Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 5 uppsatser.

SAMMANFATTNING   Bakgrund: Psykossjukdom kan beskrivas som en förändring i verklighetsuppfattning. Symtom är vanföreställningar, hallucinationer, tankestörningar, passivitet, avtrubbade affekter och känslomässiga störningar. Att drabbas av psykossjukdom innebär en stor förändring i livet för den som drabbas, med stort lidande och sänkt livskvalitet. Tidigare forskning har visat att olika bakgrundsfaktorer kan påverka livskvalitet hos patienter med psykossjukdom. Syfte: Denna studie syftar till att undersöka hur människor med psykossjukdom upplever sin livskvalitet och hur ålder, kön, hushållssituation samt utbildning och sysselsättning påverkar detta. Metod: Studiedesignen var komparativ tvärsnittsstudie medelst frågeformulär. Enkäter delades ut på en psykosöppenvårdsmottagning och en slutenvårdsavdelning på ett sjukhus i mellansverige. EQ-5D användes som instrument för att mäta livskvalitet. Deltagarna fick också besvara ett frågeformulär som undersökte deras bakgrundsfaktorer. Resultat: Sysselsättning, som arbete eller studier hade en positiv inverkan på livskvalitet.  ålder, kön, hushållssituation och utbildningsnivå hade ingen inverkan på livskvalitet. Resultatet från insamlingen på slutenvårdsavdelningen var inte möjligt att analysera på grund av bortfall. Slutsats: Denna studie hade för få deltagare som sannolikt påverkat resultatet. Framtida forskning bör vara mer omfattande. Tidigare forskning visar dock att olika bakgrundsfaktorer påverkar livskvalitet. Det är därför viktigt att sjuksköterskor oavsett var de arbetar känner till patientens enskilda bakgrundsfaktorer och utnyttjar denna kunskap för att hitta de individer som behöver mest stöd.     Nyckelord: Livskvalitet, psykossjukdom, bakgrundsfaktorer / ABSTRACT Background Psychotic disorders can be described as a change in the perceptions of reality. Symptoms include delusions, hallucinations, confused thinking, lack of motivation and emotional expressions. To suffer from psychotic disorder means a change in the life of those affected and reduced quality of life. Precious research has shown different background factors can affect the quality of life in patients with psychotic disorders. Aim The aim of this study was to measure quality of life in patients with different psychotic disorders and the impact of age, gender, occupation, household situation and level of education. Method A comparative cross-sectional design was used. In- and outpatients undergoing treatment in a Swedish psychiatric care setting was asked to participate in the study. The EQ-5D instrument was used to measure quality in life. Participants were also asked to fill in in a questioner regarding their background factors. Results Occupation had a positive outcome in quality of life. Age, gender, household situation and level of education did not impact quality of life, The group of inpatients were not included in this study due to failing filling in the questionnaires properly Conclusion The result has probably been affected by the low number of participants, making it difficult to draw any conclusions. Previous research shows different background factor does have an impact on quality of life, future research should ensure a bigger sample of participants.   Keywords: Quality of life, psychotic disorder, background factors

Introdução: As psicoses funcionais são transtornos psiquiátricos cuja principal característica é a perda da capacidade de julgar apropriadamente a realidade em decorrência de alterações na esfera do pensamento, percepção, emoção, movimento e comportamento. A esquizofrenia é o principal destes quadros, com curso crônico e/ou deteriorativo nas esferas social e ocupacional, gerando enormes custos pessoais e financeiros para os pacientes e cuidadores em todo o mundo. Estudos prévios têm mostrado a existência de prejuízos cognitivos em pacientes com transtornos psicóticos já no início da doença, sendo estes mais graves na esquizofrenia. Há evidências de que estes prejuízos são tanto inerentes aos próprios processos da doença quanto secundários ao tratamento. O presente estudo procurou caracterizar o perfil cognitivo de pacientes com psicoses de início recente (n=56), até 3 anos após o primeiro contato com serviços de saúde mental, sendo 34 com esquizofrenia e 22 com psicoses afetivas. Tais grupos de pacientes tiveram seu desempenho cognitivo comparado com o de um grupo controles saudável (n=70), recrutados a partir das mesmas áreas geográficas de São Paulo, Brasil. Até o momento, a maioria dos estudos foi realizada em países em desenvolvimento. Metodologia: A investigação utilizou ampla bateria de testes neuropsicológicos composta por 12 testes agrupados em 8 domínios cognitivos destinados a avaliar respectivamente amplitude atencional, velocidade de processamento da informação, memória verbal, memória visual, memória de trabalho, fluência verbal, funções executivas e funcionamento intelectual. O nível de significância foi de p < 0.05. Resultados: O desempenho do grupo de pacientes com psicoses foi pior do que o dos controles em todas as tarefas cognitivas, com diferenças estatisticamente significativas nas tarefas de velocidade de processamento da informação, memória verbal, fluência verbal e funcionamento intelectual, sendo os déficits mais graves no domínio da memória verbal (p < 0.001). Os grupos esquizofrenia e psicoses afetivas não diferiram significativamente quando comparados entre si. A inclusão do grupo controle na comparação mostrou que os pacientes com esquizofrenia tiveram desempenho significativamente pior do que os controles, o que não ocorreu entre os controles e as psicoses afetivas. A investigação da influência das variáveis demográficas e clínicas mostrou que o desempenho cognitivo foi beneficiado pela escolaridade, na maioria das funções; a idade atual maior teve associação negativa com a memória visual e fluência verbal; gênero masculino teve correlação positiva com a memória de trabalho, tempo de latência para produção de resposta não-convencional, e negativa com a quantidade de erros frente à necessidade de controle de respostas impulsivas.O padrão de tratamento descontínuo beneficiou o desempenho em tarefas de memória verbal, e prejudicou o desempenho na tarefa de antecipação espacial. O abuso/dependência de substâncias não mostrou correlação com nenhuma tarefa, o que ocorreu na análise de regressão. O início do transtorno em idades mais precoces não mostrou prejudicar o desempenho dos pacientes na maioria das tarefas. O tempo de duração de psicose não tratada (duration of untreated psychosis, DUP) mostrou correlação negativa com o tempo de latência para respostas não-convencionais no grupo das psicoses, influenciando negativamente o desempenho nas tarefas de vocabulário, memória verbal imediata e tardia, e a quantidade de respostas impulsivas. No grupo da esquizofrenia, a maior DUP esteve associada a piores resultados nas tarefas de raciocínio não-verbal, memória verbal imediata e tardia, e quantidade de erros no teste de antecipação espacial. Os sintomas negativos influenciaram negativamente os resultados em várias provas, o que não ocorreu com os sintomas positivos. Conclusão: Pacientes com psicoses funcionais de início recente apresentaram prejuízos cognitivos evidentes em comparação aos controles saudáveis. Confirmou-se também a existência de funcionamento cognitivo semelhante entre amostras de países desenvolvidos e em desenvolvimento através de bateria cognitiva ampla. Os prejuízos cognitivos estenderam-se a várias funções, configurando tendência a perfil de déficits generalizados. Embora tenha havido tendência a maior gravidade de déficits no grupo da esquizofrenia, não encontramos diferenças significativas entre os subgrupos diagnósticos, confirmando a presença de déficits cognitivos nas psicoses de início recente, particularmente nas de natureza não-afetiva. / Background and Purpose: Functional psychoses are psychiatric disorders which have as their main characteristic a loss of the ability to properly judge the reality due to alterations of thought, perception, emotion, movement and behavior. The main psychotic disorder is schizophrenia, which usually as a chronic and / or deteriorating course in social and occupational relationships, generating enormous personal and financial costs for the patients and their caretakers all over the world. Previous studies have shown the presence of cognitive deficits in patients at the onset of psychoses, more severely in schizophrenia. There are evidences that those deficits are both related to disease processes and to treatment effects. The present work sought to characterize the neuropsychological profile of patients with recent onset psychoses (n=56), up to 3 years after their first contact with Mental Health Service Care 34 with schizophrenia and 22 with affective psychoses. These patient groups had their results compared to a healthy control group (n=70) recruited from the same geographic area of São Paulo City, Brazil. So far, most studies of neuropsychological functioning in patients with recent onset psychoses have been conducted in high-income countries. Method: The cognitive assessment was conducted using a neuropsychological battery comprising 12 tests, grouped into 8 cognitive domains aimed at assessing respectively intellectual functioning, attentional span, information processing speed, verbal memory, visual memory, working memory, verbal fluency and executive functioning. The significance level was set at p < 0.05. Results: The performance of the psychosis group was worse than that of controls in all cognitive tasks, with statistically significant differences detected in information processing speed, verbal memory, verbal fluency and intellectual functioning tasks, most seriously in the verbal memory domain (p < 0.001). When compared against each other, the schizophrenia and affective psychoses subgroups were not significantly different. The inclusion of the control group in the analysis showed that patients with schizophrenia had significantly worse performance than controls, while such difference was not noticed when controls and affective psychoses groups were compared against. The influence of demographic variables and clinic data showed that cognitive performance was significantly associated with level of schooling in most cognitive tasks; visual memory and verbal fluency were negatively affected by age (deficit increased with age); male gender showed a positive relationship to executive memory and lag time for non-conventional answers, and a negative relationship to mistakes in impulsive answer control needs. Treatment discontinuity was related to better performance in tasks such as verbal memory, but with worse performance in the anticipation space test. Substance abuse or dependence did not influence significantly the performance in any of the tasks individually, but this occurred in the regression analysis. Earlier age of psychosis onset was non significantly related to performance of patients in any of the tasks. The duration of untreated psychoses (DUP) showed negative correlation with the lag time for non-conventional answers in the psychoses group, influencing the performance in tasks as vocabulary, immediate and delayed verbal memory, and the amount of impulsive responses negatively. In schizophrenia group, DUP was associated to worse results in non - verbal reasoning, immediate and late verbal memory, and error quantity in anticipation space test. Several activities were negatively influenced by negative symptoms, what did not occurred with positive symptoms. Conclusion: Patients with recent onset psychosis clearly display cognitive deficits when compared to healthy controls. The existence of similar cognitive functioning between samples studied in developed and developing countries was confirmed through wide cognitive test sets. Cognitive impairment was detected in multiple tasks, showing a widespread trend of deficit profiles. Although there was a tendency towards high severity deficits in the schizophrenia group, we could not find major differences amongst diagnoses subgroups. Our results reinforce the view that there are generalized cognitive deficits in association with recent-onset psychoses, particularly of non- affective nature.

Introdução: As psicoses funcionais são transtornos psiquiátricos cuja principal característica é a perda da capacidade de julgar apropriadamente a realidade em decorrência de alterações na esfera do pensamento, percepção, emoção, movimento e comportamento. A esquizofrenia é o principal destes quadros, com curso crônico e/ou deteriorativo nas esferas social e ocupacional, gerando enormes custos pessoais e financeiros para os pacientes e cuidadores em todo o mundo. Estudos prévios têm mostrado a existência de prejuízos cognitivos em pacientes com transtornos psicóticos já no início da doença, sendo estes mais graves na esquizofrenia. Há evidências de que estes prejuízos são tanto inerentes aos próprios processos da doença quanto secundários ao tratamento. O presente estudo procurou caracterizar o perfil cognitivo de pacientes com psicoses de início recente (n=56), até 3 anos após o primeiro contato com serviços de saúde mental, sendo 34 com esquizofrenia e 22 com psicoses afetivas. Tais grupos de pacientes tiveram seu desempenho cognitivo comparado com o de um grupo controles saudável (n=70), recrutados a partir das mesmas áreas geográficas de São Paulo, Brasil. Até o momento, a maioria dos estudos foi realizada em países em desenvolvimento. Metodologia: A investigação utilizou ampla bateria de testes neuropsicológicos composta por 12 testes agrupados em 8 domínios cognitivos destinados a avaliar respectivamente amplitude atencional, velocidade de processamento da informação, memória verbal, memória visual, memória de trabalho, fluência verbal, funções executivas e funcionamento intelectual. O nível de significância foi de p < 0.05. Resultados: O desempenho do grupo de pacientes com psicoses foi pior do que o dos controles em todas as tarefas cognitivas, com diferenças estatisticamente significativas nas tarefas de velocidade de processamento da informação, memória verbal, fluência verbal e funcionamento intelectual, sendo os déficits mais graves no domínio da memória verbal (p < 0.001). Os grupos esquizofrenia e psicoses afetivas não diferiram significativamente quando comparados entre si. A inclusão do grupo controle na comparação mostrou que os pacientes com esquizofrenia tiveram desempenho significativamente pior do que os controles, o que não ocorreu entre os controles e as psicoses afetivas. A investigação da influência das variáveis demográficas e clínicas mostrou que o desempenho cognitivo foi beneficiado pela escolaridade, na maioria das funções; a idade atual maior teve associação negativa com a memória visual e fluência verbal; gênero masculino teve correlação positiva com a memória de trabalho, tempo de latência para produção de resposta não-convencional, e negativa com a quantidade de erros frente à necessidade de controle de respostas impulsivas.O padrão de tratamento descontínuo beneficiou o desempenho em tarefas de memória verbal, e prejudicou o desempenho na tarefa de antecipação espacial. O abuso/dependência de substâncias não mostrou correlação com nenhuma tarefa, o que ocorreu na análise de regressão. O início do transtorno em idades mais precoces não mostrou prejudicar o desempenho dos pacientes na maioria das tarefas. O tempo de duração de psicose não tratada (duration of untreated psychosis, DUP) mostrou correlação negativa com o tempo de latência para respostas não-convencionais no grupo das psicoses, influenciando negativamente o desempenho nas tarefas de vocabulário, memória verbal imediata e tardia, e a quantidade de respostas impulsivas. No grupo da esquizofrenia, a maior DUP esteve associada a piores resultados nas tarefas de raciocínio não-verbal, memória verbal imediata e tardia, e quantidade de erros no teste de antecipação espacial. Os sintomas negativos influenciaram negativamente os resultados em várias provas, o que não ocorreu com os sintomas positivos. Conclusão: Pacientes com psicoses funcionais de início recente apresentaram prejuízos cognitivos evidentes em comparação aos controles saudáveis. Confirmou-se também a existência de funcionamento cognitivo semelhante entre amostras de países desenvolvidos e em desenvolvimento através de bateria cognitiva ampla. Os prejuízos cognitivos estenderam-se a várias funções, configurando tendência a perfil de déficits generalizados. Embora tenha havido tendência a maior gravidade de déficits no grupo da esquizofrenia, não encontramos diferenças significativas entre os subgrupos diagnósticos, confirmando a presença de déficits cognitivos nas psicoses de início recente, particularmente nas de natureza não-afetiva. / Background and Purpose: Functional psychoses are psychiatric disorders which have as their main characteristic a loss of the ability to properly judge the reality due to alterations of thought, perception, emotion, movement and behavior. The main psychotic disorder is schizophrenia, which usually as a chronic and / or deteriorating course in social and occupational relationships, generating enormous personal and financial costs for the patients and their caretakers all over the world. Previous studies have shown the presence of cognitive deficits in patients at the onset of psychoses, more severely in schizophrenia. There are evidences that those deficits are both related to disease processes and to treatment effects. The present work sought to characterize the neuropsychological profile of patients with recent onset psychoses (n=56), up to 3 years after their first contact with Mental Health Service Care 34 with schizophrenia and 22 with affective psychoses. These patient groups had their results compared to a healthy control group (n=70) recruited from the same geographic area of São Paulo City, Brazil. So far, most studies of neuropsychological functioning in patients with recent onset psychoses have been conducted in high-income countries. Method: The cognitive assessment was conducted using a neuropsychological battery comprising 12 tests, grouped into 8 cognitive domains aimed at assessing respectively intellectual functioning, attentional span, information processing speed, verbal memory, visual memory, working memory, verbal fluency and executive functioning. The significance level was set at p < 0.05. Results: The performance of the psychosis group was worse than that of controls in all cognitive tasks, with statistically significant differences detected in information processing speed, verbal memory, verbal fluency and intellectual functioning tasks, most seriously in the verbal memory domain (p < 0.001). When compared against each other, the schizophrenia and affective psychoses subgroups were not significantly different. The inclusion of the control group in the analysis showed that patients with schizophrenia had significantly worse performance than controls, while such difference was not noticed when controls and affective psychoses groups were compared against. The influence of demographic variables and clinic data showed that cognitive performance was significantly associated with level of schooling in most cognitive tasks; visual memory and verbal fluency were negatively affected by age (deficit increased with age); male gender showed a positive relationship to executive memory and lag time for non-conventional answers, and a negative relationship to mistakes in impulsive answer control needs. Treatment discontinuity was related to better performance in tasks such as verbal memory, but with worse performance in the anticipation space test. Substance abuse or dependence did not influence significantly the performance in any of the tasks individually, but this occurred in the regression analysis. Earlier age of psychosis onset was non significantly related to performance of patients in any of the tasks. The duration of untreated psychoses (DUP) showed negative correlation with the lag time for non-conventional answers in the psychoses group, influencing the performance in tasks as vocabulary, immediate and delayed verbal memory, and the amount of impulsive responses negatively. In schizophrenia group, DUP was associated to worse results in non - verbal reasoning, immediate and late verbal memory, and error quantity in anticipation space test. Several activities were negatively influenced by negative symptoms, what did not occurred with positive symptoms. Conclusion: Patients with recent onset psychosis clearly display cognitive deficits when compared to healthy controls. The existence of similar cognitive functioning between samples studied in developed and developing countries was confirmed through wide cognitive test sets. Cognitive impairment was detected in multiple tasks, showing a widespread trend of deficit profiles. Although there was a tendency towards high severity deficits in the schizophrenia group, we could not find major differences amongst diagnoses subgroups. Our results reinforce the view that there are generalized cognitive deficits in association with recent-onset psychoses, particularly of non- affective nature.

Research Doctorate - Doctor of Philosphy (PhD) / A large body of population- and treatment-based evidence exists to indicate depression and alcohol/other drug (AOD) use are highly prevalent on a global scale, and co-occur with considerable frequency. Despite this evidence, significant gaps exist in treatment research and clinical services, as people with co-occurring depression and AOD use problems have typically been excluded from randomised controlled treatment trials, and also face many individual- and service-level barriers to accessing treatment. Consequently, a well-defined and adequately tested treatment strategy does not currently exist for people experiencing the complexities of concurrent depression and AOD use problems. A small body of evidence exists to suggest that co-occurring mental and AOD use disorders (“comorbidity”) leads to poorer treatment outcomes, increased risk of relapse, higher levels of problematic symptomatology, and poorer quality of life. However, little consistent information is currently available to suggest what additional impact comorbid depression and AOD misuse produces relative to the experience of a “single” condition (such as depression or AOD misuse in isolation). Studies 1 and 2 attempted to address this important gap in knowledge by examining the presenting characteristics of 246 people with AOD use problems, according to the presence of comorbid depressive symptoms. One hundred and thirty seven participants were drawn from AOD treatment services, and a further 109 were referred via mental health services and also met criteria for a psychotic disorder. Results indicated that the presence of depression was associated with a significantly higher severity of psychiatric symptoms and personality disorder, significantly decreased social and occupational functioning and significantly reduced quality of life. Current depression was also associated with a significant increase in the experience of cravings and self-reported dependence on amphetamines. These difficulties were over and above the already high rates of disability and distress reported by each sample as a whole. Furthermore, treatment for mental health problems was rare among the AOD treatment participants, as was AOD treatment among the mental health sample. This is despite the presence of moderate to severe levels of depression and AOD use reported by each sample. In particular, Studies 1 and 2 highlight the vulnerabilities for people with comorbid mental health and AOD use problems who present to treatment in the mental health or AOD use settings, and in particular how depression significantly increases the disability and other challenges experienced by these people. These results provide a strong rationale for the development of an appropriate treatment protocol for depression and AOD use comorbidity. No clear treatment model or evidence-based approach exists to suggest how depression and AOD use comorbidity is best managed. When people with this comorbidity do manage to access clinical treatment services, they typically receive treatment targeted at one aspect of their presentation (e.g. depression-focussed or AOD-focussed treatment). Yet, it is not known whether a singular focus of treatment is effective in producing sustainable change in the outcomes of people with comorbid problems, nor whether failure to treat all components of the comorbid presentation confers a worse outcome. Studies 3 and 4 reported on two randomised controlled clinical trials of psychologicaltreatment for AOD use problems among a sample of 246 people with AOD use problems, drawn from AOD treatment services (n=137) or mental health services (n=109). In doing so, these studies provide some of the first available data on these issues. Participants were categorised according to the presence of comorbid depression (as per Studies 1 and 2) and response to treatment was analysed over a six- to 12-month follow-up period. In spite of high levels of current depressive symptoms at entry to the studies, and equally hazardous use thresholds of a range of substance, people enrolled in Studies 3 and 4 reported some gains via their experiences with these single-focussed treatments. Attendance and retention rates were higher than reported in previous research, and the presence of depression did not adversely influence the motivation of project participants to change their current AOD use patterns. A treatment effect was generally not detected among the Study 3 and 4 participants, regardless of the presence of depression, with those receiving an assessment-only control treatment in both studies reporting similar patterns of change in outcome. Regardless of the magnitude of change reported by all study participants, people with depression reported significantly higher levels of depression, poly-drug use, amphetamine dependence, hazardous use of a range of substances, HIV risk taking and criminal activity and lower levels of functioning and self-concept across the follow-up assessment period. These residual symptoms were present at sufficiently high levels of severity to increase the risk of relapse to AOD use and continued morbidity. These results suggested the potential value of targeting depression in the context of comorbid AOD use problems. One previous study has examined the impact of an adjunctive psychological treatment of depression for people hospitalised for alcohol use disorder. Results indicated that people who received the additional depression treatment reported significantly greater improvements on depression- and alcohol-related outcomes over the short-term relative to people receiving a relaxation-only control treatment. These improvements were suggested to be enhanced if treatment had integrated depression- and alcohol-related approaches into the one treatment program. In the first study of its kind, Study 5 developed and evaluated the efficacy of an integrated psychological treatment program for comorbid depression and AOD use problems. Sixty-seven participants received integrated treatment delivered by a therapist, computer-delivered integrated treatment or a brief intervention (control) treatment delivered by a therapist. Depression scores, daily use of alcohol and cannabis, hazardous use of a range of substance and poly-drug use fell significantly over a 12-month follow-up period across the integrated treatments and brief intervention (control) conditions. The small sample size of Study 5 meant that very few treatment effects were detected at a statistically significant level, however important reductions in key outcomes for depression, AOD use, quality of life and general functioning were noted for people in the integrated treatment relative to controls over a 12-month period. The magnitude of change in Study 5 across these domains was comparable with the only other study of psychological treatment of depression and alcohol-use disorders described above. The integrated treatment in Study 5 was associated with higher levels of improvement in depression, alcohol use and cannabis use (where present) than did the AOD-focussed treatment examined in Studies 3 and 4. The results further suggest that a brief intervention targeting both depression and AOD drug use problems is associated with reductions in key outcomes in the short-term, withintegrated, lengthier psychological treatment potentially associated with longer-term changes on the same outcomes. No previous study has directly compared the outcomes for people completing psychological treatment delivered via a computer program with those completing treatment with a ‘live’ clinician over an extended follow-up period of 12-months. Given the barriers people with comorbid depression and AOD use problems face in accessing available treatment services, the consideration of alternative modes of delivery of evidence-based treatment to this group is timely. Study 6 expanded on the Study 5 results by presenting further analysis of the performance of the computer-delivered version of the integrated treatment relative to the clinician-delivered equivalent, matched for content. Given the small sample size of participants, Study 6 devised a four-point criterion which, if satisfied, would suggest that the computer-delivered and clinician-delivered integrated treatments were approximately equal. Based on these criteria, the results indicated that the outcome profiles for people engaged in the computer-delivered treatment were equivalent to those reported by people involved in clinician-delivered therapy over a 12¬month follow-up period. Additionally, computer-delivered integrated treatment was associated with similar rates of improvement as the therapist-equivalent on depression scores, risky drinking patterns, hazardous use of substances, poly-drug use, levels of daily cannabis use, suicidality, treatment retention and therapeutic alliance. This result requires further replication to test these assumptions, however it is promising that a treatment requiring an average of 12-minutes face-to-face of “generic” clinician time per weekproduces a similar pattern of improvement to a treatment requiring an average of 60 minutes of face-to-face specialist psychologist input over the same time period. Studies 1-6 resulted in the development of a menu of treatment options for people with depression and AOD use comorbidity, with each treatment approach providing evidence for at least some benefit among the study participants. While encouraging, these results again raise the issue of how treatment may be incorporated into existing services (mental health, AOD use, primary care, etc.), which typically remain segregated, with little opportunity for collaboration and cross-fertilisation of skills and expertise between service settings. Chapter 7 discusses a new model of treatment for comorbid depression and AOD use problems that incorporates the results of Studies 1-6, and involves a stepped care approach to developing a treatment plan tailored to the specific needs and levels of distress experienced by people with depression and AOD use comorbidity. The stepped care model of treatment could be incorporated into existing service settings and structures, with the potential for computer-based therapy to provide access to specialised treatment for depression and AOD use comorbidity that might otherwise be unavailable. As a result, stepped care treatment could foster earlier engagement with treatment services and encourage motivation and optimism among people with comorbid depression and AOD use problems. These are important issues for service development and delivery of appropriate treatments to this underserved population.

Childhood maltreatment is extremely common in patients diagnosed with psychotic disorders. Moreover, it has been linked with impaired functioning of the Hypothalamic-Pituitary-Adrenal axis. Furthermore, abnormality of the HPA has been found in psychotic patients. Presence of childhood maltreatment could then explain why the HPA axis is dysfunctional in these subjects. Our objective was to clarify the role of childhood trauma in the cortisol profiles of psychotic patients. Thirty-one patients underwent assessments of childhood maltreatment. Diurnal cortisol and cortisol after a controlled psychosocial stress were also collected. Our results show that childhood trauma is associated with lower cortisol levels during the morning and during 24 hours. In men diagnosed with psychosis, childhood trauma is also associated with a higher cortisol response during psychosocial stress. This suggests an alteration of the HPA axis in psychotic patients, resulting from early trauma. Moreover, our results suggest that looking at specific types of childhood abuse may also be important.

Research Doctorate - Doctor of Philosphy (PhD) / A large body of population- and treatment-based evidence exists to indicate depression and alcohol/other drug (AOD) use are highly prevalent on a global scale, and co-occur with considerable frequency. Despite this evidence, significant gaps exist in treatment research and clinical services, as people with co-occurring depression and AOD use problems have typically been excluded from randomised controlled treatment trials, and also face many individual- and service-level barriers to accessing treatment. Consequently, a well-defined and adequately tested treatment strategy does not currently exist for people experiencing the complexities of concurrent depression and AOD use problems. A small body of evidence exists to suggest that co-occurring mental and AOD use disorders (“comorbidity”) leads to poorer treatment outcomes, increased risk of relapse, higher levels of problematic symptomatology, and poorer quality of life. However, little consistent information is currently available to suggest what additional impact comorbid depression and AOD misuse produces relative to the experience of a “single” condition (such as depression or AOD misuse in isolation). Studies 1 and 2 attempted to address this important gap in knowledge by examining the presenting characteristics of 246 people with AOD use problems, according to the presence of comorbid depressive symptoms. One hundred and thirty seven participants were drawn from AOD treatment services, and a further 109 were referred via mental health services and also met criteria for a psychotic disorder. Results indicated that the presence of depression was associated with a significantly higher severity of psychiatric symptoms and personality disorder, significantly decreased social and occupational functioning and significantly reduced quality of life. Current depression was also associated with a significant increase in the experience of cravings and self-reported dependence on amphetamines. These difficulties were over and above the already high rates of disability and distress reported by each sample as a whole. Furthermore, treatment for mental health problems was rare among the AOD treatment participants, as was AOD treatment among the mental health sample. This is despite the presence of moderate to severe levels of depression and AOD use reported by each sample. In particular, Studies 1 and 2 highlight the vulnerabilities for people with comorbid mental health and AOD use problems who present to treatment in the mental health or AOD use settings, and in particular how depression significantly increases the disability and other challenges experienced by these people. These results provide a strong rationale for the development of an appropriate treatment protocol for depression and AOD use comorbidity. No clear treatment model or evidence-based approach exists to suggest how depression and AOD use comorbidity is best managed. When people with this comorbidity do manage to access clinical treatment services, they typically receive treatment targeted at one aspect of their presentation (e.g. depression-focussed or AOD-focussed treatment). Yet, it is not known whether a singular focus of treatment is effective in producing sustainable change in the outcomes of people with comorbid problems, nor whether failure to treat all components of the comorbid presentation confers a worse outcome. Studies 3 and 4 reported on two randomised controlled clinical trials of psychologicaltreatment for AOD use problems among a sample of 246 people with AOD use problems, drawn from AOD treatment services (n=137) or mental health services (n=109). In doing so, these studies provide some of the first available data on these issues. Participants were categorised according to the presence of comorbid depression (as per Studies 1 and 2) and response to treatment was analysed over a six- to 12-month follow-up period. In spite of high levels of current depressive symptoms at entry to the studies, and equally hazardous use thresholds of a range of substance, people enrolled in Studies 3 and 4 reported some gains via their experiences with these single-focussed treatments. Attendance and retention rates were higher than reported in previous research, and the presence of depression did not adversely influence the motivation of project participants to change their current AOD use patterns. A treatment effect was generally not detected among the Study 3 and 4 participants, regardless of the presence of depression, with those receiving an assessment-only control treatment in both studies reporting similar patterns of change in outcome. Regardless of the magnitude of change reported by all study participants, people with depression reported significantly higher levels of depression, poly-drug use, amphetamine dependence, hazardous use of a range of substances, HIV risk taking and criminal activity and lower levels of functioning and self-concept across the follow-up assessment period. These residual symptoms were present at sufficiently high levels of severity to increase the risk of relapse to AOD use and continued morbidity. These results suggested the potential value of targeting depression in the context of comorbid AOD use problems. One previous study has examined the impact of an adjunctive psychological treatment of depression for people hospitalised for alcohol use disorder. Results indicated that people who received the additional depression treatment reported significantly greater improvements on depression- and alcohol-related outcomes over the short-term relative to people receiving a relaxation-only control treatment. These improvements were suggested to be enhanced if treatment had integrated depression- and alcohol-related approaches into the one treatment program. In the first study of its kind, Study 5 developed and evaluated the efficacy of an integrated psychological treatment program for comorbid depression and AOD use problems. Sixty-seven participants received integrated treatment delivered by a therapist, computer-delivered integrated treatment or a brief intervention (control) treatment delivered by a therapist. Depression scores, daily use of alcohol and cannabis, hazardous use of a range of substance and poly-drug use fell significantly over a 12-month follow-up period across the integrated treatments and brief intervention (control) conditions. The small sample size of Study 5 meant that very few treatment effects were detected at a statistically significant level, however important reductions in key outcomes for depression, AOD use, quality of life and general functioning were noted for people in the integrated treatment relative to controls over a 12-month period. The magnitude of change in Study 5 across these domains was comparable with the only other study of psychological treatment of depression and alcohol-use disorders described above. The integrated treatment in Study 5 was associated with higher levels of improvement in depression, alcohol use and cannabis use (where present) than did the AOD-focussed treatment examined in Studies 3 and 4. The results further suggest that a brief intervention targeting both depression and AOD drug use problems is associated with reductions in key outcomes in the short-term, withintegrated, lengthier psychological treatment potentially associated with longer-term changes on the same outcomes. No previous study has directly compared the outcomes for people completing psychological treatment delivered via a computer program with those completing treatment with a ‘live’ clinician over an extended follow-up period of 12-months. Given the barriers people with comorbid depression and AOD use problems face in accessing available treatment services, the consideration of alternative modes of delivery of evidence-based treatment to this group is timely. Study 6 expanded on the Study 5 results by presenting further analysis of the performance of the computer-delivered version of the integrated treatment relative to the clinician-delivered equivalent, matched for content. Given the small sample size of participants, Study 6 devised a four-point criterion which, if satisfied, would suggest that the computer-delivered and clinician-delivered integrated treatments were approximately equal. Based on these criteria, the results indicated that the outcome profiles for people engaged in the computer-delivered treatment were equivalent to those reported by people involved in clinician-delivered therapy over a 12¬month follow-up period. Additionally, computer-delivered integrated treatment was associated with similar rates of improvement as the therapist-equivalent on depression scores, risky drinking patterns, hazardous use of substances, poly-drug use, levels of daily cannabis use, suicidality, treatment retention and therapeutic alliance. This result requires further replication to test these assumptions, however it is promising that a treatment requiring an average of 12-minutes face-to-face of “generic” clinician time per weekproduces a similar pattern of improvement to a treatment requiring an average of 60 minutes of face-to-face specialist psychologist input over the same time period. Studies 1-6 resulted in the development of a menu of treatment options for people with depression and AOD use comorbidity, with each treatment approach providing evidence for at least some benefit among the study participants. While encouraging, these results again raise the issue of how treatment may be incorporated into existing services (mental health, AOD use, primary care, etc.), which typically remain segregated, with little opportunity for collaboration and cross-fertilisation of skills and expertise between service settings. Chapter 7 discusses a new model of treatment for comorbid depression and AOD use problems that incorporates the results of Studies 1-6, and involves a stepped care approach to developing a treatment plan tailored to the specific needs and levels of distress experienced by people with depression and AOD use comorbidity. The stepped care model of treatment could be incorporated into existing service settings and structures, with the potential for computer-based therapy to provide access to specialised treatment for depression and AOD use comorbidity that might otherwise be unavailable. As a result, stepped care treatment could foster earlier engagement with treatment services and encourage motivation and optimism among people with comorbid depression and AOD use problems. These are important issues for service development and delivery of appropriate treatments to this underserved population.

Diss. (sammanfattning) Umeå : Univ., 2004. / Härtill 5 uppsatser.

Poor insight has clinical significance as a predictor of non-adherence to treatment, increased number of relapses, hospitalisations, recovery and risk of violence. Empirical research has led to advances in the redefinition, knowledge and understanding of insight in psychosis. However, the use of a wide range of definitions and measures has created difficulties in interpreting research findings, without clarifying the concepts being measured and evaluating the quality of their associated assessment tool. Therefore, the aim of the first piece of work, a Systematic Review (SR), was to identify and describe the constructs of insight in psychosis and their assessment tools and briefly evaluate their psychometric properties. Insight in psychosis is particularly relevant to Forensic Mental Health Services, given its link with offending behaviour and risk to others. However, outside of those provided by risk appraisal tools, there are no current guidelines that specifically target the assessment, or intervention, of insight. Therefore, the second piece of work, a research project (RP), aimed to explore current practices, as described by experienced clinicians. The SR identified twelve assessment tools and fourteen papers for detailed analysis. Twelve theoretical constructs were identified, the most prominent being awareness of mental illness and awareness of the need for treatment. Other prominent theoretical constructs included awareness of negative consequences of illness and awareness of generic or specific symptoms. However, few of the subscales associated with each theoretical construct were supported by empirical evidence. Further work to clarify aspects of insight that are important areas for intervention, along with the provision of data to support these, should continue to be a focus for on-going research. The RP was a qualitative design using Thematic Analysis. Data was collected by semi-structured interviews from 11 qualified Clinical Psychologists working in Forensic Mental Health Services across Scotland. The RP identified three overarching themes. The first “risk related” illustrated the influence of risk to other when assessing and treating patients. The second “holistic approach” illustrated that insight or mental illness was rarely looked at in isolation. The third theme “no specific or satisfactory unified approach” illustrated the diversity of the conceptualising, assessment and treatment of insight. Opportunities exist to develop a more uniformed approach and to introduce or develop outcome measures for interventions.

Introdução: A Depressão Psicótica (DP) afeta cerca de 15-20% dos pacientes com diagnóstico de depressão. Esta condição está ligada a maior cronicidade, maior incidência de tentativas de suicídio e maior frequência de internação hospitalar em relação à Depressão Não-Psicótica. No entanto, evidências recentes sugerem que a incidência de características psicóticas pode não estar relacionada à intensidade dos sintomas depressivos. O curso distinto de doença, associado a pior resposta ao tratamento e a pior prognóstico suscitam a discussão de que a depressão psicótica pode ser uma entidade clínica distinta da depressão, representando um ponto em um continuum que tem em um de seus extremos os transtornos psicóticos e no outro, os transtornos de humor. Objetivos: Avaliar se a presença de sintomas psicóticos em pacientes internados por episódio depressivo se correlaciona com a intensidade de sintomas depressivos. Avaliar se há diferenças clínicas e funcionais que podem se relacionar com os sintomas psicóticos dos pacientes da amostra. Observar a melhora de sintomatologia psiquiátrica ao longo da internação, e se há diferença na variação de sintomas, ao longo da internação, entre os pacientes psicóticos e não-psicóticos. Métodos: 288 pacientes internados por episódio depressivo em uma unidade psiquiátrica de um hospital geral universitário foram avaliados na admissão e na alta hospitalar. Foi realizada entrevista semi-estruturada com o MINI para avaliação diagnóstica. Nos dois momentos de avaliação foram aplicadas a Escala de Hamilton para Avaliação de Depressão (HAM-D), a Escala Breve de Avaliação Psiquiátrica (BPRS), a avaliação da Impressão Clínica Global (CGI) e a Escala Global de Avaliação do Funcionamento (GAF). Outros parâmetros clínicos e epidemiológicos também foram avaliados: idade de início de sintomas, quantidade de internações prévias, tentativas de suicídio prévias, tempo de duração da internação atual e realização de Eletroconvulsoterapia (ECT) durante a internação. Resultados: 131 pacientes (45,4%) apresentaram sintomas psicóticos. Após ajuste para controle de variáveis que tinham potencial de viés de confusão – história prévia de mania ou hipomania, história prévia de uso de substâncias, sexo, idade, e anos de estudo – os dois grupos tiveram resultados similares nos resultados da HAM-D, tanto na admissão quanto na alta. Em relação às outras medidas, no entanto, os pacientes com depressão psicótica apresentaram piores níveis de funcionamento (GAF), piores resultados na avaliação clínica (CGI) e escores mais elevados na BPRS, na admissão e na alta hospitalar. Conclusão: Os pacientes com depressão psicótica apresentaram história mais grave de sintomas psiquiátricos e maior prejuízo funcional. No entanto, as diferenças entre os pacientes psicóticos e não-psicóticos não tiveram relação com os sintomas depressivos dos pacientes. Tais achados vão ao encontro de evidências recentes que sugerem que a depressão psicótica pode ser um transtorno distinto da depressão maior. / Introduction: Psychotic Depression (DP) is a medical condition that affects a significant portion of depressive patients, 15-20%. This disorder is linked to greater cronicity, higher incidence of suicide attempts and a higher frequency of hospitalization, when compared to depressive episodes without psychotic features. Nevertheless, recent evidences suggest that the presence of psychotic symptoms may not correlate to depressive symptoms severity. The discrete clinical course, along with worse response to usual treatment and worse prognosis draw a hypothesis that Psychotic Depression might be a distinct disorder in relation to major depression. It reflects the intersection of psychotic and affective dimensions, and may be placed in a point of a continuum between psychotic and affective disorders. Objectives: To evaluate if the presence of psychotic symptoms in hospitalized depressive patients correlates to depressive symptoms intensity. To evaluate the existence of clinical and functioning differences among psychotic and non-psychotic depressive inpatients that could be related to the psychotic features. To estimate clinical improvement during hospitalization, and if there are dissimilarities in the variation of symptoms between psychotic and non-psychotic depressive individuals. Methods: 288 depressive inpatients of a psychiatric ward of a university tertiary hospital were assessed at admission and at discharge. We conducted MINI semi-structured interview to determine patient diagnosis. At both assessments we applied the Hamilton Depression Rating Scale (HAM-D), the Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI) and the Global Assessment of Functioning (GAF). Other clinical and epidemiological parameters were also assessed: age at onset, number of previous hospitalizations, previous suicide attempts, length of stay and Electroconvulsive therapy (ECT) in current hospitalization. Results: 131 patients (45,4%) had psychotic features. After adjusting for potential confounding variables – previous presence of mania or hypomania, history of substance use, gender, age and years of study –, both psychotic and non-psychotic depressive patients presented similar HAM-D scores at admission and at discharge. However, psychotic depressive inpatients showed worse functioning levels (GAF), worse clinical status (CGI) and higher BPRS scores, both at admission and at discharge. Conclusion: Psychotic depressive inpatients presented more severe history of psychiatric symptoms and greater functioning disability. The differences between both groups of patients did not correlate to depressive symptoms. These findings are in conformity with recent evidences that suggest that psychotic depression might be a distinct disorder in relation to major depression.