A COLLABORATIVE, INTEGRATIVE MENTAL HEALTH APPROACH: "THE STEPPED CARE MODEL. / ISBIRLIGINE DAYALI, ENTEGRE BIR RUH SAGLIGI YAKLASIMI: "KADEMELI BAKIM MODELI".

Dear Editor, In this paper, it is aimed to raise awareness about the stepped care model as an approach in the organization of mental health services related to the protection, development, care and treatment of mental health. Concerning mental health, World Health Organization emphasizes that "Mental Health is more than mental disorders. It is a state of well-being that includes using one's own abilities, self-realization, coping with the stresses in the natural flow of life, learning to be well and trying to heal, working efficiently and contributing to the society in which they live." (World Health Organization 2022a). It has been reported that the disease burden of common mental disorders (depression, anxiety, post-traumatic stress disorder, psychoactive substance use disorders, suicide, etc.) is gradually increasing (World Health Organization 2021). Especially in the last century, the importance and seriousness of endemic and pandemic events (HIV, SARS virus, and still continuing Covid-19, etc.) or non-communicable diseases (cancer, heart diseases, diabetes, etc.), climate changes, economic, socio-political dynamics and wars are noteworthy as a predisposition and/or precipitating factors in terms of mental health (World Health Organization 2022a, World Health Organization 2022b). Protection and improvement of mental health, together with individual, social, and structural mental health determinants, predict interventions that reduce risks, increase resilience, and create a supportive environment for mental health. These interventions are recommended to be designed individually, in a way to be disseminated to special groups across the community. Globally, one person dies by suicide every 40 seconds, and more than 18 million health workers are needed in terms of human resources.

[Prevalence of depressive symptoms, ways of coping, and related factors among medical school and health services higher education students]. / Tip Fakültesi ve Saglik Yüksekokulu Ogrencilerinde Depresif Belirti Yayginligi, Stresle Basaçikma Tarzlari ve Etkileyen Faktörler.

OBJECTIVE: The aims of this study were to explore the prevalence of depressive symptoms, ways of coping, and their relationships to sociodemographic variables among students of the Medical Faculty (MF) and the Health Services Higher Education School (HSHES) at Inönü University. METHOD: The Beck Depression Inventory (BDI), Styles of Coping Inventory (SCI), and a sociodemographic questionnaire were used. RESULTS: Among the HSHES students (n = 128), the prevalence of depressive symptoms was higher. The MF students whose fathers had a higher level of education had higher BDI scores. The MF students from families with lower levels of income had a higher frequency of depressive symptoms. In both groups, the students with previous histories of psychiatric and physical ilness had higher BDI scores. Among the MF students, older age (OR = 2.72), and among the HSHES students, having a previous history of psychiatric disorder (OR = 5.25) and female gender (OR = 1.85) affected the prevalence of depressive symptoms. The HSHES students used passive styles of coping more frequently. Active coping styles were used more frequently by the male students in both groups. The HSHES students whose mothers had lower levels of education, had higher passive coping style scores; active coping styles and higher family income correlated positively. In both groups, BDI and active styles scores correlated positively. Passive styles were used more frequently by male and female students that had a higher frequency of depressive symptoms. CONCLUSION: The rate of mental health problems was quite high among the students. Preventive mental health programs should be developed and implemented.

[Patients' explanation models for their illness and help-seeking behavior]. / Psikotik Hastalarda Hastalik Açiklama Modeli ve Care Arama Davranisi

OBJECTIVE: The aim of this study was to investigate some variables that affect patients' explanation models for their illness and help-seeking behavior. METHODS: Sampling was done between 2002 and 2003 among psychiatric patients who were admitted to university hospital in Malatya. Diagnoses of schizophrenia and schizoaffective disorder were made according to DSM-IV criteria. A semi-structured interview based on a short questionnaire was conducted for collecting patient demographic data, and patient explanatory model for illness and help-seeking behavior. RESULTS: The 88 patients that were evaluated included 50 males and 38 females. The mean age of the patients was 31.22+/-9.29 years (range: 16-57 years). In explaining their disease, 46.6% of the patients cited family trouble, 42% their inner problems, 19.3% economic difficulties, and 10.2% cited the consequences of supernatural forces. Among the patients, help-seeking behavior included visiting traditional and religious healers (51.1%), presenting to medical doctors (19.3%), and visiting a psychiatrist (65.9%). CONCLUSION: The study revealed that patients with low-level education were more prone to seek religious solutions and those with high-level education tended to visit a psychiatrist. It has been suggested that psycho-educational programs for patients and families will be very useful in ameliorating the problems created by the disease.

Possible malignant neuroleptic syndrome that associated with hypothyroidism.

A 54-year-old woman with schizophrenia presented to hospital with unconsciousness, fever and marked muscle rigidity. She had been given fluphenazine decanoete 20 mg intramuscularly 15 days before the admission and she had continued taking haloperidol 20 mg daily and oral biperiden 2-4 mg. She was extremely rigid and unresponsive. On laboratory investigations revealed: serum sodium 120 mEq/l, creatinine phosphokinase 12,980 IU/l (normal up to 170), lactate dehydrogenase 1544 IU/l (150-500), free trioidothyronine < 1.00 pg/ml (1.5-4.5), free throxyine 0.76 ng/dl (0.8-1.9), thyroid stimulating hormone 1.14 microU/ml (0.4-4), cortisol (at 8.00 a.m.) 9 microg/dl (5-25). Antipsychotic drugs were withdrawn after admission. A diagnosis of secondary adrenal insufficiency and secondary hypothyroidism was made. Hormonal substitution with hydrocortisone and levothyroxine and correction of hyponatremia with intravenous hypertonic saline solution resulted in rapid improvement of symptoms and signs. It seems that the symptoms and signs of hypothyroidism and hyponatremia were attributed to acute psychosis in this patient. As a conclusion failure to recognize the endocrinopathy may not only produce recovery difficulties but also psychiatric and endocrine repercussions if psychotropic medications are given in such masked cases.

Sevoflurane as an alternative anaesthetic for electroconvulsive therapy.

OBJECTIVES: The aim of this study was to investigate the effects of sevoflurane and propofol used in electroconvulsive therapy (ECT) on hemodynamic variables and duration of seizure activity and recovery profiles. METHODS: Sixteen patients who were not premedicated, with a mean age 27.1 years, were enrolled in this prospective open trial, receiving a total of 64 ECT treatments. Each patient was given the following 2 anesthetic regimens in random order: In group S, anesthesia was induced with 7% sevoflurane in 100% oxygen at 6 L min fresh gas flow until the loss of consciousness and 1.5 mg kg propofol in group P. Adequate muscle relaxation was achieved with suxamethonium, 1.0 - 1.2 mg kg. Noninvasive mean arterial pressure (MAP) and heart rate (HR) values, duration of motor seizure activity, and recovery times were recorded. RESULTS: The mean motor seizure duration was significantly longer with sevoflurane (mean [SD]: 43.09 [16.6] s) than with propofol (28.91 [7.9] s; P < 0.05). The MAP 1 minute and 10 minutes after ECT (101.25 [7.5] mm Hg and 100.16 [11.0] mm Hg, respectively) was significantly increased compared with before ECT (94.56 [6.9] mm Hg) in sevoflurane group (P < 0.05). Time to spontaneous breathing, eye opening and obeying commands, and changes in MAP and HR during and after ECT were similar in both regimens. CONCLUSION: Induction with 7% sevoflurane allows prolonged duration of motor seizures in ECT. We concluded that induction of anesthesia with sevoflurane inhalation is a reasonable alternative for patients undergoing ECT.

Psychiatric disorders and large interdialytic weight gain in patients on chronic haemodialysis.

AIMS: Psychiatric disorders have been considered in terms of non-compliant behaviour and low life quality in haemodialysis patients. The aim of this study is to investigate the potential association of psychiatric disorders with compliance of fluid restriction and nutritional status and to measure the effects of psychiatric disorders on the life quality in chronic renal failure patients on haemodialysis. METHODS: The study was conducted between April 2002 and December 2002 at a University hospital haemodialysis unit. The study population included 40 chronic renal failure patients (15 females/25 males). The Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS) and Primary Care Evaluation of Mental Disorders (PRIME-MD), The Mini Mental State Examination (MMSE) and Short Form Health Survey 36 (SF-36) were used for patient assessment by a trained psychiatrist. The subjects' medical charts were reviewed by a physician who was unaware of the the results of the psychiatric assesments. Interdialytic weight gain (IDWG %) and nutritional status were used as an index of diet compliance. Nutrition was assessed by using subjective global assessment (SGA), serum albumin, predialysis phosphorus and potassium levels. RESULTS: All patients' MMSE were normal. A diagnosis of a depressive or anxiety or somatoform disorder by the PRIME MD was made in 65% of the patients. Fourteen (35%) of the patients had a depressive disorder, 13 (32.5%) of the patients had a somatoform disorder, and 12 (30%) had an anxiety disorder. We found no relationship between any psychiatric disorder and age, sex, duration of dialysis therapy, education, marital status, employment, socioeconomic status, serum albumin, phosphorus, potassium or SGA (P > 0.05). In patients with depression or a somatoform disorder, the interdialytic weight (%) was significantly higher than those of the patients without these disorders (P < 0.05). All indices of quality of life decreased in patients diagnosed with a psychiatric disorder. CONCLUSION: Depressive symptoms are important determinants of patients' large interdialytic weight gain and psychiatric disorders that effect a patients' overall quality of life. Evaluation of psychiatric status should be part of the care provided to haemodialysis patients.

[Family functioning in patients with schizophrenia, bipolar affective disorder and epilepsy]. / Sizofreni, Iki Uçlu Duygudurum Bozuklugu ve Epilepsi Hastalarinda Aile Islevlerinin Karsilastirilmasi.

OBJECTIVE: To evaluate the impact of illness progression on the family functioning of patients with schizophrenia, bipolar affective disorder and epilepsy showing chronic relapsing progress and affecting functionality. METHOD: A total of 75 patients who were diagnosed according to DSM-IV criteria as having schizophrenia (n: 25), bipolar affective disorder (n: 25) or epilepsy (n: 25) and their 134 family members were included in the study. A socio-demographical data form was completed by consulting the patient and family members, and a Family Assessment Device (FAD) was used. RESULTS: The general functionality level was low in patients with schizophrenia. Families of patients with bipolar affective disorder had healthier functioning than families of patients with schizophrenia and epilepsy. Subscales of "communication" and "behavioral control" were reported as highly ineffective by the schizophrenia patients. The epilepsy patients have family dysfunction in "behavioral control" and "roles" subscales. The families of bipolar affective disorder patients evaluated their "problem solving" and "general functioning" as problematic. CONCLUSION: The family's experience of disease and adaptation is a dynamic and ongoing process. Our data suggest that chronic psychiatric and neurological diseases may cause some specific difficulties in family functions.

Altered diurnal variation of nitric oxide production in patients with panic disorder.

The aim of this prospective study was to investigate the diurnal change in serum nitric oxide (NO) levels in active and remission phases of patients with panic disorder. This study included 15 patients fulfilling the criteria for panic disorder of Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition and 15 healthy controls matched for age and sex. All patients were receiving a selective serotonin reuptake inhibitor at therapeutic doses. The serum nitrite and nitrate levels of subjects were determined at 10:00 a.m. after overnight fasting and at 3:00 p.m. 2 hours after lunch. NO levels of all patients measured in the morning were significantly higher than those of controls. The patients were also divided into active and remission groups according to clinical status and Panic Agoraphobia Scale's cut-off point. There were no statistically significant differences in serum nitrite and nitrate levels of the active group between the 10:00 a.m. and 3:00 p.m. measurements. In contrast, statistically significant differences were found in the serum levels of nitrite (p<0.05) and nitrate (p<0.05) in the remission group. Notably, the afternoon nitrite and nitrate levels of the remission group were higher than those of the morning levels as seen in control subjects. Thus, diurnal variation of NO production is altered in patients with panic disorder but is resumed in the remission phase. The present study suggests that serum NO levels are a good marker for evaluation of panic disorder.

Weight gain and improvement with quetiapine in bipolar I disorder: a case report.

Observations made with quetiapine (QUET) in this case give clues for some aspects of its use for patients with bipolar disorder. Weight gain (11 kg; 16.6% increase in 21 weeks) and improvement in manic symptoms occurred after QUET add-on to lithium (Li). Patient's mood improved after QUET add-on without causing extrapyramidal symptoms (EPS), while QUET was discontinued due to weight gain. Short-term QUET add-on to Li may help mood stabilization in bipolar I disorder. Weight changes must be observed carefully.