Effects of training program on recognition and management of depression and suicide risk evaluation for Slovenian primary-care physicians: follow-up study.

AIM: To implement and evaluate an educational program for primary care physicians on recognition and treatment of depression and suicide prevention. METHOD: The study was conducted in 3 Slovenian neighboring regions (Celje, Ravne na Koroskem, and Podravska) with similar suicide rates and other health indicators. All primary care physicians from Celje (N=155) and Ravne na Koroskem (N=35) were invited to participate in the educational program on depression treatment and suicide risk recognition. From January to March 2003, approximately half of them (82 out of 190; educational group) attended the program, whereas the other half (108 out of 190; control group 1) and physicians from the Podravska region (N=164; control group 2) did not attend the program. The prescription rates of antidepressants and anxiolytics before and after the intervention were compared between the studied regions. Also, suicide rates three-years before and after the intervention were compared. RESULTS: From 2002 to 2003, there was a 2.33-fold increase in the rate of antidepressant prescriptions in the educational group (P<0.05) and only 1.28-fold (P<0.05) and 1.34-fold (P<0.05) increase in control groups 1 and 2, respectively. However, the 12% decrease in suicide rate in the intervention regions was not significantly greater than the 4% decrease in the non-intervention region (P>0.05). CONCLUSION: Our training program was beneficial for primary care physicians' ability to recognize and manage depression. However, there was no significant decrease in local suicide rates.

Gender, psychosis and psychotropic drugs: differences and similarities.

Acute psychosis is diagnosed by clearly defined operational criteria embedded into international classification systems. Many studies have tried to determine the role of gender in psychosis but mainly in terms of epidemiology and course of illness, most often schizophrenia. There are however also important gender-specific differences in clinical symptoms of acute psychosis. No guidelines or treatment recommendations suggest gender as an important factor in the choice of antipsychotic treatment, which is true for all treatment modalities (antipsychotic, dose, duration). We will review shortly available literature and present some of our own research data on gender differences in clinical presentations of acute psychosis. When the diagnosis of an illness depends almost entirely on symptoms and their presentations as in the case of acute psychosis, important gender specific differences might challenge the diagnostic process as well as treatment choice and course of psychosis. Our as well as other data confirm that acute psychosis manifest itself differently in males and females. To define further the impact of observed differences we need further research into gender specific clinical and not just epidemiological variables.

Acute psychosis and gender.

In this review of Psychosis and gender we will present the relevant. Treatment principles and consider the foreign and local published data.

Off-label use of antipsychotics: rethinking "off-label".

Antipsychotics are currently registered for the use in psychosis, mania and agitation. They have although been in common practice used for a wide range of psychiatric disorders even in the era of first generation antipsychotics. Such a use is termed "off-label". There are several drawbacks in off-label antipsychotics' prescribing among them legislative in case of complications, poorly defined criteria for their use (dosages, possible complications, time span), missing guidelines and treatment algorithms as well as missing consensus among clinicians about indications and treatment protocol. We have reviewed existing literature on the topic using Medline search for controlled and naturalistic data about off-label use of antipsychotics. The results have been combined with our descriptive clinical experiences as well as the process of making national recommendations on off-label use of antipsychotics. The results have shown that the practice of off-label use is widely accepted in clinical work not just for antipsychotics but for other psychotropic drugs in psychiatry as well. The level of evidence is however different and will be discussed. Indications for the use of antipsychotics are evolving with new generations, which is consistent with their mechanisms of action and anticipated from drug profiles of different newer antipsychotics. New official indications do show the dynamic properties of the term "off-label" which tends to be more a cross-sectional descriptive term rather then scientific fact. According to the evidence and practice antipsychotics are becoming antidepressants, anti-anxiety drugs, mood stabilizers, cognitive enhancers, anti-aggressive, anti-impulsive, anti-suicidal and hypnotic medications. We will propose a different way to classify the use of antipsychotics in indications different from those officially recognized.

Pharmacotherapy for the soul and psychotherapy for the body.

The "mind-body" dualism has shaped the development of psychiatry. At the very beginning psychiatry was related to the mind and the rest of the medicine to the body. The main reasons for such division were lack of biological evidence for psychiatric disorders and wrong beliefs about demonic origins of "lunacy". But although the development of science offered more than enough biological evidence to understand brain as an organ of origin for psychiatric disorders, the dualism of mind and body remained alive even in the modern classification systems. One of the consequences was another dualism that differ biological (e.g. pharmacotherapy) from psychological therapy (e.g. psychotherapy) as completely different approaches. The purpose of this article is to offer enough evidence to reframe the existing dualisms into a different paradigm. In every illness both mind and body can be affected to a different extent. Which part of an illness is body and which part is mind is often difficult to differentiate even when we compare a person with broken leg with a person with acute stress reaction. For that reason it might be an over-simplification to differentiate sharply between biological and psychological therapies. The evidence show that psychotherapy influences biology of the brain and that pharmacotherapy influences psychological, social and developmental dimensions of the diseased person as well as overall well-being and functionality. In the era where medicine discovered psychology and psychiatry discovered biology, the debates and divisions that steam out of past dualisms should end. Every practising physician regardless of the medical discipline uses in everyday practice both biological and psychological approaches to help the patient successfully.

Two generations of Slovenian suicidal adolescent inpatients.

BACKGROUND: The political and socio-economic situation in Slovenia, a former Yugoslav republic, a country in transition and a country with a high suicide rate, which joined the European Union in 2004, has changed steadily since the beginning of the 1970s. Literature shows constancy in suicide statistics in Slovenia during these times. AIM: The present study examines whether the suicidal adolescent inpatient population in Slovenia reflects recent social changes and upheavals. METHOD: Data on two groups of patients admitted to a specialized adolescent psychiatry department after attempting suicide were collected. The first group (n = 74) were patients admitted from 1975 to 1977, the second group (n = 73) from 2002 to 2004. They were compared on general characteristics, family and living circumstances, risk behaviors, suicide attempts and diagnoses. RESULTS: The comparison revealed statistically significant differences between groups on educational level, number of siblings, frequency of smoking and psychoactive medication misuse as well as number of previous suicide attempts. No differences were found in other family and living circumstances, methods used in the index suicide attempt, other risk behaviors or diagnoses. CONCLUSIONS: The post-independence suicidal inpatient population in Slovenia shows a tendency towards higher morbidity, but has changed less than expected considering the vast changes in the society. These results suggest a certain constancy in adolescent suicidal behavior.

The development of psychiatric reform in Slovenia.

The situation of mental health care in Slovenia is briefly reviewed. The reduction of beds in psychiatric hospitals has started already in the 1970s; a further decrease has occurred in the last few years. The number of admissions to these hospitals has increased recently, while hospitalizations have become shorter. On the other hand, the access to psychiatric outpatient facilities is becoming increasingly difficult. Under these circumstances, it is necessary to enhance community mental health care. Patients and families have great expectations about the new mental health legislation, which is supposed to be associated with a national mental health program.

Suicidal ideation in adolescence--an indicator of actual risk?

BACKGROUND: The aim of the study was to assess both the frequency of suicidal ideation and also its link to other risk factors for suicidal behavior in the community population of adolescents. METHOD: In the study, we have used a structured questionnaire for assessing the risk factors for suicidal behavior, and self-assessment scales for measuring depression and self-esteem. The research included 4,692 adolescents aged from 14 to 19 years. The sample is representative of the population of Slovene high school students. RESULTS: The prevalence of suicidal ideation was 44% at anytime in respondent's life, and 10.3% during the recent month, and statistically significantly more frequent in girls than in boys. Suicidal ideation proved to be linked to high level of depression and low self-esteem, and also to the important psychosocial risk factors for suicidal behavior, such as: tendency to react on stress by consuming alcohol, alcohol and substance abuse, frequent conflicts with parents and frequently running away from home, pessimism about the future and self estimation of high probability of suicide in the future. CONCLUSIONS: Suicidal ideation is an important suicide risk factor in adolescence, and requires adequate attention among all other relevant risk factors.