders. Therefore we propose for DSM-V that pathological gambling should be attributed as gambling addiction (or gambling dependence syndrome) together with other substance-related and non-substance related addictions (e.g. internet addiction, buying addiction, working addiction) to a new group of dependence disorders.

Antipsychotic treatment is frequently associated with unspecific EEG abnormalities; however, in a minority of subjects under antipsychotics severe alterations of brain electric activity including epileptiform activity might occur. Consequently, the risk of seizures is increased under psychopharmacology; however, differences between classes of antipsychotics (e.g. first or second generation drugs) have not been studied extensively and risk profiles regarding changes in brain electric activity remain to be established yet. We investigated psychiatric patients under antipsychotic medication using routine clinical neurophysiological assessments and compared first and second generation drugs. Aim of the study was to estimate the risk of EEG abnormalities under either class of medication by using both visual (standard) and quantified electroencephalography (qEEG) and to analyse the clinical relevance of such findings. In addition the association of brain electric activity under antipsychotics as assessed by novel electromagnetic imaging techniques with clinical parameters such as symptomatology or drug response was investigated.

There were significant differences in the prevalence of EEG abnormalities between first and second generation antipsychotics, with severe abnormalities being more pronounced under some of the second generation drugs. The use of either class was safe in general, but the differences might be of relevance in subjects with a history of seizures. The use of qEEG techniques in the clinical setting in terms of characterising the patients and the respective responses to medication will further be discussed.