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Does intensive home treatment change treatment trajectories of psychiatric disorders?
- A. Martín-Blanco, A. González-Fernández, A. Farré, S. Vieira, P. Alvaro, C. Isern, D. Giménez, C. Torres, V. de la Cruz, C. Martín, N. Moll, O. Castro, M. Sagué-Vilavella
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S167-S168
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Introduction
Intensive home treatment (IHT) for people experiencing a mental health crisis has been progressively established in many western countries as an alternative to in-ward admission. But is this a real alternative? We previously reported that patients treated in our IHT unit only differ from those voluntarily admitted to hospital in suicidal risk and severe behaviour disorders (not in other factors such as clinical severity) (Martín-Blanco et al., Rev Psiquiatr Salud Ment 2022;15:213-5). Now we are interested in disentangle if those patients who used to require inward management can be successfully treated at home.
ObjectivesTo describe subsequent treatment trajectories of the first 1000 admissions to our IHT unit and to compare clinical characteristics among the different groups of trajectories.
MethodsRetrospective cohort study. Subsequent treatment trajectories were collected from December 2016 to October 2022 and classified: absence, hospital, IHT, and mixed (hospital and IHT). Statistical significance was tested by means of ANOVA or Kruskal-Wallis test for quantitative variables (corrected for multiple comparisons) and chi-square tests for qualitative variables.
ResultsTables 1 shows the characteristics of the whole sample. Of the 1000 IHT admissions, 12.1% needed subsequent hospital admission(s), 12.7% IHT admission(s), and 9.3% mixed admission(s). There were no differences among these groups in median severity at IHT admission, but there were differences in the number of previous admissions (p=0.0001): the group with no subsequent admissions had less previous admissions than the other groups (pBonf<0.0001), and the group with subsequent IHT admissions had less than the group with mixed admissions (pBonf=0.0123). There were differences between groups regarding distribution of diagnoses (p<0.0001) (Fig. 1). When considering subsequent admissions by diagnosis, there were differences in severity at IHT admission (p=0.0068) and in number of previous hospitalizations (p<0.0001) (Fig. 2).
Table 1. Clinical characteristics of the whole sample (N=1000) mean SD Age (years) 47.07 17.02 CGI-s at admission * 5 4-5 N % Sex (female) 548 54.8% Psychotic disorders 463 46.3% Affective disorder 257 25.7% Bipolar disorder 128 12.8% Other disorders 152 15.2% Hospital admission in the previous 5 years 313 31.3% CGI-s: clinical global impression - severity. * median and IQR
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ConclusionsPatients that used to require inward management can now be treated at home when suffering an acute episode. Therefore, IHT has changed treatment trajectories for some patients with psychiatric disorders.
Disclosure of InterestNone Declared
A tale of excess: the curious case of the woman with 1447 emergency visits
- M. Sagué Vilavella, A. Giménez Palomo, A. Àvila-Parcet, T. Fernández Plaza, L. Navarro Cortés, G. Oretega Hernández, M. Pons Cabrera, L. Tardón Senabre, M. Vázquez
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S286
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Introduction
Frequent attenders to emergency services are challenging and costly. We report the case of a woman in her mid-twenties who stands out for a total of 1447 emergency visits.
ObjectivesOur primary objective was to describe the emergency visits of our patient. Secondary objectives were to assess her use of other healthcare services and to calculate her health expenditure.
MethodsThis is a clinical case report. We reviewed the patient’s electronic medical records for sociodemographic and clinical data. We obtained detailed information of psychiatric ED visits (length, most frequent times and days) regarding the second most-visited hospital. We assessed the efficacy of hospitalizations in reducing ED visits with a paired samples t Test, comparing the number of visits 30 days pre- and post-hospitalization. We estimated the health expenditure using the regional public health system prices, including three direct costs: emergency visits, hospitalizations and ambulance transportation. We obtained written informed consent from the patient’s legal guardian.
ResultsA 26-year-old woman from Barcelona (Catalonia, Spain), diagnosed with mild intellectual disability, made 1447 emergency visits between 2009 and 2021 (figure 1). 946 visits (65%) took place in psychiatric emergency departments (EDs), whilst 353 (24%) in non-psychiatric EDs and 148 (10%) in urgent primary care. She attended 24 hospitals (ranking number one the closest to the patient’s home, with 387 visits) and seven primary care centers, distributed across 17 cities in Catalonia. Most visits were self-referred, being the main presenting problems anxiety and instrumental suicidal behaviour. Saturday was her favorite day for hospital visits (24,1%), while she seeked care on Tuesdays much less often (4.5%). She made 73.5% of consultations between 1pm and 6pm, with a median length per visit of 2.8 hours (range 0.33-20.9 hours). Regarding other therapeutic approaches, she attended day hospitals, psychiatric rehabilitation programs and family therapy, among others (figure 2), for which she showed low adherence and scarce benefit. She had ten acute hospitalizations, interventions that did not reduce ED visits (t=-0.9835, p=0.36). Health expenditure reached 410.035€.
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ConclusionsThe most common definition of frequent attendance is a patient who has five or more visits per year. Many times, but not always, repeat visits are also inappropriate. The case we report is a grotesque example of both frequent and inappropriate attendance, which has been resistant to all kinds of interventions and has quality-of-care, financial and ethical implications. As of today, it is still a pending case. Maybe it is worth considering residential treatment?
Disclosure of InterestNone Declared
Consultation trends in patients admitted to a Psychiatric Emergency Service before and during COVID-19 pandemic
- M. Gomez Ramiro, A. Gimenez, G. Fico, M. Sague Vilavella, M. Valenti, M. Vazquez
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S591-S592
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Introduction
The COVID-19 outbreak had significant implications worldwide, including mental health. Consultations in the Emergency Service of the Hospital Clínic of Barcelona varied in terms of reasons for consultations, psychopathology, and other aspects, before and during the pandemic.
ObjectivesThis study aims to assess differences in the profile of patients admitted within the last three years to the Psychiatric Emergency Service of a third-level hospital, in order to analyze variations in the number of patients visited, diagnoses and admissions throughout the different seasons.
MethodsAll adults admitted from 2019 to 2021 to the Psychiatric Emergency Service of Hospital Clínic of Barcelona, Spain, were retrospectively included for analysis and divided into three groups depending on the year they attended the Emergency Service. SPSS v25.0 and R statistics were used in order to compare differences between groups.
ResultsA total of 13677 adult individuals who attended the psychiatric emergency service of Hospital Clínic of Barcelona between 2019 and 2021 were included in the analysis. 4814 patients were visited in 2019, 4007 in 2020 and 4856 in 2021. The majority of patients were male (50.1%), with a mean age of 40.47 years (SD 15.83). In terms of acute admission rates, 24.6% of the total sample were hospitalized in an acute psychiatric unit, whereas in the spring of 2020, 34.3% of patients attending the Emergency Service were hospitalized. This revealed significant differences when compared with spring of 2019 and 2021 and with the rest of seasons (p<0.05). With regard to suicide attempts and intentional poisonings, significant differences were only observed between winter of 2019, with the lowest rate, and autumn of 2020, with the highest proportion. In spring of 2019, the lowest rate of patients attending with suicidal ideation was observed, which showed significant differences compared to winter of 2020, spring of 2021, summer of 2021 and autumn of 2021 (p<0.05). Also, statistically significant differences between winter of 2019 and summer of 2021 and also between summer of 2019 and summer of 2021 were observed, with the highest rate in the last one. No significant differences were observed in rates of patients with severe mental disorders visited.
ConclusionsThe COVID-19 pandemic and the situation of lockdown lead to an overall reduction in the overall consultations to the Emergency Service, being this reduction non-significant in patients with severe mental disorders, such as psychotic disorders. In addition, our study shows a decrease in consultations with suicidal ideation in summer of 2019 and a significant increase in summer of 2021. In contrast, an increased tendency in suicide attempts was not observed.
Disclosure of InterestNone Declared
A family history of suicide in bipolar disorders: powerful, powerless
- M. Sagué Vilavella, G. Fico, G. Anmella, A. Giménez, M. Gómez Ramiro, M. T. Pons Cabrera, S. Madero, A. Murru, E. Vieta
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S387
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Introduction
When completing the medical record of a patient with bipolar disoder (BD), hardly anything is more impacting than a family history of completed suicide (FHS). In fact, FHS is a main risk factor for personal suicide attempts and death in this population. There are few modifiable protective factors against suicide in BD, such as lithium treatment and absence of substance abuse.
ObjectivesWe aimed to explore the relationship between a FHS and clinical characteristics in patients with BD. Given the impact that FHS has on the individual and on healthcare professionals, we hypothesized that it would modify behaviors towards a higher prevalence of the modifiable protective factors against suicide, namely more treatment with lithium and less drug addiction.
MethodsThis is a cross-sectional study that included all patients with BD that were followed up in a specialised unit between 1998 and 2020. Only subjects with complete information on FHS were retained for the analysis. We assessed sociodemographic and clinical data and described it with measures of frequency, central tendency and dispersion. Differences between subjects with and without FHS were calculated with χ², Fisher’s exact test and Student’s t-test as appropriate. We set the significance level at p≤0.05. All tests were two-tailed.
ResultsThe sample consisted of 480 subjects with a mean age of 45.9 years (standard deviation 14.4, range 18-88), of which 54.4% (n=261) were women. 69.2% (n=332) had a diagnosis of BD type I and 30.8% (n=148) of BD type II. 77 subjects (16%) had a FHS. Regarding differences between groups, those with relatives who had committed suicide did not show statistically significant differences in terms of sociodemographic variables (age, gender, civil status, employment) or key clinical features (type of BD, illness duration, psychotic features, predominant polarity, rapid cycling, number of lifetime manic and depressive episodes, comorbid personality disorder), neither did they have a higher use of lithium (55.8% vs 59.3%, p=0.572) nor lower substance use disorder (10.9% vs 15.5%, p=0.34). Predictably, people with FHS had a higher prevalence of family history of mental and affective disorders (96.1% vs 70.9%, p<0.001; 86.3% vs 56.3%, p<0.001) and of stressful life events (71.6% vs 58.9%, p=0.05). Personal lifetime suicide attempts also tended to be higher (36.4% vs 26.7%, p=0.088).
ConclusionsContrary to our hypothesis, in our sample of subjects with BD a FHS was not associated with a higher prevalence of the modifiable protective factors against suicide. Therefore, although suicide has a major impact both in families and healthcare professionals, our results suggest it does not modify attitudes towards prevention in a real-life scenario. The main limitation of our study is its cross-sectional design, which does not allow for causal inference. In conclusion, there is room for improvement in the fight against suicide.
Disclosure of InterestNone Declared
Cariprazine as a useful treatment for patients with schizophrenia and antipsychotic-induced extrapyramidal symptoms: a case report and literature review
- C. Llach, L. Ilzarbe, M. Sagué-Vilavella, N. Arbelo, R. Catalan, F. Gutierrez
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- Journal:
- European Psychiatry / Volume 65 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 01 September 2022, p. S792
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Introduction
The discovery of second-generation antipsychotics represented an authentic breakthrough for the management of psychotic disorders. Nevertheless, they still don’t adequately manage some aspects of these disorders, such as negative symptoms (NS), cognitive impairment, or extra-pyramidal symptoms (EPS). New-generation antipsychotics present different pharmacological mechanisms and have been reported to ameliorate these aspects. Among them, cariprazine acts as a D2/D3 partial agonist with variable affinity with serotoninergic receptors, and many studies show its efficacy for preventing and treating positive symptoms as well as for the management of NS and EPS.
ObjectivesTo report a case of a patient diagnosed with schizophrenia with highly invalidating antipsychotic-induced EPS that remitted after switching to cariprazine, while maintaining clinical stability. To review literature about cariprazine and its relationship with NS and EPS.
MethodsWe describe the case of a 66-year-old woman diagnosed with schizophrenia and under treatment with three-month injectable paliperidone 175mg. During her follow-up at outpatient clinic, she presented a progressively highly invalidating non-trembling parkinsonian syndrome attributable to medication. Paliperidone plasmatic levels were within therapeutic range. An antipsychotic switch was agreed, and cariprazine was started.
ResultsThe switch from a second-generation antipsychotic to cariprazine entailed the remission of a highly invalidating EPS while improving some of the NS and maintaining psychopathological stability.
ConclusionsAssessing and differentiating NS and EPS is of an utmost importance during the follow-up of patients under antipsychotic treatment. Cariprazine is an interesting alternative when treating patients diagnosed with psychotic disorders that present mostly NS and antipsychotic-induced EPS.
DisclosureNo significant relationships.
Bipolar disorders and suicide: stumbling twice with the same stone?
- M. Sagué-Vilavella, G. Fico, G. Anmella, A. Giménez-Palomo, M. Gómez-Ramiro, M. Pons Cabrera, S. Madero, E. Vieta, A. Murru
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- Journal:
- European Psychiatry / Volume 65 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 01 September 2022, pp. S222-S223
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Introduction
Suicide is the most terrible outcome of bipolar disorders (BD). It impacts families and healthcare professionals deeply. Family history of suicide (FHS) is one of its main risk factors, whereas lithium treatment and absence of substance use disorders (SUD) are two of its few modifiable protective factors.
ObjectivesTo explore the relationship between FHS and clinical characteristics in BD. We hypothesized that FHS would be associated with less SUD, higher rates of lithium treatment and shorter duration of untreated illness (DUI).
MethodsCross-sectional analysis of subjects with BD followed-up in a specialised outpatient unit (Barcelona, October’08-March’18). We described data with measures of frequency, central tendency and dispersion, and we used χ², Fisher’s test and t-tests for comparisons.
ResultsThe sample consisted of 83 subjects, 56.6% males, mean age 41.9 years (SD 12.7). 74.7% (n=62) had a diagnosis of BD-I and 25.3% (n=21) of BD-II. 11 subjects (13.3%) had FHS. Those with FHS did not show significant differences in sociodemographic data, DUI (58.5+/-60.4 vs 38.19+/-84.9 months, p=0.341), lithium use (72.7% vs 73.6%, p=0.95) or SUD (27.3% vs 23.6%, p=0.79). There were differences in terms of lifetime suicide attempts (54.5% vs 20.8%, p=0.026), family history of mental disorders (100% vs 69.4%, n=0.032).
ConclusionsContrary to our hypothesis, FHS was not associated with the modifiable protective factors against suicide (namely, less SUD and more lithium prescription). Similarly, we did not find an association with earlier access to mental health services at symptom onset (DUP as proxy). Therefore, our results suggest FHS does not modify attitudes towards prevention.
DisclosureNo significant relationships.