Treatment decision-making capacity in hospitalized patients with schizophrenia.

In contemporary medical ethics and clinical practice the autonomy of patients and their right to accept or refuse an offered treatment is acknowledged and respected. Prerequisite for the right of a patient to consent to any medical act is the capacity to make valid decisions regarding his/ her treatment. The objective of our study was to assess -for the first time in our country- treatment decision-making capacity of hospitalized patients with schizophrenia; to explore any possible association with demographic and clinical variables; and to compare treatment decision-making capacity of patients with schizophrenia with medical patients' capacity. The sample of patients comprised of 21 patients with schizophrenia who were hospitalized in the psychiatric ward of the General Hospital of Arta, north-west Greece. Those patients' capacity was compared with treatment decision-making capacity of 78 patients hospitalized in the internal medicine ward of the same hospital. All patients' capacity was assessed within 72 hours of admission with the use of the Greek version of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a valid and reliable tool for capacity assessment. The performance of patients with schizophrenia on the MacCAT-T was significantly worse than medical patients' performance, suggesting that patients with schizophrenia, as a group had poorer decision-making capacity compared to medical patients. Both negative symptomatology (anergia) and positive symptoms (hostility and suspiciousness), as measured with the use of the Brief Psychiatric Rating Scale (BPRS) were associated with poor performance on the MacCAT-T. Although medical patients as a group scored better in the MacCAT-T, there were several cases that lacked decision-making capacity. In conclusion, patients with schizophrenia had higher incapacity rates than medical patients during the first days of hospitalization. Lack of treatment decision-making capacity is not necessarily the rule for patients with schizophrenia, and capacity is not present in all medical patients. The ability of patients to consent to treatment should be re-assessed during hospitalization, and when restored, informed consent should be obtained by clinicians.

Once-monthly paliperidone palmitate in recently diagnosed and chronic non-acute patients with schizophrenia.

OBJECTIVE: To explore the treatment response, tolerability and safety of once-monthly paliperidone palmitate (PP1M) in non-acute patients switched from oral antipsychotics, stratified by time since diagnosis as recently diagnosed (≤3 years) or chronic patients (>3 years). RESEARCH DESIGN AND METHODS: Post hoc analysis of a prospective, interventional, single-arm, multicentre, open-label, 6-month study performed in 233 recently diagnosed and 360 chronic patients. MAIN OUTCOME MEASURES: The proportion achieving treatment response (defined as ≥20% improvement in Positive and Negative Syndrome Scale [PANSS] total score from baseline to endpoint) and maintained efficacy (defined as non-inferiority in the change in PANSS total score at endpoint [Schuirmann's test]). RESULTS: 71.4% of recently diagnosed and 59.2% of chronic patients showed a ≥20% decrease in PANSS total score (p = 0.0028 between groups). Changes in PANSS Marder factors, PANSS subscales, and the proportion of patients with a Personal and Social Performance scale (PSP) total score of 71-100 were significantly greater in recently diagnosed compared with chronic patients. PP1M was well tolerated, presenting no unexpected safety findings. CONCLUSION: These data show that recently diagnosed patients treated with PP1M had a significantly higher treatment response and improved functioning, as assessed by the PSP total score, than chronic patients.

[Compulsory hospitalization: α case of conflict between the psychiatrist and the persecutor due to the obscurity of the law].

The process of involuntary psychiatric examination and/or hospitalization is a rare experience for the average modern man. As part of it, the citizen shall be subjected to a restriction of his freedom and forced hospitalization without himself having sought neither of the above situations.The rarity of this experience, assisted by the severity of the threat to individual freedom and dignity that leads to, impose the existence of a clear legal framework which will describe the permissive or non-implementation of procedures, the pious keeping on behalf of the stakeholders of these legal provisions and the operation of a reliable system of registration and control of these processes. In our country legal act nr.2071 for involuntary hospitalization in a psychiatric unit became the legal framework, which in 1992 was decided to be adopted, to describe the necessary conditions and requirements needed be fulfilled for the realization of involuntary examination and/or hospitalization in patients with mental illness, while respecting individual rights and freedoms. Although the replacement of previous relevant law with the adoption of this law was hailed by many sides, full implementation thereafter and, where applicable, "stumbled" because it never met with the full agreement of all parties involved. It is estimated that, in Greece, 40 to 50% of all hospitalizations taking place in public psychiatric units are involuntary hospitalizations. This percentage is extremely high, being nearly four times the European average. Therefore, it is now more than ever important to undertake initiatives towards re-testing the conditions under which the involuntary examination and/or treatment is realized in our country. The purpose of this short article is to present a case where the prosecutor and the psychiatrist disagreed on the interpretation of a paragraph of law nr. 2071/92 so the first to prosecute the second. Fortunately, the psychiatrist, who defended the view that only the judiciary has the power and authority to order involuntary hospitalization of a mentally ill patient, of course after the evidences based medical positive opinion of the psychiatrists, was acquitted by the court. In conclusion, we suggest that for the obscure points of interpretation of the law, professionals involved in its implementation (that is psychiatrists, prosecutors, police personnel etc.) must (a) adopt a spirit of conciliation and (b) establish measures and procedures that will allow continuous monitoring of the implementation of each case of involuntary examination and/or hospitalization.

[The cost of treating schizophrenia in Greece].

The objective of this study was to estimate the direct annual cost of treating patients with schizophrenia in Greece in 2005. Due to the lack of quantitative data, information on the treatment pathway and medical resource utilization of patients were collected from a consensus panel of 9 psychiatrists and 5 health economists. For estimating the costs a bottom up approach from the National Health System perspective was used. The panel of experts defined three patient categories based on the severity of the disease and the medical setting where treatment is received: (a) outpatient setting, (b) ambulatory care, (c) inpatient setting and long-term care. The annual direct cost of treatment per patient was found to be 3,187 € (2,659-4,166 €) in the first category, 10,135 € (7,429-13,972 €) in the second category and 20,782 € (17,482-25,462 €) in the third category. The total cost of treatment increased with the severity of the disease and the use of hospitalization. Systematic data collection on medical resource utilization must be established at the national level to facilitate further research, guide the efficient use of resources and improve the healthcare provision.

Psychiatric morbidity among repatriated Greek migrants in a rural area.

This paper reports on psychiatric case identification by the application of the Structured Clinical Interview for DSM-III-R (SCID) in a sample of 198 Greek migrants repatriated from western europe in a northwestern province of Greece. The current (1 month) prevalence of psychiatric morbidity, based on the total number of diagnosed cases, was found to be 43.4%. Lifetime prevalence of psychiatric disorders was found to be higher (49.4%). The majority of the sample were diagnosed as suffering from anxiety disorders and dysthymia. Psychiatric disorders were found to be more prevalent among middle-aged respondents. Duration of stay in the foreign country was a factor correlated with psychiatric morbidity. Of short-term migrants 54% were found to suffer from specific nosological entities, whereas 32% of long-term migrants were diagnosed as cases. The results are discussed within the framework of the existing sociocultural context of emigration and repatriation.