The mental health system in Bulgaria: socialist heritage and prospects.

The article overviews the current system of psychiatric care in Bulgaria based on statistical data for the country. We attempted to look at the reality of the psychiatric care system in Bulgaria as regards its structural parts, the relationships between them, their resource provision, as well as its financing. Attention is focused on some practices and policies that seem inadequate to the needs of patients, their successful treatment, and successful social rehabilitation and integration. It can be said that in recent years the Bulgarian mental health care system has not changed much and that it has a long way to go. There are socio-economic difficulties in the country, and the system needs to evolve to improve the level of care provided to patients. More importantly, Bulgaria must invest in mental health education, in preventive psychiatry, and in developing a culture of clinical management and organization.

In Schizophrenia, the Effects of the IL-6/IL-23/Th17 Axis on Health-Related Quality of Life and Disabilities Are Partly Mediated by Generalized Cognitive Decline and the Symptomatome.

Schizophrenia patients show increased disabilities and lower quality of life (DisQoL). Nevertheless, there are no data on whether the activation of the interleukin (IL)-6, IL-23, T helper (Th)-17 axis, and lower magnesium and calcium levels impact DisQoL scores. This study recruited 90 patients with schizophrenia (including 40 with deficit schizophrenia) and 40 healthy controls and assessed the World Health Association QoL instrument-Abbreviated version and Sheehan Disability scale, Brief Assessment of Cognition in Schizophrenia (BACS), IL-6, IL-23, IL-17, IL-21, IL-22, tumor necrosis factor (TNF)-α, magnesium and calcium. Regression analyses showed that a large part of the first factor extracted from the physical, psychological, social and environmental HR-QoL and interference with school/work, social life, and home responsibilities was predicted by a generalized cognitive deterioration (G-CoDe) index (a latent vector extracted from BACs scores), and the first vector extracted from various symptom domains ("symptomatome"), whereas the biomarkers had no effects. Partial Least Squares analysis showed that the IL6IL23Th17 axis and magnesium/calcium had highly significant total (indirect + direct) effects on HR-QoL/disabilities, which were mediated by G-CoDe and the symptomatome (a first factor extracted from negative and positive symptoms). The IL6IL23Th17 axis explained 63.1% of the variance in the behavioral-cognitive-psycho-social (BCPS) worsening index a single latent trait extracted from G-CoDe, symptomatome, HR-QoL and disability data. In summary, the BCPS worsening index is partly caused by the neuroimmunotoxic effects of the IL6IL23Th17 axis in subjects with lowered antioxidant defenses (magnesium and calcium), thereby probably damaging the neuronal circuits that may underpin deficit schizophrenia.

Lower Noise Annoyance Associated with GIS-Derived Greenspace: Pathways through Perceived Greenspace and Residential Noise.

Growing amounts of evidence support an association between self-reported greenspace near the home and lower noise annoyance; however, objectively defined greenspace has rarely been considered. In the present study, we tested the association between objective measures of greenspace and noise annoyance, with a focus on underpinning pathways through noise level and perceived greenspace. We sampled 720 students aged 18 to 35 years from the city of Plovdiv, Bulgaria. Objective greenspace was defined by several Geographic Information System (GIS)-derived metrics: Normalized Difference Vegetation Index (NDVI), tree cover density, percentage of green space in circular buffers of 100, 300 and 500 m, and the Euclidean distance to the nearest structured green space. Perceived greenspace was defined by the mean of responses to five items asking about its quantity, accessibility, visibility, usage, and quality. We assessed noise annoyance due to transportation and other neighborhood noise sources and daytime noise level (Lday) at the residence. Tests of the parallel mediation models showed that higher NDVI and percentage of green space in all buffers were associated with lower noise annoyance, whereas for higher tree cover this association was observed only in the 100 m buffer zone. In addition, the effects of NDVI and percentage of green space were mediated by higher perceived greenspace and lower Lday. In the case of tree cover, only perceived greenspace was a mediator. Our findings suggest that the potential for greenspace to reduce noise annoyance extends beyond noise abatement. Applying a combination of GIS-derived and perceptual measures should enable researchers to better tap individuals' experience of residential greenspace and noise.

Pathways linking residential noise and air pollution to mental ill-health in young adults.

BACKGROUND: Recent years have seen growing, but still tentative, evidence of the potential associations of environmental noise and air pollution with mental disorders. In the present study, we aimed to examine the associations between residential noise and air pollution exposures and general mental health in young adults with a focus on underlying processes METHODS: We sampled 720 students (18-35 years) from one university in the city of Plovdiv, Bulgaria. Residential noise (LAeq; day equivalent noise level) and air pollution (NO2) were assessed at participant's residential address by land use regression models. General mental health was measured with a short form of the General Health Questionnaire (GHQ). The following putative mediators were considered: annoyance from environmental pollution, sleep disturbance, restorative quality of the neighborhood, neighborhood social cohesion, and commuting/leisure time physical activity. Structural equation modeling was used to analyze the theoretically-indicated interplay between exposures, mediators, and GHQ. RESULTS: We observed an association between higher LAeq and GHQ, in which environmental annoyance and neighborhood restorative quality emerged as key mediators. First, LAeq was associated with higher annoyance, and through it with lower restorative quality, and then in turn with lower physical activity, and thus with higher GHQ. Simultaneously, higher annoyance was associated with higher sleep disturbance, and thereby with higher GHQ. NO2 had no overall association with GHQ, but it was indirectly associated with it through higher annoyance, lower restorative quality, and lower physical activity working in serial. CONCLUSION: We found evidence that increased residential noise was related to mental ill-health through several indirect pathways. Air pollution was associated with mental health only indirectly.

Multiple pathways link urban green- and bluespace to mental health in young adults.

BACKGROUND: A growing body of scientific literature indicates that urban green- and bluespace support mental health; however, little research has attempted to address the complexities in likely interrelations among the pathways through which benefits plausibly are realized. OBJECTIVES: The present study examines how different plausible pathways between green/bluespace and mental health can work together. Both objective and perceived measures of green- and bluespace are used in these models. METHODS: We sampled 720 students from the city of Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI), tree cover density, percentage of green areas, and Euclidean distance to the nearest green space. Bluespace was measured in terms of its presence in the neighborhood and the Euclidean distance to the nearest bluespace. Mental health was measured with the 12-item form of the General Health Questionnaire (GHQ-12). The following mediators were considered: perceived neighborhood green/bluespace, restorative quality of the neighborhood, social cohesion, physical activity, noise and air pollution, and environmental annoyance. Structural equation modelling techniques were used to analyze the data. RESULTS: Higher NDVI within a 300 m buffer around the residence was associated with better mental health through higher perceived greenspace; through higher perceived greenspace, leading to increased restorative quality, and subsequently to increased physical activity (i.e., serial mediation); through lower noise exposure, which in turn was associated with lower annoyance; and through higher perceived greenspace, which was associated with lower annoyance. Presence of bluespace within a 300 m buffer did not have a straightforward association with mental health owing to competitive indirect paths: one supporting mental health through higher perceived bluespace, restorative quality, and physical activity; and another engendering mental ill-health through higher noise exposure and annoyance. CONCLUSIONS: We found evidence that having more greenspace near the residence supported mental health through several indirect pathways with serial components. Conversely, bluespace was not clearly associated with mental health.

Cross-cultural validation of the revised temperament and character inventory in the Bulgarian language.

RATIONALE, AIMS AND OBJECTIVES: Health-care professions have long been considered prone to work-related stress, yet recent research in Bulgaria indicates alarmingly high levels of burnout. Cloninger's inventory is used to analyse and evaluate correlation between personality characteristics and degree of burnout syndrome manifestation among the risk categories of health-care professionals. The primary goal of this study was to test the conceptual validity and cross-cultural applicability of the revised TCI (TCI-R), developed in the United States, in a culturally, socially and economically diverse setting. METHODS: Linguistic validation, test-retest studies, statistical and expert analyses were performed to assess cross-cultural applicability of the revised Cloninger's temperament and character inventory in Bulgarian, its reliability and internal consistency and construct validity. RESULTS: The overall internal consistency of TCI-R and its scales as well as the interscale and test-retest correlations prove that the translated version of the questionnaire is acceptable and cross-culturally applicable for the purposes of studying organizational stress and burnout risk in health-care professionals. CONCLUSIONS: In general the cross-cultural adaptation process, even if carried out in a rigorous way, does not always lead to the best target version and suggests it would be useful to develop new scales specific to each culture and, at the same time, to think about the trans-cultural adaptation.

Rendering clinical psychology an evidence-based scientific discipline: a case study.

RATIONALE, AIMS AND OBJECTIVES: Both modern neuroscience and clinical psychology taken as separate fields have failed to reveal the explanatory mechanisms underlying mental disorders. The evidence acquired inside the mono-disciplinary matrices of neurobiology, clinical psychology and psychopathology are deeply insufficient in terms of their validity, reliability and utility. Further, no effective trans-disciplinary connections have been developed between them. ARGUMENT: In this context, our case study aims at illustrating some specific facets of clinical psychology as a crucial discipline for explaining and understanding mental disorder. The methods employed in clinical psychology are scrutinized using the exemplar case of the Minnesota Multiphasic Personality Inventory (MMPI). We demonstrate that a clinical interview and a clinical psychological rating scale consist of the same kind of cognitive content. The provisional difference can be described in terms of its having two comparable complementary cognitive structures. The test is composed of self-evaluation reports (items) formulated as questions or statements. The psychopathological structured interview is formulated in terms of subjective experience indicated as symptoms (these are self-reports recorded by the physician), complemented with the so-called 'signs' or the presumably 'objective' observations of the overt behaviours of the patient. However, the cognitive content of clinical judgment is beyond any doubt as subjective as the narrative of the patient. None of the components of the structured psychopathological interview is independent of the inter-subjective system created in the situation of clinical assessment. CONCLUSION: Therefore, the protocols from various clinicians that serve to sustain the reliability claim of the 'scientific' Diagnostic Statistical Manual of Mental Disorders cannot be regarded as independent measurements of the cognitive content and value of the psychological rating scales or vice versa.

Relation of people-centered public health and person-centered healthcare management: a case study to reduce burn-out.

Healthcare management is one practical tool for mediation and implementation of public health into clinical healthcare outcomes and is taken in our case study as an exemplar arena to demonstrate the vital importance of the person-centered approach. Healthcare personnel are frequently at risk for the 'burn-out' syndrome. However, modern measures of burn-out recognize burn-out only at a late stage when it is fully developed. There are no available methods to assess the risk for vulnerability to burnout in healthcare systems. Our aim was therefore to design a complex person-centered model for detection of high risk for burn-out at an early stage, that has been termed 'flame-out'. We accept the observation that decreased personal performance is one crucial expression of burn-out. Low personal performance and negative emotions are strongly related to low self-directedness as measured by the Temperament and Character Inventory (TCI). At the same time, burn-out is characterized by decreased interest and positive emotions from work. Decreased positive emotion is directly related to low self-transcendence as measured by the TCI. Burn-out is also frequently associated with feelings of social alienation or inadequacy of support, which is in turn related to low TCI Cooperativeness. However, high Persistence and Harm Avoidance are predisposing traits for burn-out in healthcare professionals who are often overly perfectionistic and compulsive, predisposing them to anxiety, depression, suicide and burn-out. Hence, people at risk for future burn-out are often highly conscientious over-achievers with intense mixtures of positive and negative emotions. The high demand for perfection comes from both intrinsic characteristics and from features of the social milieu in their psychological climate. Letting go of the unfulfillable desire to be perfect by increasing self-transcendence allows acceptance of the imperfection of the human condition, thereby preventing burn-out and other negative emotions while promoting positive emotions and work in the service of others. Hence, we can evaluate vulnerable populations via a person-centered diagnostic method using the TCI and also relate wellbeing to the psychological climate of the work place. The proposed diathesis-stress model can directly impact on the management of human resources and related decision-making. The introduction of such person-centered assessments can encourage and improve public health outcomes by promoting the personal wellbeing of healthcare employees.