Psychiatric wards in general hospitals - the opinions of psychiatrists employed there. / Oddzialy psychiatryczne w szpitalach wielospecjalistycznych - opinie zatrudnionych w nich psychiatrów.

OBJECTIVES: The world literature is reporting economic destabilisation of psychiatric wards in general hospitals related to the new rules of financing (managed care). The aim of this paper is to analyse the literature on psychiatric wards in general hospitals, and to know the opinions of psychiatrists employed in these wards in Poland regarding organisational model and the stability of these wards. METHODS: The 18-items Likert-type questionnaire was send to 83 psychiatric wards in Poland and published on the website psychiatria.pl. RESULTS: 50 psychiatrists from psychiatric wards in general hospitals in 11 provinces had responded. The prevailing number of respondents positively assessed: the organisational model of the ward, implications for therapy arising from its location in the general hospital and the relationships with colleges of other specialties. However, they assessed negatively: the working conditions, stability of employment, the mode of treating the psychiatrists by the management of the hospital, and the interest of the authorities in these wards. The majority of respondents (72%) prefer to work in integrated stationary/ambulatory services, and postulates (86% of respondents) that the psychiatric wards in general hospitals should be guaranteed permanent status in the mental health system. CONCLUSIONS: The psychiatrists employed in the psychiatric wards in general hospitals in Poland evaluate this organisational model positively. However, the destabilisation of economic foundations of these wards reported in the world literature was also reflected in the results of a survey conducted in Poland. There is a need to develop standards for the organisation and financing departments of psychiatry in general hospitals providing them stable status in the healthcare system in Poland.

Acute psychosis in the course of treatment of acute adrenal crisis with hydrocortisone in the patient with secondary adrenal insufficiency - a case study.

OBJECTIVES: Presentation of the risk of psychosis induced by the treatment of adrenal crisis with high doses of hydrocortisone. METHODS: A case analysis in the context of the literature. RESULTS: There are reported psychoses in the patients with adrenal hypofunction and hyperfunction. Psychoses following implementation of substitution with small doses of corticosteroids due to adrenal insufficiency were also observed. The hypereactivity of the glucocorticoid receptor is supposed mechanism. We have not found any description of psychosis connected with steroid administration in adrenal crisis. We present a case of 55 years old female, so far mentally healthy with untreated adrenocortical insufficiency secondary to radiotherapy of pituitary adenoma (prolactinoma) performed 3 years ago. She was admitted to the hospital because of acute adrenal crisis provoked by infection. In the fourth day of treatment with intravenous Hydrocortisone (up to 400mg/24 hours) there occurred acute psychosis with hallucinations, delusions and life-threatening behaviours. The patient was admitted to the psychiatric inpatient unit. Following 3 days of treatment with haloperidol, and decreasing the steroid dosage - the psychosis disappeared, without recurrence, despite of discontinuation of haloperidol. CONCLUSIONS: The case focuses attention on the risk of psychosis connected with the treatment of the adrenal crisis with high doses of Hydrocortisone. Because of the risk of psychiatric complications, the patients treated with high doses of corticosteroids, require an evaluation of risk factors for mental disturbances, and safety precautions in cooperation of endocrinologist and psychiatrist.

Depression in Parkinson's disease: the effectiveness and risk of pharmacotherapy. Clinical review.

Parkinson's disease (PD) is a neurological disease with a heterogeneous pattern of neurological symptoms and concomitant psychiatric syndromes. These syndromes are triggered by alterations to neurotransmission that are likely common for both neurological and psychiatric symptoms. Syndromes such as depression, anxiety, or cognitive impairment can precede motor symptoms of PD and delay its diagnosis. Recently, questions related to aetiological factors and treatment strategies of depression in PD have become a growing concern of PD researchers. This article describes the main features of depression in PD and presents current hypotheses on its aetiology and recommended treatment modes.

Bupropion in the treatment of depression in Parkinson's disease.

A 78-year-old female with a nine-year history of depression was hospitalized due to worsening depression and symptoms associated with Parkinson's disease (PD). Her motor abilities improved on levodopa and the depression improved after a trial of bupropion, following unsuccessful treatment with other antidepressants. We found four reports on successful treatment of depression in PD with bupropion. However, no controlled double-blind studies have been conducted so clinicians should be cautious when administering bupropion in depression in PD.

[The level of cortisol, DHEA, DHEA-s in plasma serum and the connection with the lipids and response to treatment in women with depression]. / Poziom kortyzolu, dehydroepiandrosteronu i jego siarczanu (DHEA i DHEA-S) w surowicy krwi a obraz lipidogramu i reakcja na leczenie u kobiet z depresja.

UNLABELLED: In depression an increase, decrease, or a relative deficiency of dehydroepiandrosterone (DHEA) and the beneficial effects of its administration were observed. The correlation of low serum DHEA level and increased cardiac risk was confirmed in healthy subjects only in men (not in women). Taking into consideration the increased risk of heart disease in depression, it is interesting to investigate the level of DHEA, DHEA-S, and cortisol, as so its correlation with lipid profile, and reaction to treatment in women with depression. AIM: To assess serum ACTH, cortisol, DHEA and DHEA-S, and their relationship with lipid profile in depressed females, including the treatment response and stress load. METHOD: In 11 healthy females and 18 with depression, the following were examined before and after treatment: the severity of symptoms (on the Hamilton and Beck Inventory Depression scale), serum cortisol, DHEA, DHEA-S, and lipidogram. The results were compared in healthy and depressed females, and in relation to the therapy and stress load. The correlation of DHEA, DHEAS, and cortisol with lipid profile was analysed. RESULTS: In females poorly responsive to antidepressant treatment higher serum cortisol, ACTH and DHEA. The lipid profile did not vary in the depressed and healthy females. Serum DHEA correlated negatively with serum cholesterol (total and LDL fraction) in healthy women but not in depressed women. CONCLUSIONS: DHEA deficiency and the rationale for its supplementation were not confirmed in depressed women. The protective action of DHEA to hypercholesterolemia was confirmed in healthy, but not in the depressed women.

[Dissociative fugue in a maternity ward patient--a case report]. / Fuga dysocjacyjna u pacjentki oddzialu polozniczego--studium przypadku.

AIM: To pay attention to the role of stress connected with delivery, obstetric history, as to the pathologies in the infant as predictors of dissociative disturbances in the patient of the maternity ward. METHOD: The case analysis. CASE DESCRIPTION: The thirty-year-old woman with secondary education, married and employed had left the maternity ward with her baby unnoticed on the fourth day after giving birth. The patient didn't remember this fact after finding her and the infant by the police. The patient had no genetic predisposition in her history and had suffered head injury in her childhood. Her mother lost two of her siblings (miscarriage and early death of infant). The patient miscarried her first pregnancy, and then she had waited several years for the baby. The second pregnancy was at risk, the labor was premature and the infant was born with palatoschisis. In the maternity ward, the patient had difficulties with feeding the baby. She experienced fear about the baby's life, as well as the feeling of being neglected by the staff. In the psychiatry ward, the patient did not reveal any symptoms of mental illness. A memory gap covered the period of her flight. She had shown interest in her child and was motivated to nurse him by herself. The tendency to use immature defence mechanisms (denial and suppression), as well as mild cognitive dysfunctions were observed in psychological testing. Dissociative fugue was diagnosed. CONCLUSIONS: The interaction of past and present traumatic experiences with cognitive dysfunctions and immature defence mechanisms could influence the patient's ability to cope with fear about the child negatively. It led consequently to dissociative loss of memory with disintegration of perception, identity, and conscious control over the behaviour in the fugue. The case shows a need for early diagnosing and providing psychological support to patients of the maternity ward, especially those laden with multiple stress factors.

[MORS--the stationary model centre of sociopsychiatric rehabilitation for youths--the program and evaluation]. / Modelowy Osrodek Rehabilitacji Socjopsychiatrycznej dla mlodziezy--MORS--program i badania ewaluacyjne.

INTRODUCTION: The psychosocial consequences of psychosis in the youth are educational negligence's, poor peer relations and difficulties in achieving life independency. MORS--the Stationary Model Centre of Sociopsychiatric Rehabilitation was created for overcoming these problems. AIM: To present the programme of rehabilitation and its effects in MORS. METHOD: The evaluation was performed in 18 of the 26 young persons being admitted to MORS in the years 2006-2008. Structured Questionnaires of past history for the staff and clients, the SOC-29 and KIDscreen -52 scales were used. RESULTS: A significant number of young people from incomplete families, and/or families burdened with parental mental health problems was noticeable. The best effects were achieved in compensating for educational negligence's, and improving the social and life skills. The self estimation of health and life satisfaction was lower in the youth clients on discharge from MORS than in the general population. CONCLUSIONS: According to retrospective evaluation, the stationary programme of psychosocial rehabilitation in MORS seems to be effective in youths with psychotic disorders and difficulties in social functioning. Further development, and prospective evaluation of that programme would be valuable. Social support in local communities for the youth being discharged from MORS is needed.

[Dehydroepiandrosteron (DHEA) in the mechanisms of stress and depression]. / Dehydroepiandrosteron (DHEA) w mechanizmach stresu i depresji.

There is growing interest in the role of Dehydroepiandrosteron (DHEA) in depression. To evaluate the validity of its administration in depression, the role of DHEA in the mechanism of depression and cardiovascular risk, as so the results of clinical trials must be considered. According to accessible literature, both concepts of depression--monoaminergic and glucocorticoid--are related. The key role may be played the impairment in regulatory function of monoaminergic, glucocorticoid and GABAergic receptors in the limbic area of the brain, caused by a genetic factor or acquired by stress. Consequently even weak stimulation could lead to inefficiency of the Limbic- hypothalamic-pituitary-adrenal (LHPA) homeostasis, with overproduction of cortisol. The excess of cortisol is facilitating the development of depression by damaging the limbic, especially hippocampal neurons. Furthermore, the cortisol is increasing cardiovascular risk by its atherogenic properties. The DHEA, because of its antiglucocorticoid activity is supposed to be a protective factor against depression and cardiovascular risk. Positive effects of administration of DHEA in depression were observed in clinical trials. However the results of estimation of DHEA and SDHEA in the blood of depressed patients were inconsistent. In animals, administration of high doses of DHEA was decreasing the experimental atherogenesis. However the investigation in numbered human populations showed correlation of increased level of DHEA with a decreased risk of cardiovascular disorder in men--but not in women. Further research on relation between depression, DHEA and cardiovascular risk, with special concern upon the differences in men and women is needed.

[Evaluation of the ICAR program--Internet communication and active rehabilitation for people with mental disorders]. / Ocena programu ICAR--"komunikacja w internecie i aktywna rehabilitacja dla psychicznie chorych".

UNLABELLED: Prevalence of Internet use indicates, that introducing internet to people with mental disorders might have a positive impact on their social integration. There are concerns about negative effects of dealing with virtual reality on the mental health of Internet users. AIM: Evaluation of the ICAR program--"Internet communication and active rehabilitation for people with mental disorders" concerning its utility in psychiatric rehabilitation. METHOD: 22 participants of the ICAR programme and 22 controls (people with mental disorders not participating in the programme) were investigated before and after the completion of the programme. There following were compared: their computer and Internet use skills, social functioning (Birchwood Scale), self-estimation of the mental health (Frankfurt Scale FBS), self-reported quality of life (WHO QOL BREV) and number of psychiatric hospitalisations during 11 months of the observation period. RESULTS: Among participants, their reported skills and motivation increased significantly following the programme. During 11 months of the observation there were less hospitalisations (1 fulltime and 1 daily) in the study group than in the control group (3 and 1). An increase of symptoms was observed in the Frankfurt Scale in 10 participants and 13 controls. The level of social functioning and severity of symptoms was not significantly different and did not change during observation. The self-reported quality of life increased in both groups during this period. CONCLUSIONS: ICAR training programme for the mentally ill, increases participants skills and motivation towards computer and Internet use, as well as their self-reported quality of life. The participation in the programme doesn't have any significant effect on the overall social functioning and number of psychiatric hospitalisations during the 11 months of observation. A positive effect of the ICAR programme on the quality of life, as well as some activating effect leading to exacerbation of the psychopatological symptoms--has an unspecific character and is therefore similar to the other community rehabilitation programmes. Wider spreading of computer training workshops similar to the ICAR programme might have a positive effect on social integration of people with mental disorders.

[Personality and behavioural disturbances, with delusional-hallucinatory and delirium episodes in the course of hyponatremia due to paraneoplastic inappropriate vasopressin secretion (SIADH)]. / Zaburzenia osobowosci i zachowania oraz epizody urojeniowo-omamowe i zaburzen swiadomosci w przebiegu hiponatremii wywolanej paranowotworowym nadmiernym wydzielaniem wazopresyny (SIADH).

AIM: To broaden the knowledge about somatic mechanisms of psychic disturbances. METHOD: Presentation of a 54 year old male with psychic disturbances and hyponatremia. RESULTS: After six months with head ache, nausea, exhaustion, irritability, lacking drive, and appetite--acute psychic disturbances abruptly arose. These recurrent episodes with agitation, aggression, delusions, hallucinations, sometimes--disorientation and memory loss; appearing simultaneously with hyponatremia (Na in blood 104-118 mEq/L); were classified as organic delusional disturbances, and (in case of disorientation and memory loss) as delirium (F06.2, F05 - in ICD-10). The symptoms were manifested for 6 months and were classified as personality disturbances due to brain dysfunction (F07.8 in ICD 10). The acute psychic disturbances interrupted the hospitalization in the medical ward, twice and caused three psychiatric hospitalizations; until the diagnosis of hyponatremia in the course of inappropriate vasopressin secretion (SIADH), due to small cell carcinoma of the left lung was established. CONCLUSION: The SIADH syndrome with hyponatremia, and polymorphic psychic disturbances had preceded the clinical and radiological manifestations of the hidden development of left lung small cell carcinoma for a long time. The legitimated involuntary admission to a psychotic ward in a general hospital with easy access to specialized laboratory tests and consultations facilitated establishing the diagnosis. The restriction of water administration with oral salt supplementation stabilized the psychic state and enabled treatment in the Institute of Oncology. The case illustrates the complicated somatic mechanisms of psychic disturbances and the necessity of multi-specialist cooperation in the border area between psychiatry and other medical disciplines.

[Social support of chronically mentally ill patients]. / Wsparcie spoleczne pacjentów przewlekle chorych psychicznie.

AIM: Assessment of the social support system of mentally ill persons covered by a local rehabilitation programme situated in Targówek, Warsaw. METHOD: The sample consists of 92 participants with serious mental illness. Bizon's Social Support Inventory and Social Support Map were used. RESULTS: Patients' social networks were small (9 persons in average) but had a broad scope of functions. Therapists from community rehabilitation services constitute the biggest group of persons included in the individual network of social support. Lack of emotional support is observed. CONCLUSION: Participation in a local system of rehabilitation improves the quantity and quality of individual systems of social support.

Implementation of social services for the chronically mentally ill in a Polish mental health district: consequences for service use and costs.

BACKGROUND: In accordance with the mental health reform in Poland, from 1970 to 1980 the following mental health facilities were established within the general health system in the Warsaw District of Targowek: general hospital psychiatric ward, day hospital, outpatient clinic (OC), and community mobile team (CMT) with some procedures of assertive community treatment (ACT). In 1998 (according to the Mental Health Act of 1994), within the social welfare system, new community facilities were established in this district with psychosocial rehabilitation programs for the chronically mentally ill. These new social welfare facilities were a vocational rehabilitation center (VCR), community center of mutual help (CCOMH), and specialized social help services at client homes (SSHS). AIM OF THE STUDY: To determine the change of care delivered to chronic psychiatric patients in both the mental health and social welfare systems, and to compare the costs of care during two 2-year periods: before (Period A) and after (Period B) the 1998 implementation of the new social welfare facilities in the Warsaw District of Targowek. METHODS: The sample consisted of 73 chronic psychiatric patients, admitted since 1998 to the new social welfare facilities. The authors evaluated and calculated the costs of the patients' use of mental health facilities during the two years before their first admission to VCR, CCOMH or SSHS in 1998 (Period A: 1996-1998) and their use of mental health and social welfare facilities during the two years after their admission to VCR, CCOMH or SSHS in 1998 (Period B: 1998-2000). RESULTS: In this group of chronic patients, during Period B, the total duration of both full and partial hospitalizations decreased (-75.9% and -78.9% respectively), while the total number of outpatient mental health visits went up (+62.9%). In Period B the new social welfare facilities offered a substantial amount of day care and the global amount of supplied day care increased markedly. The total costs of the mental health system significantly decreased in Period B (-65.7%), but new costs emerged in the social welfare system. Taken together, the total costs of care provided by the two systems in Period B were higher than the costs incurred by the mental health system alone in Period A (+33.9 %), but the increase in the total amount of services delivered was also relevant (+98.3%). The "out of pocket" expenses incurred by patients increased in Period B (+13.9%). DISCUSSION: The activity of the new social welfare facilities (VRC, CCOMH, SSHS) seems to reduce both full time and partial hospitalizations. Despite the increasing costs of medication reimbursement, and the increased use of CMT and OC, the overall costs for the mental health system were substantially reduced. The decrease in day hospital use is probably due to the large amount of daily social support and home services offered in VRC, CCOMH and SSHS. The results emphasize the importance of evaluating the coordination of care for chronically mentally ill patients in the mental health and social welfare systems.

[The influence of community support services on the costs of treatment of chronically mentally ill patients]. / Znaczenie srodowiskowych placówek wsparcia spolecznego dla kosztów leczenia osób przewlekle chorych psychicznie.

AIM: To determine changes in costs of treatment for chronically mentally ill patients after their admittance to new social help units; Vocational Rehabilitation Center, Community Center of Mutual Help and Specialised Social Help Services at Client's Home. METHOD: In the group of 73 chronically mentally ill persons, for two years before and after their admission to social help units, the global amount of care (months x persons) and all the costs (PLN) in both social help and mental health systems were compared. RESULTS: For two years after the admission to the mentioned services all the costs in mental health system were significantly decreasing (71.9%), but new costs in social welfare system emerged. The overall costs of care were higher than before, but the elevation (35.4%) of all the costs was not so high as the increase (99,3%) of the care. The structure of care was improved (more day-, and less stationary care). The "out of the pocket" expenses for patients increased. CONCLUSIONS: The implementation of social help services for chronic mentally ill patients is reducing the amount of stationary and day treatment, but increasing active community treatment. Money in the health system is saved, but all the expenses on community care are increased. Coordination of care and finances between the mental health and social welfare is needed. Common financing for both systems is questionable because of impending over medicalisation. The allocation of money saved to early rehabilitation in schizophrenia would be profitable in the future.

[Specifics of working with chronic mentally ill patients in Specialised Social Help Services--experiences in training and supervision meetings]. / Specyfika pracy z przewlekle chorym psychicznie w ramach psychiatrycznych specjalistycznych uslug opiekunczych--doswiadczenia ze spotkan superwizyjnych.

Information was presented on the development and efficiency of The Specialised Psychiatric Social Help Services for the mentally ill in Poland. It took into consideration the specifics of this work and formal requirements for special training of the staff. The experiences of the 3.5 years of work of the specialised services in the Warszawa Targówek district (October 1997 - June 2001) were discussed. Organisational solutions and basic data about clients and staff and establishments and experiences coming from training and supervision meetings were discussed. Problems and difficulties most often experienced by the staff workers at their work with chronic mentally ill patients were described. Consideration was put from one side on the big rotation of the staff and from the other on the need of the extension of the theoretical and practical knowledge as well as of supervision and support was often mentioned in the questionnaire. A need of elaborating the programme of training and professional courses for workers of the specialised psychiatric social help services was also pointed out.

[The importance of community services for rehabilitation and social support to decrease psychiatric hospitalization]. / Znaczenie srodowiskowych placówek rehabilitacji i oparcia spolecznego dla ograniczenia hospitalizacji psychiatrycznych.

GOAL: The evaluation of community services for social support concerning minimalization of psychiatric hospitalizations. METHOD: Mean duration, global time and the number of stays in hospital ward, day treatment ward and "home hospitalisation"; in two year periods before and after their admission to an Occupational Therapy Workshop (O.T.W.), a Community Home Of Mutual Help (C.H.O.M.H.) or to Community Specialised Social Help Services (C.S.S.H.S.) at home were compared in the group of 73 chronic patients. RESULTS: In two years after the admission to the social support units, the number of all the hospitalizations was decreased (twice or three times). A mean duration of stay in the hospital ward and in the day treatment ward shortened (from 101 days to 48.4 days, from 108 days to 73.3 days), and "home hospitalisation" prolonged (from 112 days to 190 days). The global time of stay in the hospital and in the day ward became significantly shorter (by 12.2% and 5.1%), but "home hospitalisation" did not change significantly. The most effective was the care of specialised services at home connected with the participation at the same time in one of the day units O.T.W. or the C.H.O.M.H. (16 persons). The minimalization of the number (3x) and the time of staying in the day treatment ward referred to the participants of the O.T.W. or the C.H.O.M.H. (by 7.2%, 7.9%), but not of the C.S.S.H.S. at home. CONCLUSIONS: Introducing of O.T.W., C.H.O.M.H. and C.S.S.H.S. resulted in a significant reduction of hospital stays. The best results come from the combination of the care given by the daily units (O.T.W. or C.H.O.M.H.) with specialised services at home. The care supplied at the O.T.W. or the C.H.O.M.H. reduced the number and time of staying in the day treatment ward.