The Residential Educational Therapeutic Unit Accompany from Hospital Sant Joan de Déu Barcelona, is a device integrated into the public health network, intended for the comprehensive care of children and adolescents under 18 years of age who suffer from an illness complex mental disorder, at serious risk of becoming chronic and generating significant disabilities at a functional, cognitive and emotional level. It was a result from a joint venture between the Department of Social Rights and the Department of Health. The device was created to respond to the increase in behavioral problems and mental health disorders of children underguardianship.

General Objective

To improve the quality of life in the physical, mental and social spheres of vulnerable children and adolescents with serious complex mental pathology through a biopsychosocial and community care model that integrates health, social, family and educational care and which is aimed at the recovery of the person’s life project.

Specific Objectives

To offer intensive intervention, personalized and in a co-responsible manner, that is to say, that integrates the therapeutic, education, social services and child protection teams.

Promote the community and social reintegration avoiding stigmatization and social exclusion.

Improve the intra-family relationship and the burden perceived by caregivers.

Decrease the number of renunciations of parental authority of a minor.

The unit has a capacity for 28 beds: 23 places for children/adolescents underguardianship of the administration and 5 places for cases that are at risk of family claudication due to their therapeutic and educational needs.

There are 5 coexisting therapeutic units. The apartments are referred as ‘homes’ and their organization is designed to encourage the active participation of residents with the professionals who attend them.

The Unit has a multidisciplinary team made up of the following professionals: Psychyatrists, Nurses, clinical psychologists, Social Workers, Educational worker, nursing assistants, administrative.

- 110 children and adolescents have been taken care, with an average cumulative stay of 13 months. In all cases in which the family had the guardianship of the patient, family claudication has been avoided There is a 36% discharge of those patients under guardian that have returned to their original family home 100% of the cases have been linked to an educational center adapted to their needs or to a training project

Image:

Image 2:

Overall, the care model implemented by the population served in the Acompanya’m unit is positively evaluated. Since it provides an intensive and personalized care, treatment and intervention for children suffering from a serious mental disorder of high complexity. A comprehensive, personalized, interdisciplinary approach is offered, coordinated and co-responsible with educational, protection and social services.

None Declared

Conversion disorder (a term that describes what was previously called hysteria) refers to motor or sensory symptoms, or both, that resemble a neurological disease, but that do not originate from or cannot be explained by a known physical disease.

To find reliable tools that can guide the difficult diagnosis of conversion disorder.

Bibliographic review

The exact prevalence of the disorder is unknown. It is estimated that approximately 5% of referrals to neurology are for this disorder. Approximately one third of patients referred to the neurologist have symptoms that cannot be explained by an organic disease. Involuntary movements are the most common motor manifestations of the conversive syndrome, being tremor one of the most frequent manifestations. The first differential diagnosis of conversion disorder is neurological disease. It is currently not necessary for the diagnosis to assess whether or not the symptoms are produced intentionally, as the assessment of conscious intentionality is unreliable. The neurological examination is the fundamental tool for the diagnostic approach, being even more enlightening than the complementary tests. Hoover’s sign, Babinski’s combined leg flexion, plantar flexion of the ankle, tremor and its distraction and synchronisation manoeuvres, as well as the clinical differences between epileptic seizures and non-epileptic seizures of psychogenic origin, are some of the reliable tools for a correct diagnosis.

The diagnosis of the disease should be one of exclusion. There must be clinical data showing clear evidence of incompatibility with a neurological disease and conversion symptoms do not correspond to known physiological mechanisms and anatomical pathways.

No significant relationships.

The lack of a standardised definition for the concept of TRD and an adequate criteria for therapeutic response make difficult the management of patients with MDD who do not achieve remission with one or more courses of treatment. All classifications suggested to define TRD are arbitrary, partially evidence-based, subordinated to the pharmacological findings of the time in which they are written and with serious inconsistencies, making it difficult to construct a universal and enduring diagnostic system.

Considering that the most important goal in treating a patient with Major Depressive Disorder (MDD) should be remission and return to previous functionality, the search for a standardised, evidence-based classification system will allow timely and effective interventions leading to the reduction of this devastating condition.

Bibliographic review

The proposed therapeutic algorithm arises from the combination of several fundamental principles for the management of treatment-resistant depression: the different classification systems of the concept, as well as the concepts of response, relapse, recurrence and remission; the scientific evidence found in the current literature, routine clinical practice, knowledge of switching and augmentation strategies, the new pharmacological targets and neurobiological hypothesis discovered, without forgetting finally the different clinical profiles of depressive symptomatology and the specific indications of each antidepressant.

Resistant depression is difficult to treat successfully and is not a uniform entity. Recently there has been a move to characterise treatment-resistant depression as ‘difficult-to-treat’ depression on the basis that the former description implies that depression treatments are normally effective and that non-response is therefore somehow abnormal.

No significant relationships.

The use of antipsychotics (APS) is essential. Despite their great efficacy, some of them are associated with an increase in prolactin levels that can lead to hormonal changes needing to be identified and managed [1,2,3]. Hormonal changes use to have clinical implications including hypogonadism, infertility and sexual dysfunction

To evaluate possible hormonal alterations and some clinical implications produced by hyperprolactinemia (HPRL) derived from the use of some antipsychotic compounds.

A complete fasting blood test was performed on a sample of 113 subjects (69 men and 44 women). 54% (n = 61) showed a normal prolactin level and 46% (n = 52) showed hyperprolactinaemia ( >50ng / ml). On the global sample, 39.8% (n = 45) was treated with some hyperprolactinemic drug , mostly risperidone and paliperidone.

Some differences were found depending on the gender of the subjects. A highly significant inverse relationship between the values of prolactin and testosterone was found in males (p=0.020, r=-0.285). In females, increased prolactin level was significantly related to decreased cortisol values.

Antipsychotic-related Hyperprolactinaemia ( mainly risperidone and paliperidone) is related with a decrease in testosterone levels in males and with an increase in cortisol levels in females.

No significant relationships.

Psychiatric illnesses are related with a reduced life expectancy and an increase of mortality rates (around 60%) mainly associated with cardiovascular diseases [1]. The high prevalence of obesity, metabolic syndrome, diabetes mellitus and tobacco use among these patients undoubtelly predispose to the impairment in physical health and mortaility increase. Regular physical activity in the general population is associated with a decrease in cardiovascular risk but litle is know about iss influence in some chronic and severe mental disorders like schizophrenia [2].

To quantify the physical activity performed by a sample of subjects with psychosis, borth males and female, compared to a control group.

A sample composed of 141 patients with schizoprenia was compared to 103 healthy subjects as a control group. The International Physical Activity Questionnaire - Short Form (IPAQ) scale was applied to all participants. The time (minutes) of physical activity performed in a week (METs) was collected by each participant [3].

The differences in the total physical activity Mets for the patients with schizophrenia were highly significant (p = 0.001), showing a lower degree of physical activity compared to the control group. A higher and significant percentage of sedentary lifestyle among the psychiatric group (64.5%), compared to 35.5% in the control group was found.

The group of pateints with Schizophrenia showed a significant higher sedentary lifestile including less physical activity. This finding could be highly related with a higher risk of cardiovascular disease and deterioration of the physical health.

No significant relationships.

Patients with bipolar disorder (BD) have an increased risk for cardiovascular morbimortality. Clinical risk factors, specifically for arrhythmias and sudden cardiac death remain understudied.

This study was conducted to assess differences in cardiac conduction among BD patients.

We included patients with BD in a cross-sectional design, confirmed by structured interview, age 18 through 80. Clinical characteristics were obtained using a structured questionnaire or medical records review. ECG intervals duration and morphology were manually assessed by cardiologists and compared among clinical subgroups using Chi-square, Mann-Whitney, and Kruskall-Wallis tests. Exploratory multivariable linear and logistic regression models were fitted to adjust for potential confounders.

We included 117 patients (60.7% women, 76.9% bipolar I, 50% history of psychosis, 22.6% suicide attempts). We found a significantly longer QTc interval in BD patients with hypertension (difference: 9.5 ms, p=0.006), obesity (difference: 25 ms, p=0.001), and metabolic syndrome (difference: 13 ms, p=0.007). Hypertension remained a significant predictor of longer QTc after adjusting for age, gender, and antipsychotic use (estimate 17.718, p=0.018). We observed a significantly shorter PR interval in women (difference: 6 ms, p=0.029), early age of onset (difference 6 ms, p=0.025), non-users of lithium (difference 4 ms, p=0.002), and early trauma (difference 4 ms, p=0.038). Finally, we identified significant correlations between symptom severity, blood glucose and PR interval (r=0.298, p=0.001; r=0.278, p=0.003; respectively).

Patients with BD and hypertension may have an increased risk for QTc prolongation. Careful cardiovascular monitoring may be warranted.

No significant relationships.

Stigma is one of the most important barriers to help-seeking, treating maintenance and recovery for people suffering mental disorders. These attitudes, when present in mental health workers, may have a negative effect on the quality of health care.

to evaluate the levels of stigma in a representative sample of mental health workers and to explore potential modifiable factors associated to stigma attitudes.

An online survey was conducted on the mental health workers of Castilla y León (Spain, 2409164 habs) while projecting the 2022 Mental Health Humanization plan in order to asses educational skills, burnout (Maschlach MBI), Professional Quiality of life (CVP-35) and Stigma attitudes (Mental Illness: Cinician’s Attitudes Scales, MICA4) together with sociodemographic and work position variables.

193 workers completed completed the survey. Stigma Attitude values of the sample were low (MICA4: 31.71; SD:7.3) and burnout were low or medium (medium Emotional Exhaustion: 19.22; SD8.89; low Depersonalization: 4.91; SD:3.61; Medium Personal Accomplishment: 34,17; 6.3). In the linear regression (R2=0.249; F:11,527; p<0,001), a lower Stigma was predicted by psychologist (Beta:0,207; p=0,003) or psychiatrist position (Beta:0,204; 0,005), Self-efficacy assessed by the item “I am qualified” in the CVP-35 (Beta:-10,144; p=0,023), and a higher stigma was predicted by nurse assistant position (Beta: -0.230; p=0.001), Depersonalization Burnout dimension (Beta:0,351; p<0,001) and years of service (Beta:0.148; p=0,023)

Some groups of mental workers are more vulnerable to develop stigma attitudes. These, may be increased by fatigue and burnout. Future interventions should determine if reducing burnout and increasing capacitation may be effective in stigma eradication

No significant relationships.

Electroconvulsive therapy (ECT) is today one of the main treatments available and used in psychiatry for serious mental illnesses. Eighty years after its introduction, the ECT procedure has evolved to become a safe option based on scientific evidence. Nowadays there are no absolute contraindications for ECT, regardless of the type of population and clinical situation.

To illustrate the electroconvulsive therapy in medical comorbidities context with a case report.

Descriptive case study.

We present a 66 years old patient who suffers from a psychiatric decompensation with a diagnosis of major depressive disorder with psychotic symptoms. Due to her cardiological history (prolongation of the QT interval of possible psycopharmacological origin and a 2:1 AV block, that required the implantation of a definitive pacemaker) and partial response to psychotropic medication, the initiation of electroconvulsive therapy is proposed as the best alternative. The pacemaker was previously studied by cardiology for a very complete analysis before the procedure. It was recommended to convert it to fixed rate pacing by using a magnet. To do this, we placed it over the pacemaker during the technique. While waiting for a clinical improvement, no incidence has been produced during the sessions.

ECT should not be postponed as a last resort. Numerous studies conclude that ECT is globally the treatment of choice (70-85% response) in severe depressive conditions, over and above antidepressant drugs. The incidence of relevant cardiac complications on ECT is relatively rare (0.9%). Regarding the use of pacemakers, electroconvulsive therapy represents an effective and safe option for the patient.

No significant relationships.

Antipsychotic treatment is known to be associated with secondary sexual dysfunction (SD). Recognition and treatment of this adverse effect has received growing attention. Until now, all antipsychotic agents were thought to potentially cause SD mediated by increased prolactin. Our aim was to observe whether aripiprazole modifies SD in patients with schizophrenia after 3 months of treatment.

Multicenter, observational, open-label, prospective, three-month study with single group of aripiprazole treated patients. Sexual activity was assessed using CGI-S and CGI-I for SD; SALSEX scale, validated for Spanish, 3 times after initiating study drug. Patient's clinical status was evaluated by CGI-S and CGI-I for psychotic disorders, and by BPRS Scale.

Result: 42 patients (70% men), 38 completed the study. Incidence of SD at 3 months was null for all patients studied. As period of treatment advanced, the Salsex score decreased, showing a mean overall reduction of –5 points (SD 3.6). Largest reduction was observed in subgroup of patients with SD in baseline visit, who exhibited a mean reduction of –6 points (SD 3.1).

Men with SD in baseline evaluation showed more marked improvement than women at 40 days of treatment (p=0.0447). However, recovery was similar for both groups at 90 days of treatment.

In schizophrenia, SD secondary studies to antipsychotics are important in establishing effectiveness of these agents in chronic treatment. After 3 months of aripiprazole treatment, no SD was observed in patients. Patients who presented SD at study initiation improved over course of 3 months treatment with aripiprazole.

Evaluate the sex differences in first episode psychosis.

We present an open prospective and muti – center study with a follow – up of 2 years in patients with a first psychoses episode. The patients were treated with risperidone and assessments were made in the first month and then every three months for 2 year. Therefore, we used a protocol including the following scales: PANSS, Global Assessment of Functioning scale (GAF-EEAG), CGI, Young mania rating scale, Hamilton scale for the depression, UKU, OCS, Premorbid Adjustment scale (Cannon-Spoor), the Information Subtest (WAIS) and Psychosocial Stress Global Assessment (DSM III R).

231 patients were included (32.5% women). Males have consistently an earlier onset even after controlling the cofounding factors and poorer premorbid functioning. Women have a shorter DUP, and they are more likely to be married than men and to live with their couples or children. Women have also better adherence to treatment than men. Males don't show differences in negative, positive symptoms or cognitive deficits. There was no difference between the sexes in the dose of the prescribed antipsychotic. There are no clear sex differences in family history and obstetric complications. Sex doesn't have influence on the course of illness in middle-term (2 years).

This paper supports the presence of significant differences between schizophrenic males and women, but there aren't differences in the outcome of the disease.

Pregabalin is indicated for the treatment of GAD in adults in Europe. The efficacy and safety of pregabalin for the treatment of adults and elderly patients with GAD has been demonstrated in 6 of 7 short-term clinical trials of 4 to 8 weeks.

To characterise the long-term efficacy and safety of pregabalin in subjects with GAD.

Subjects were randomised to double-blind treatment with either high-dose pregabalin (450-600 mg/d), low-dose pregabalin (150-300 mg/d), or lorazepam (3-4 mg/d) for 3 months. Treatment was extended with drug or blinded placebo for a further 3 months.

At 3 months, mean change from baseline Hamilton Anxiety Rating Scale (HAM-A) for pregabalin high- and low-dose, and for lorazepam ranged from -16.0 to -17.4. Mean change from baseline Clinical Global Impression-Severity (CGI-S) scores ranged from -2.1 to -2.3 and mean CGI-Improvement (CGI-I) scores were 1.9 for each active treatment group. At 6 months, improvement was retained for all 3 active drug groups, even when switched to placebo. HAM-A and CGI-S change from baseline scores ranged from -14.9 to -19.0 and -2.0 to -2.5, respectively. Mean CGI-I scores ranged from 1.5 to 2.3. The most frequently reported adverse events were insomnia, fatigue, dizziness, headache, and somnolence.

Efficacy was observed at 3 months, with maintained improvement in anxiety symptoms over 6 months of treatment. These results are consistent with previously reported efficacy and safety trials of shorter duration with pregabalin and lorazepam in subjects with GAD.

This study was funded by Pfizer Inc.