Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles.

PURPOSE OF REVIEW: In this review, we provide an update of recent studies on the age of onset (AOO) of the major mental disorders, with a special focus on the availability and use of services providing prevention and early intervention. RECENT FINDINGS: The studies reviewed here confirm previous reports on the AOO of the major mental disorders. Although the behaviour disorders and specific anxiety disorders emerge during childhood, most of the high-prevalence disorders (mood, anxiety and substance use) emerge during adolescence and early adulthood, as do the psychotic disorders. Early AOO has been shown to be associated with a longer duration of untreated illness, and poorer clinical and functional outcomes. SUMMARY: Although the onset of most mental disorders usually occurs during the first three decades of life, effective treatment is typically not initiated until a number of years later. There is increasing evidence that intervention during the early stages of disorder may help reduce the severity and/or the persistence of the initial or primary disorder, and prevent secondary disorders. However, additional research is needed on effective interventions in early-stage cases, as well as on the long-term effects of early intervention, and for an appropriate service design for those with emerging mental disorders. This will mean not only the strengthening and re-engineering of existing systems, but is also crucial the construction of new streams of care for young people in transition to adulthood.

Duration of untreated prodromal symptoms and 12-month functional outcome of individuals at risk of psychosis.

Individuals seeking help from prodromal services may have been experiencing attenuated psychotic features and psychosocial impairments for a long period prior to referral. The effect of an extended duration of these untreated ;at risk' symptoms on patients' long-term functional outcome was assessed in a 12-month longitudinal observational study (n=49). A longer duration of untreated ;at risk' symptoms was correlated with a reduced improvement in Global Assessment of Functioning scores after 12 months (beta=-0.375, P=0.008). This effect was independent of age and gender and may have implications for the improvement of treatment strategies in pre-psychotic phases.

[Working with families in the early stages of psychosis: a structured intervention for caregivers]. / Lavorare con le famiglie negli esordi psicotici: un intervento strutturato per i caregiver.

In the field of early psychosis psychoeducation is considered fundamental to increase coping skills with diseases and to improve the quality of life of patients and their families. The more recent and updated guidelines on schizophrenia underline the extreme importance of the families involvement in treatment of young people in the initial phases of illness. "Families are the main support for many young patients. They could be the primary carers but they have also to face individual and social consequences following the onset course. Where feasible, family members must be involved in the treatment". This work describes the components of the work with families carried on by the Centre for the early detection of psychoses and high-risk situations--Programma 2000 ("Niguarda Ca' Granda" Hospital-Milan) and is mostly focused on psychoeducation and on Expressed Emotions aspects. Even the advances suggested by the international literature drove Programma 2000 to define both the steps of caregivers assessment and intervention. During the last ten years, Programma 2000 has followed 191 caregivers. Aims of this work is to verifier the outcome of the "pilot project", started in 2007, projected specifically to increase the normally used strategies to improve the caregivers adherence and involvement in the therapeutic process. The individualized multi-componential intervention has been structured in 8 session over one years. Outcome measures used in this article are the scores of the Camberwell Family Interview and from the Psychosis Knowledge Assessement Semistructured Interview (VCP). The subjects enrolled in the structured pilot project were 25 family caregiver to young (18-30 yrs old) patients. Results shows change in the Expressed Emotion level: 13% of families moved from High Expressed Emotion to Low Expressed Emotion. Furthermore data on the knowledge of illness knowledge level illustrate a reduction in the percentage, from 47% to 18%, of carers who have just a very vague knowledge of illness, and an increase from 16% to 27% of carers who obtain a good level of specific knowledge. In conclusion we can sustain mental health expert with aim to treatment project programme individualized and multi-componential tailored for young's caregiver at the onset phase of psychosis.

Hypotension and cognitive impairment: Selective association in patients with heart failure.

BACKGROUND: Arterial hypotension has been associated with increased risk of dementia in some large prospective studies; and cognitive impairment is common among elderly with left ventricular function. The authors assessed whether arterial hypotension might be associated with cognitive impairment among older subjects with heart failure. METHODS: This study involved all 13,635 patients (of whom 1,583 had heart failure) without cerebrovascular disease or AD, admitted to 81 Italian academic hospitals in 1995 and 1997. The association between blood pressure and cognitive impairment (as indicated by a Hodkinson Mental Test score < 7) according to the presence of heart failure was assessed by univariate analyses, including linear discriminant analysis. This association was also verified by multivariate analyses after stratifying for diagnosis of heart failure. RESULTS: Cognitive impairment was found in 26% of patients with heart failure and in 19% of remaining subjects (Fisher exact p < 0.0001). Blood pressure levels did not differ according to diagnosis of heart failure, but discriminant analysis indicated that systolic blood pressure levels below 130 mm Hg predicted cognitive impairment only among participants with heart failure. Among such participants, systolic blood pressure was associated with cognitive impairment in multiple logistic regression modeling (for 10 mm Hg intervals, OR = 0.78; 95% CI = 0.71 to 0.86). Again, this association was not found among participants without heart failure. CONCLUSIONS: Systolic hypotension is selectively associated with cognitive impairment in older patients with heart failure. As early treatment of cardiac low-output states can reverse cognitive dysfunction, the routine management of heart failure should include systematic assessment of cognitive performance.

Physical restraint and subcutaneous hematoma in an anticoagulated patient.

A large subcutaneous hematoma extending from the breastbone region to the left axillary region and left flank developed in a 86-year-old anticoagulated man because of repeated microtrauma from a physical restraint used to prevent his rising from a chair. Physicians, nurses, and physiotherapists should recognize that physical restraints causing pressure on the skin increase hemorrhagic risk in patients who take low molecular weight heparin. Accordingly, they should systematically check for hemorrhagic complications and attempt to limit the use of such devices.

Cognitive dysfunction as a major determinant of disability in patients with heart failure: results from a multicentre survey. On behalf of the GIFA (SIGG-ONLUS) Investigators.

Cognitive dysfunction is a frequent finding among older patients with left ventricular systolic dysfunction; however, the clinical outcomes of such a finding are unknown. Also, disability is a common condition in heart failure, poorly responding to commonly used cardiovascular medications. The association between cognitive dysfunction and disability was assessed in 1583 patients with heart failure, but without cerebrovascular disease, previous stroke, or Alzheimer's disease, who were enrolled during 2 years of a multicentre pharmacoepidemiology survey. The association between groups of variables (demographics, comorbid conditions, medications, and objective tests, including the Hodkinson abbreviated mental test) and functional disability (as indicated by need for intensive assistance in at least one of Katz' activities of daily living) was first analysed using separate age and sex adjusted logistic regression models. Those variables, significant at a p<0.1 level in these models, were simultaneously entered into an age and sex adjusted summary regression model. Among 1583 patients suitable for analysis, cognitive dysfunction (as detected by abbreviated mental test score <7) was detected in 265/461 disabled patients, and in 150/1122 independent subjects (p<0.0001). According to logistic regression analysis, cognitive dysfunction was associated with disability (OR=6.49; 95% CI=4.39-9.59) after adjusting for potential confounders.Thus, cognitive dysfunction in patients with heart failure is independently associated with disability, which currently represents an overwhelming medical and financial problem to patients, caregivers, and public health services. As early recognition and treatment of low cardiac output states might reverse cognitive dysfunction, cost effective treatment for heart failure should include systematic diagnostic and therapeutic approaches to cognitive dysfunction.

Dose-related impact of alcohol consumption on cognitive function in advanced age: results of a multicenter survey.

BACKGROUND: Moderate alcohol consumption has been associated in several studies with decreased risk of cardiovascular and cerebrovascular events; however, available data on the effects of alcohol intake on cognitive functioning are conflicting. We assessed the association between alcohol consumption and cognitive impairment in a series of older subjects enrolled in a multicenter pharmacoepidemiology survey. METHODS: The association between average alcoholic intake and cognitive performance was assessed in 15,807 patients admitted to participating centers during the survey periods. Demographic variables, comorbid conditions, medications, and objective tests that were associated with cognitive impairment (as indicated by a Hodkinson Abbreviated Mental Test score <7) in separate logistical regression models were examined as potential confounders in a summary model. RESULTS: Cognitive impairment was detected in 1693 (19%) of 8755 drinkers and 2008 (29%) of 7052 nondrinkers (Fisher's exact test, p < 0.0001). After adjusting for potential confounders, alcohol consumption was associated with decreased probability of cognitive impairment (odds ratio, 0.75; 95% confidence interval, 0.66-0.85). The relationship between drinking level and cognitive dysfunction was nonlinear, because the probability of cognitive impairment was decreased for moderate alcohol use as compared with abstinence, but it was increased for daily consumption exceeding one wine-equivalent liter among men and 0.5 liter among women. This nonlinear association persisted when cerebrovascular and Alzheimer's disease were considered separately. CONCLUSIONS: Alcohol abuse is associated with increased prevalence of cognitive dysfunction among older subjects; however, a daily alcohol consumption of less than 40 g for women and 80 g or less for men might be associated with a decreased probability of cognitive impairment. This possible protective effect of alcohol consumption should be further assessed by prospective studies.

Older age and in-hospital development of hypokalemia from loop diuretics: results from a multicenter survey. GIFA Investigators. Multicenter Italian Pharmacoepidemiologic Study Group.

BACKGROUND: Hypokalemia is a common finding among older patients taking diuretic medications. However, it is not known whether older age per se carries an increased risk of hypokalemia, particularly during a patient's treatment with loop diuretics. METHODS: The association between age and incident hypokalemia was examined in 18,872 patients with normal baseline serum potassium enrolled during three yearly multicenter surveys; 4,035 patients started receiving loop diuretics during their hospital stay. Demographic variables, comorbid conditions, medications, and objective tests that were associated with incident hypokalemia in separate age- and sex-adjusted logistic regression models were examined as potential confounders. RESULTS: Among patients with normal baseline serum potassium, the factors of age, presence of coronary disease or diabetes, comorbidity, the use of ACE inhibitors, loop diuretics, digitalis, corticosteroids, or insulin, and baseline serum potassium were associated with incident hypokalemia in initial models. After these variables were adjusted for, age (for each decade, odds ratio = 1.30; 95% confidence interval = 1.17-1.46; p < .0001) was associated with incident hypokalemia. The use of parenteral (2.30; 1.53-3.46; p < .0001) but not oral (1.16; 0.79-1.69; p = .44) loop diuretics was associated with hypokalemia. Eventually, age was associated with hypokalemia when the summary regression model was analyzed in patients taking loop diuretics (1.33; 1.03-1.71; p = .027), as well as in those taking intravenous loop diuretics only (1.84; 1.25-2.70; p = .002). CONCLUSIONS: Older age is independently associated with the in-hospital development of hypokalemia, particularly among patients taking loop diuretics. Monitoring of serum potassium levels is therefore advisable when older patients are treated with these agents.

Use of calcium antagonists and hemoglobin loss in hospitalized elderly patients: a cohort study. Gruppo Italiano di Farmacoepidemiologia nell'Anziano (GIFA) investigators.

OBJECTIVE: To assess the association between in-hospital use of calcium antagonists and incident reduction in hemoglobin levels, as well as the impact of individual baseline risk for gastrointestinal bleeding on such an association. METHODS: The association between calcium antagonists and hemoglobin decrease > 1.2 g/dL was examined in 6,721 patients enrolled in a collaborative pharmacoepidemiology study who did not take calcium antagonists before admission and with baseline hemoglobin > or =12 g/dL. Among these participants, 1,076 patients started taking calcium antagonists during their hospital stays. Demographic variables, comorbid conditions, medications, and objective tests that were associated with incident hemoglobin loss in separate age- and sex-adjusted logistic regression models were examined as potential confounders in a summary model. Higher risk for gastrointestinal bleeding was defined by diagnosis, treatment for peptic disease, or both. RESULTS: Hemoglobin decrease was detected in 24% of participants who started treatment with calcium antagonists and in 19% of other patients (P < .0001). In addition, use of calcium antagonists was independently associated with increased probability of hemoglobin loss (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.03 to 1.45; P = .018) after adjusting for potential confounders. Treatment with calcium antagonists was associated with hemoglobin loss in patients with higher baseline risk for gastrointestinal bleeding (OR, 1.67; 95% CI, 1.26 to 2.22; P < .0001) but not among other participants (OR, 1.02; 95% CI, 0.82 to 1.25). CONCLUSION: Starting treatment with calcium antagonists is associated with a reduction in hemoglobin levels during a hospital stay. However, the increased risk of hemoglobin loss seems to be limited to patients with diagnosis or symptoms of peptic disease.

[Cost of psychiatric patients by disability type]. / Il costo dei pazienti psichiatrici per classi di gravità.

OBJECTIVE: The study of the relation between treatment costs and disability of psychiatric patient groups. DESIGN: Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. SETTING: OPUs of Magenta (MI) and Desio (MI). METHOD: The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three-months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD-10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. RESULTS: Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7,127,000 lire (sd 19,499,000) and a cost per "day in charge" of 27,172 lire (sd 68,358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0.0001) overall difference on both their disability level and treatment cost. CONCLUSIONS: All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.

Left ventricular dysfunction: a clue to cognitive impairment in older patients with heart failure.

OBJECTIVES: Cognitive impairment has been reported in middle aged patients with end stage heart failure. This cross sectional study assessed the prevalence and determinants of cognitive dysfunction in older patients with mild to moderate heart failure. METHODS: 57 consecutive patients (mean age 76.7 years) with chronic heart failure underwent physical examination, blood chemistry, urinalysis, chest radiography ECG, Doppler echocardiography, and the mini mental state examination (MMSE), mental deterioration battery, depression scale of the Center for Epidemiological Studies (CES-D), Katz activities of daily living, and instrumental activities of daily living 24 hours before hospital discharge. RESULTS: MMSE scores <24 were found in 53% of participants. The MMSE score was associated with left ventricular ejection fraction according to a non-linear correlation, so that cognitive performance was significantly lower in subjects with left ventricular ejection fraction < or =30%. The same pattern of correlation was evidenced between left ventricular ejection fraction and both the attention sub-item of MMSE and the Raven test score. In a multivariate linear regression model, after adjusting for age, sex, and a series of clinical data and objective tests, both age (beta=-0.30; P=0.038) and the natural log of left ventricular ejection fraction (beta=0.58; P=0.001) were associated with the MMSE score. CONCLUSION: Cognitive impairment in older patients with chronic heart failure is common, and independently associated with lower left ventricular ejection fraction. Given the overwhelming incidence and prevalence of heart failure in older populations, early detection of cognitive impairment in these subjects with prompt, intensive treatment of left ventricular systolic dysfunction may prevent or delay a remarkable proportion of dementia in advanced age.