Anticipated and experienced stigma and discrimination in the workplace among individuals with major depressive disorder in 35 countries: qualitative framework analysis of a mixed-method cross-sectional study.

OBJECTIVES: Workplace stigmatisation and discrimination are significant barriers to accessing employment opportunities, reintegration and promotion in the workforce for people with mental illnesses in comparison to other disabilities. This paper presents qualitative evidence of anticipated and experienced workplace stigma and discrimination among individuals with major depressive disorder (MDD) in 35 countries, and how these experiences differ across countries based on their Human Development Index (HDI) level. DESIGN: Mixed-method cross-sectional survey. PARTICIPANTS, SETTING AND MEASURES: The qualitative data were gathered as part of the combined European Union Anti-Stigma Programme European Network and global International Study of Discrimination and Stigma Outcomes for Depression studies examining stigma and discrimination among individuals with MDD across 35 countries. Anticipated and experienced stigma and discrimination were assessed using the Discrimination and Stigma Scale version 12 (DISC-12). This study used responses to the open-ended DISC-12 questions related to employment. Data were analysed using the framework analysis method. RESULTS: The framework analysis of qualitative data of 141 participants identified 6 key 'frames' exploring (1) participants reported experiences of workplace stigma and discrimination; (2) impact of experienced workplace stigma and discrimination; (3) anticipated workplace stigma and discrimination; (4) ways of coping; (5) positive work experiences and (6) contextualisation of workplace stigma and discrimination. In general, participants from very high HDI countries reported higher levels of anticipated and experienced discrimination than other HDI groups (eg, less understanding and support, being more avoided/shunned, stopping themselves from looking for work because of expectation and fear of discrimination). Furthermore, participants from medium/low HDI countries were more likely to report positive workplace experiences. CONCLUSIONS: This study makes a significant contribution towards workplace stigma and discrimination among individuals with MDD, still an under-researched mental health diagnosis. These findings illuminate important relationships that may exist between countries/contexts and stigma and discrimination, identifying that individuals from very high HDI countries were more likely to report anticipated and experienced workplace discrimination.

Triangulation study of needs assessment of people with severe mental illness in "follow-up" day hospital settings.

AIM: The aim of research was to assess the needs of patients with severe mental illness (SMI) attending follow-up day hospital (DH) programmes from the patients', relatives' and experts' perspective. DESIGN: This triangulation research relies on three sources of information and two techniques of data collection. METHODS: Qualitative research was conducted comprising semi-structured interviews (n = 15) and focus groups (n = 4) in three sequential rounds, triangulating patients', relatives' and experts' views. A content analysis was carried out. RESULTS: Study reveals a diverse spectrum of needs of SMI patients in follow-up DH programmes. The analysis yielded six themes: optimal daily functioning, work and educational activities, social network inclusion, continuous treatment, support and guidance, long-term care. DH programmes should assess the needs of patients with SMI and be adapted according to the findings. In addition to clinical treatment, requirements for continuous treatment, psychological and social needs, therapeutic relationship in less-restrictive settings should be considered.

Mental Health Needs Assessment During the COVID-19 Pandemic: Consensus Based on Delphi Study.

The COVID-19 pandemic has revealed significant gaps in mental health in terms of unrecognized and unmet needs. The goal was to accurately assess the needs and identify gaps in this area during the epidemiological crisis. A Delphi study to identify the needs was conducted with a group of decision-makers, experts, and users of mental health services. A starting point of the Delphi study was prepared in two working groups, based on recognizable international recommendations and experiences of the practitioners from the field situation. This initial set of emergency measures was supplemented through the first Delphi round, and consensus about the importance was reached in the second round. A total of 41 activities were derived, the vast majority of which were rated with a score of 4 or more. Mental health activities, which should be addressed in terms of needs, can be divided into systemic measures and service measures. This study recognizes a need to reorganize services in the direction of improving local accessibility and strengthening the network of services for immediate responses to the psychological, health, and social needs of individuals, including those arising from crisis situations, such as COVID-19 pandemic. The results of this study are in line with the international recommendations and also influenced the formulation of the Action Plan of the National Mental Health Program, while some of the measures were already implemented during the publication of the research results.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis.

BACKGROUND: Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period. METHODS: We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels. FINDINGS: Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings. INTERPRETATION: Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries. FUNDING: Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Time from the Admission as the Predictor of Aggressive Behavior of Inpatients with Schizophrenia Spectrum Disorder.

The aim was to assess the incidence of aggressive events (AE) committed by patients diagnosed with schizophrenia spectrum disorethder (SSD) after the first 7 days of hospitalization in psychiatric institution, in comparison to other psychiatric patients. This retrospective cohort study was performed at Psychiatric Hospital "Sveti Ivan", Zagreb, Croatia, using hospital safety records of all patients admitted between 2015 and 2017. Primary outcome was the proportion of patients who committed AE more than a week after the admission to the hospital. Secondary outcome was the time in days from admission to the first incident of AE. The primary analysis was performed using a multivariable binary logistic regression. SSD patients committed AE more often than other patients (incidence rate ratio 3.97 (95% CI 2.35-6.69; p < 0.001; FDR q = 0.002), but these occurred earlier in the course of hospitalization: median (IQR) 2 (1-10) days from admission compared to 11 (2-32) days in other patients. SSD patients had significantly and clinically relevantly lower odds for AE after the first week of hospitalization adjusted for the large number of pre-planned possible confounders (OR = 0.10; 95% CI 0.02-0.45; p = 0.003; FDR q = 0.002). SSD patients seem to express more aggression earlier in the course of hospitalization. Findings of this study indicate that hospitalization-inherent AE risk factors may play an important role in the etiology of AE and inpatients aggressive behavior. Their possible moderating effect should be included in risk-assessment instruments.

Gender differences in early onset of chronic physical multimorbidities in schizophrenia spectrum disorder: Do women suffer more?

AIM: The association between various physical illnesses and schizophrenia spectrum disorder (SSD) is well-established. However, the role of gender remains unclear. The present study explored the gender-based differences in the prevalence and early onset of chronic physical multimorbidities (CPM) in patients with SSD and the general population (GEP). METHODS: We recruited 329 SSD patients and 837 GEP controls in this nested cross-sectional study. The primary outcome was the prevalence of the chronic physical multimorbidities, especially in the youngest age group (<35 years). RESULTS: Women with SSD had more than double the odds for having CPM than men (OR = 2.47; 95% CI 1.35-4.50), while the gender-related burden of chronic diseases in controls was nearly the same (OR = 0.89; 95% CI 0.65-1.22). Furthermore, the prevalence of chronic disease in younger women patients was significantly higher than in controls (P = .002), while younger men did not seem to experience this increased comorbidity burden. CONCLUSIONS: This study suggests that women with SSD are at increased physical comorbidity risk compared to men, particularly early in the course of psychiatric illness. Tailored and individualized treatment plans must consider this, aiming to deliver holistic care and effective treatment outcomes.

Stigma in mental disorders: What is psychiatry able to do?

The problem of stigma in mental health in connected to the problem of human rights. Mental health professionals, psychiatrists included, display stigmatization of people with mental disorders mostly through social distance, even though they have "politically correct" opinions about their patients. Negative beliefs and attitudes in psychiatric profession should be opposed because of their important influence on public opinion, opinion of patients' themselves and of their family members. The "disabling environment" formed through discriminative practices in all society levels can be improved through mental health policy documents and plans that involve clear human rights protection premises, resource allocation and development priorities in line with international standards. Slovenia invests at least 80% of mental health budget in psychiatric hospitals and social care institutions, which employ 90% of psychiatrists. Redirection of these resources to local level, together with reallocation of human resources, should improve attitudes of mental health workers towards people with mental problems, because of timely, effective and needs-led approach that enables recovery.

Mental Health in Domesticated Immigrant Population - a Systematic Review.

BACKGROUND: Migration is a process during which a person moves from one cultural setting to another in order to settle for a longer period of time or permanently. The number of immigrants in the world has more than doubled since 1975, with majority of migrants living in Europe today. Migration is now being increasingly recognized as a risk factor for multiple mental-health related issues, such as schizophrenia, psychosis, anxiety disorders and others. AIM: The aim of this study was to collect, systematically review and analyze relevant articles pertaining to the mental health of second-or-higher generations of domesticated immigrant population, as well as to determine common socio-cultural predisposition factors leading to the development of mental illness among the mentioned population. METHODS: Systematic search of relevant and peer-reviewed electronic database ScienceDirect was performed to identify studies related to mental health and healthcare in before-mentioned immigrant population. Study selection was performed by two independent reviewers, following the agreed specific inclusion and exclusion criteria. RESULTS: 2 036 records were identified through initial database search, out of which 5 studies were included in this review, after the selection process. CONCLUSION: The most consistent clinical finding is an increase in the rate of diagnosis of schizophrenia and related psychoses among migrants when compared to the host population, however the relationship between migration and psychotic disorders remains unexplained. So far, biological factors, such as cannabis use or obstetric complications, have failed to account for the risk of schizophrenia among migrant groups. Socio-environmental factors are now being looked upon as potential contributing factors for psychotic disorders in migrants.

Prevalence and incidence of attention-deficit/hyperactivity disorder in Slovenian children and adolescents: a database study from a national perspective.

AIM: To estimate prevalence and incidence of attention deficit hyperactivity disorder (ADHD) in children and adolescents in Slovenia using different epidemiological models. METHODS: Data from the National Institute of Public Health of the Republic of Slovenia for the period 1997-2012 were analyzed. The database includes the annual number of newly diagnosed outpatients with ADHD in Slovenia. The evaluation for ADHD diagnoses was done in accordance with the Tenth Revision of the International Classification of Diseases (ICD-10) outpatient data codes. In model 1, a linear increase was proposed to fit the data in the period from 1997 to 2003 in order to extrapolate the data before 1997. In model 2 and 3, an exponential increase in the annual incidence rate was proposed. RESULTS: The incidence rate of ADHD diagnosis in 1997 was 0.032% and in 2012 it increased to 0.082%. Mean prevalence rate was 750 (95% confidence interval: 660-840) per 100 000 children and adolescents. It was estimated that the prevalence rate in 2020 would be 1% (95% confidence interval: 0.875-1.125), which is 6.3-fold higher than in 1997. CONCLUSIONS: ADHD is a common mental health disorder among Slovenian children and adolescents, but it remained underdiagnosed compared with Western countries. Our results indicated a need for improved timely interventions in Slovenia, not only in child and adolescent psychiatry but also in primary settings and adult psychiatry, where ADHD should be more efficiently recognized.

Comparative efficacy and acceptability of atomoxetine, lisdexamfetamine, bupropion and methylphenidate in treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis with focus on bupropion.

OBJECTIVES: There is a lack of comparative effectiveness research among attention deficit hyperactivity disorder (ADHD) drugs in terms of efficacy and acceptability, where bupropion is compared with atomoxetine, lisdexamfetamine and methylphenidate. The main aim of this work was to compare the efficacy and acceptability of these drugs in children and adolescents using a metaanalysis. METHODS: A literature search was conducted to identify double-blind, placebo-controlled, noncrossover studies of ADHD. PubMed/Medline and Clinicaltrials.gov were searched. Comparative drug efficacy to placebo was calculated based on the standardized mean difference (SMD), while the comparative drug acceptability (all cause discontinuation) to placebo was estimated on the odds ratio (OR). RESULTS: In total 28 trials were included in the meta-analysis. Efficacy in reducing ADHD symptoms compared to placebo was small for bupropion (SMD=-0.32, 95% CI; -0.69, 0.05), while modest efficacy was shown for atomoxetine (SMD=-0.68, 95% CI; -0.76, -0.59) and methylphenidate (SMD=-0.75, 95% CI; -0.98, -0.52) and high efficacy was observed for lisdexamfetamine (SMD=-1.28, 95% CI; -1.84, -0.71). Compared to placebo treatment discontinuation was statistically significantly lower for methylphenidate (OR=0.35, 95% CI; 0.24, 0.52), while it was not significantly different for atomoxetine (OR=0.91, 95% CI; 0.66, 1.24), lisdexamfetamine (OR=0.60, 95% CI, 0.22, 1.65), and bupropion (OR=1.64, 95% CI; 0.5, 5.43). LIMITATIONS: The heterogeneity was high, except in atomoxetine trials. The crossover studies were excluded. The effect sizes at specific time points were not computed. Studies with comorbid conditions, except those reporting on oppositional defiant disorder, were also excluded. All studies involving MPH were combined. CONCLUSIONS: The results suggest that lisdexamfetamine has the best benefit risk balance and has promising potential for treating children and adolescents with ADHD. More research is needed for a better clinical evaluation of bupropion.

Trends in attention-deficit/hyperactivity disorder drug consumption in children and adolescents in Slovenia from 2001 to 2012: a drug use study from a national perspective.

OBJECTIVE: In most Eastern and Central European countries, except Germany, there is a lack of drug consumption studies for attention-deficit/hyperactivity disorder (ADHD). The main purpose of the present study was to present the pattern and the evolution of national ADHD drug consumption in Slovenia. METHODS: The national consumption data for the period 2001-2012 and medication costs were obtained from the database of the Health Insurance Institute of Slovenia. A defined daily dose (DDD) per 1000 inhabitants per day and the total medication cost in euro were extracted. Only immediate-release methylphenidate (IR-MPH), methylphenidate-osmotic release oral delivery system (OROS-MPH) and atomoxetine (ATX) have been approved for ADHD in Slovenia and are included in this study. Amphetamines have not been available in Slovenia. RESULTS: ADHD drug consumption increased in Slovenia from 0.0537 DDD/1000 inhabitants/day in 2001 to 0.0687 DDD/1000 inhabitants/day in 2006 and to 0.3076 DDD/1000 inhabitants/day in 2012. The rise was largely because of an increase in OROS-MPH consumption and increase in ATX consumption, whereas the consumption of IR-MPH decreased rapidly. During the study period, the total cost of the medicines increased 31-fold. From 2007 to 2010, the total cost of ADHD medicines increased 14-fold and from 2010 to 2012 the cost increased by 11.4% only. CONCLUSIONS: When new drugs are licensed in a jurisdiction, their prescription rates increase rapidly. The changes in the pattern of prescribing medicines are evident in Slovenia, primarily in the increase of OROS-MPH and ATX prescriptions and in the rapid decrease of IR-MPH prescriptions. Results indicate a need for appropriate interventions in Slovenia.

Nature and impact of European anti-stigma depression programmes.

Stigma associated with depression is a major public health issue in the EU, with over 20 million people experiencing depression and its associated personal distress each year. While most programmes against stigma related to mental health problems are of a general nature, the knowledge about programmes tackling stigma against people with depression is limited. This study therefore aims to assess the nature and impact of depression-specific programmes in EU countries. Using a web-based tool, 26 programmes were identified across the 18 EU countries taking part in the study. Most were universal and targeted the whole population, while many also targeted specific population groups or settings, such as young people or health professionals. The most common programme aim was improving literacy, although reducing stigmatizing attitudes and discriminatory behaviour and promoting help-seeking were also common. Most programmes originated from professional bodies, or as grassroots initiatives from service user groups/NGOs, rather than as part of national and local policy. The approaches used were primarily different forms of education/information, with some, but very limited, use of positive personal contact. Overall, the quality and extent of impact of the programmes was limited, with few leading to peer-reviewed publications. Specific programmes were identified with evidence of positive impact, and we drew on these examples to develop a framework to be used for future programmes against stigma and discrimination associated with depression. These findings are provided in full in the Anti-Stigma Partnership European Network Toolkit available at www.antistigma.eu.

Barriers and errors in the implementation of community psychiatry in Slovenia.

Background Slovenian psychiatry is predominantly hospital based. A programme for the development of general community psychiatric services was proposed to improve access to and quality and comprehensiveness of psychiatric care according to the modern standards of delivery of psychiatric services. Aim The aim of the paper is to present the programme for developing community services that was proposed to the Slovenian government, and to describe the barriers to its implementation that were encountered, as well as the errors made by the programme authors, that contributed to the rejection of the programme last year. Conclusions There are historical, political, professional and service organisation characteristics that impede the development of community psychiatry in Slovenia. These are to be addressed through coordinated action involving primary care professionals, non-government organisations with service users and carers, the Health Insurance Agency and politicians involved in the planning of health services.

Time trends in prescribing habits of anxiolytics and antidepressants in Slovenian family practices (with emphasis on elderly patients).

The aim of the study was to investigate prescription of anxiolytics and antidepressants among Slovenian family physicians regarding drug class with an emphasis on the elderly population and possible time-trends. Exploratory survey and register-based analysis of anxiolytic and antidepressant prescriptions of one hundred family physicians in Slovenia was performed in 2005 and 2008. Drugs included in the study were classified according to the Anatomical-Therapeutic-Chemical (ATC) drug classification system, and ATC data were used to calculate defined daily doses (DDD) per 1,000 practice population per day. The most often prescribed anxiolytics and antidepressants were identified and anxiolytic/antidepressant ratio was estimation by patient age-group for the two studied years. Benzodiazepines showed highest share in the overall utilization of psychotropic drugs. The ratio between short- and long-acting benzodiazepines decreased by about one tenth during the observed period. Long-acting benzodiazepines were prescribed more often to the older patients. The decrease in anxiolytic/antidepressant ratio from 2005 to 2008 was the smallest in the elderly population. Further research is needed to ascertain the prescribers' attitudes in order to devise strategies to further improve prescribing performance in elderly patients.

Health-related lifestyle, physical and mental health in children of alcoholic parents.

AIM: To identify potential differences between children of alcoholics (COAs) and controls in their health-related lifestyle, mental and physical health. METHODS: The recruitment of COAs took place in inpatient and outpatient treatment and rehabilitation units. Controls were recruited in elementary and high schools. 57 COAs (72% response rate) and 84 controls (88% response rate) aged between 12 and 18 years completed a postal questionnaire about their health-related lifestyle, and mental and physical health. RESULTS: Bivariate analysis showed that COAs' families have higher unemployment rates and lower economic status (P = 0.000). COAs reported poorer school performance (P = 0.000), spending more time in sedentary (television: P = 0.000, Internet: P = 0.014, music: P = 0.040) and less time in physical activities (P = 0.048), having poorer eating habits (fruits and vegetables: P = 0.001, sweets: P = 0.001, fast food: P = 0.000, soft drinks: P = 0.004), a higher substance use (cigarettes: P = 0.030; marijuana: P = 0.564, heavy drinking: P = 0.050) and more mental health difficulties (emotional symptoms: P = 0.015, conduct problems: P = 0.012, suicidal tendencies: P = 0.007, mental disorder: P = 0.040). Among COAs, girls reported more emotional and somatic symptoms compared to boys (P = 0.020 and P = 0.047, respectively). Multivariate analysis showed that after controlling for socioeconomic status, significant mental health and health-related lifestyle inequalities between COAs and controls persist. CONCLUSION: Our findings suggest that COAs have a less healthy lifestyle and more mental health difficulties above and beyond the poorer economic environment they live in.

Prescribing changes in anxiolytics and antidepressants in Slovenia.

BACKGROUND: The ratio of anxiolytics to antidepressants is an indicator of the quality of treatment of depression and anxiety in primary care. The objective of the study was to investigate the prescription of anxiolytics and antidepressants among Slovenian family physicians, including patient demographics and possible time-trends. SUBJECTS AND METHODS: An exploratory survey and register-based analysis of anxiolytic and antidepressant prescriptions in 2005 and 2008 was performed. Drugs included in the study were classified according to an Anatomical-Therapeutic-Chemical (ATC) drug classification system, and ATC data were used to calculate defined daily doses (DDD) per 1,000 practice population per day. Descriptive analysis of anxiolytic/antidepressant ratio by patients' age, gender and region of residency was performed. RESULTS: Total amount of prescribed antidepressant drugs increased by 45% during the observed 3-year period, while total prescribing of anxiolytics decreased by 14%, leading to the anxiolytics/antidepressants ratio diminishing from 1 to about 0.5. The highest reduction in the ratio was observed in the northeast region, characterised by high social deprivation and one of the highest suicide rates in Europe. The highest prescribing of anxiolytics and antidepressants was observed in the central region around the capital Ljubljana. CONCLUSIONS: The reduction of anxiolytic prescribing and increase in antidepressant prescribing indicates improvement in prescribing practice of Slovenian family physicians. There are big variations in prescribing among different Slovenian regions, which are attributable to the number of psychiatrists and access to psychiatric treatment.

Suicide index reduction in Slovenia: the impact of primary care provision.

Background Education of primary care providers about diagnosis and treatment of depression and anxiety is an evidence-based suicide prevention measure.Aim To analyse suicide index, mental health epidemiological data and primary care provision in Slovenian regions and to identify examples of good suicide prevention practices in different Slovenian regions.Methods Analysis of existent epidemiological data on mental health in Slovenia.Results Anxiety and depression are the most common complaints in a representative sample of the Slovene population. The number of suicides in Slovenia had been dropping in the period from 2002 to 2006 and was again slowly rising in 2008. The number of visits to family physicians' practices because of mental health problems is low in comparison to other European countries, which might be attributed also to the high workload of family physicians. Suicide prevention programmes follow the example of the Suicide Prevention Project in the central-east region of Slovenia. This programme is based on education of primary care providers and the general public about recognition and treatment of depression in line with international guidelines.Conclusions The differentiation of causes for suicide reduction needs further research, as well as urgent improvement in the accessibility of primary care teams in Slovenia.

Prescription of benzodiazepines in Slovenian family medicine: a qualitative study.

INTRODUCTION: Previous quantitative research showed large variations in prescribing volume and prescribing patterns of benzodiazepines among Slovenian family physicians. We performed a qualitative interview study to investigate how high-prescribing family physicians explain their own prescription. METHODS: Five family physicians with benzodiazepine prescriptions in volumes larger than 4000 defined daily doses per month and five who prescribed volumes smaller than 2000 defined daily doses per month, selected randomly from the representative sample of Slovenian family physicians, were interviewed. Physicians' self-explanations about their daily decisions regarding benzodiazepine prescribing, patients' and practice characteristics and their attitudes towards patients were analysed. RESULTS: Family physicians were reporting about patients' needs and their demands, co-morbidity of older patients, previous good experience with benzodiazepines, concerns about decreasing dosage or discontinuation of benzodiazepines, high workload and time constraints, limited access to mental health workers and insufficient education and training. CONCLUSION: Family physicians consider the task of initiating, withdrawing or reducing benzodiazepines as demanding due to complexity of psychosocial problems, co-morbidity, workload, time-consumingness, need to master counselling skills, demands of their patients, particularly the long-term ones and due to low access to mental health services. The majority of family physicians agreed with restrictions in their prescription based on the guidelines.