Burnout syndrome among psychiatric trainees in 22 countries: Risk increased by long working hours, lack of supervision, and psychiatry not being first career choice.

BACKGROUND: Postgraduate medical trainees experience high rates of burnout, but evidence regarding psychiatric trainees is missing. We aim to determine burnout rates among psychiatric trainees, and identify individual, educational and work-related factors associated with severe burnout. METHODS: In an online survey psychiatric trainees from 22 countries were asked to complete the Maslach Burnout Inventory (MBI-GS) and provide information on individual, educational and work-related parameters. Linear mixed models were used to predict the MBI-GS scores, and a generalized linear mixed model to predict severe burnout. RESULTS: This is the largest study on burnout and training conditions among psychiatric trainees to date. Complete data were obtained from 1980 out of 7625 approached trainees (26%; range 17.8-65.6%). Participants were 31.9 (SD 5.3) years old with 2.8 (SD 1.9) years of training. Severe burnout was found in 726 (36.7%) trainees. The risk was higher for trainees who were younger (P<0.001), without children (P=0.010), and had not opted for psychiatry as a first career choice (P=0.043). After adjustment for socio-demographic characteristics, years in training and country differences in burnout, severe burnout remained associated with long working hours (P<0.001), lack of supervision (P<0.001), and not having regular time to rest (P=0.001). Main findings were replicated in a sensitivity analysis with countries with response rate above 50%. CONCLUSIONS: Besides previously described risk factors such as working hours and younger age, this is the first evidence of negative influence of lack of supervision and not opting for psychiatry as a first career choice on trainees' burnout.

EPA guidance on the role and responsibilities of psychiatrists.

Psychiatry is that branch of the medical profession, which deals with the origin, diagnosis, prevention, and management of mental disorders or mental illness, emotional and behavioural disturbances. Thus, a psychiatrist is a trained doctor who has received further training in the field of diagnosing and managing mental illnesses, mental disorders and emotional and behavioural disturbances. This EPA Guidance document was developed following consultation and literature searches as well as grey literature and was approved by the EPA Guidance Committee. The role and responsibilities of the psychiatrist include planning and delivering high quality services within the resources available and to advocate for the patients and the services. The European Psychiatric Association seeks to rise to the challenge of articulating these roles and responsibilities. This EPA Guidance is directed towards psychiatrists and the medical profession as a whole, towards other members of the multidisciplinary teams as well as to employers and other stakeholders such as policy makers and patients and their families.

Methylenetetrahydrofolate reductase gene variants and antipsychotic-induced weight gain and metabolic disturbances.

Weight gain and metabolic disturbances represent serious side-effects in antipsychotic (AP) treatment, particularly with clozapine and olanzapine. The methylenetetrahydrofolate reductase (MTHFR) gene is a key determinant in the folate metabolism and previous studies reported a significant effect on AP-induced weight gain and related metabolic abnormalities. Thus, we investigated MTHFR gene variants and changes in several important metabolic parameters in AP-treated patients. In this study, two functional MTHFR polymorphisms, rs1801133 (C677T) and rs1801131 (A1298C), were investigated for changes in weight and metabolic parameters. Genotypic associations were evaluated in a large population (n = 347 including 66 first episode psychosis, FEP patients) treated mostly with clozapine and olanzapine. We did not detect any genotypic association with weight changes (p > 0.05) in our total sample and in the sample refined for ancestry and medication. In our allelic analyses, we observed a trend for the 677-C allele to be associated with weight gain in the total sample (p = 0.03). This effect appeared to be driven by the FEP patients where those carrying the C-allele gained, on average, twice as much weight. Exploratory analyses revealed a significant association between the C677T and the A1298C polymorphism with HDL cholesterol serum levels in patients (p = 0.031). Overall we did not detect a major effect of two functional MTHFR gene variants and AP-induced weight gain. However, our findings suggest an effect of the C677T polymorphism in FEP patients and changes in weight and cholesterol levels. Further investigations in a larger sample are required.

Suicide ideators and attempters with schizophrenia--the role of 5-HTTLPR, rs25531, and 5-HTT VNTR Intron 2 variants.

AIM: To examine the role of 5-HTTLPR, rs25531 and 5-HTT VNTR Intron 2 variants in subjects with psychotic disorders manifesting suicide ideation and behaviour. METHODS: The study included 519 subsequently hospitalized subjects who were genotyped for 5-HTTLPR, rs25531 and 5-HTT VNTR In2 variants. Clinical assessments included structured psychiatric interview, sociodemographic characteristics, suicide ideation and behaviour (SIBQ), severity of psychopathology (PANSS) and depression (CDSS). RESULTS: Three subgroups were identified: suicide attempters (N = 161), suicide ideators (N = 174) and subjects who never reported suicide ideation or behaviour (comparative group, N = 184). MAJOR FINDINGS: 1) Suicide attempters scored highest on the CDSS, while no differences between the three clinical subgroups were detected in the PANSS scores; 2) Suicide attempters were more frequently the carriers of L(A) allele, while subjects in the comparative group were more frequently the carriers of low expression 5-HTTLPR/5-HTT rs25531 haplotype SL(G); 3) No difference was found between the three clinical groups in the 5-HTT VNTR In2 variants; 4) Subjects with 5-HTTLPR/5-HTT rs25531 intermediate expression haplotype (L(A)L(G,)SL(A)) scored higher on the PANSS general psychopathology subscale; 5) There was no association between suicide attempt or ideation and 5-HTTLPR/In2 or 5-HTTLPR/rs25531/In2 haplotype distribution. CONCLUSION: The suicide ideators, attempters and controls did not differ significantly in 5-HTTLPR or 5-HTT VNTR In 2 variants, but 5-HTTLPR/5-HTT rs25531 haplotype might be a useful genetic marker in distinguishing these three clinical groups.

Association study of MDR1 and 5-HT2C genetic polymorphisms and antipsychotic-induced metabolic disturbances in female patients with schizophrenia.

The objective of this study was to determine the association of 5-HT2C (serotonin 2C receptor) and MDR1 (multidrug resistant protein) genetic polymorphisms and antipsychotic-induced metabolic abnormalities among female patients with DSM IV schizophrenia spectrum disorders. We have previously reported the associations of -759CT 5-HT2C and G2677T and C3435T MDR1 genetic polymorphisms and olanzapine/risperidone-induced weight gain in a similar sample of patients. Here, we included a total of 101 previously non-medicated female patients treated with olanzapine/risperidone over a 3-month period. The variables analyzed included fasting glucose, total cholesterol, low-density lipoprotein, high-density lipoprotein and triglyceride levels in blood, blood pressure and waist circumferences. We observed significant association of -759T 5-HT2C genetic variant and greater increase in waist circumference (P=0.03), fasting glucose level (P=0.046) and triglyceride level (P=0.045) in blood after a 3-month period. The 2677T and 3435T MDR1 genetic variants were significantly associated with the greater increase in fasting glucose level in blood when patients were using olanzapine (P<0.001 and P=0.028, respectively). Our data indicate a possible influence of -759CT 5-HT2C and MDR1 G2677T and C3435T MDR1 genetic polymorphisms on the development of metabolic abnormalities among female patients treated with olanzapine/risperidone.

Metabolic syndrome in female patients with schizophrenia treated with second generation antipsychotics: a 3-month follow-up.

The objective of this study was to determine the occurrence of metabolic abnormalities among previously unmedicated female patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition schizophrenia spectrum disorders and their associations with olanzapine and risperidone treatment. We analysed 94 female patients who were treated with olanzapine or risperidone in the period of 3 months. Analysed variables included fasting glucose, total cholesterol, low-density lipoprotein (LDL), high-density lipoproteins and triglycerides in blood, blood pressure (BP), waist and hip circumferences and body mass index (BMI). At baseline, 14 patients (15%) fulfilled criteria for metabolic syndrome. After 3 months of treatment, 25 patients (27%) fulfilled criteria for metabolic syndrome, and their baseline BMI was the only predictor for its development. Treatment with both antipsychotics was associated with significant increase in waist circumference. Positive family history of diabetes mellitus contributed to a significant greater increase in abdominal obesity, significant higher baseline levels and a borderline significant increase in fasting glucose among olanzapine-treated patients. Olanzapine admission was associated with a significant increase in LDL and risperidone with a significant increase in triglycerides. Metabolic abnormalities seem to be more prevalent in unmedicated female patients with schizophrenia spectrum disorders than expected based on results in general population (adjusted for age and sex). Olanzapine treatment might induce significant alterations in metabolic profiles, especially among patients with positive family history of diabetes, mostly by inducing abdominal obesity. The association of risperidone application and increase in triglyceride level still needs to be determined.

[Hospitalization for systemic connective tissue diseases in Croatia in 1997: examples of the use of hospital morbidity registery data bases]. / Hospitalizacije zbog sistemskih bolesti vezivnoga tkiva u Hrvatskoj 1997. godine: primjer uporabe baze podataka registra bolnickog morbiditeta.

By using the explanatory analysis methods, we examined a possible model for the utilization of the Croatian Hospital Morbidity Register data for decision making in the managerial process for national health system development. To build a draft informational model, data were selected on 843 cases hospitalized in 1997 for diseases M30-M36 (ICD-10) in 45 health institutions. This was used as an index of the diagnostically/therapeutically most demanding group of rheumatic autoimmune diseases. Treatment standards were established for our health system for the patients having an M30-M36 disease by classifying Croatia's health institutions into four clusters by intensity of hospitalization, and by analyzing demographic characteristics and the length of stay by disease entity. These standards could represent a good informational base for forming consensus group panels to deal with inpatient treatment problems of patients with systemic connective tissue diseases.

Bed utilization performances of Slovenian and Croatian acute hospitals systems.

With Barber-Johnson-Yates scattergrams (BJYS), the performances of Slovenian and Croatian acute hospital system were explored by taking turnover interval as a predictor variable, length of stay as a dependent variable, and by looking at the variables of bed throughput and percentage of bed emptiness on installed network. The growing influences on the Slovenian hospital system of a cost-containment policy and of the past war on the Croatian hospital system are the best illustrations of the informatics potential inherent in BJYS presentations for the exploratory data analysis (EDA) used to identify systematic relations between variables in a setting of not complete a priori expectations of these relations.

Doctor in the house: trends in GPs home visiting in Croatia 1990-1995 compared to current trends in USA and UK.

During the period of intensive economic, political and epidemiological transition in Croatia (1990-1995), significant changes in patterns, intensity and organization of home visiting were registered and reported. Quantitative instruments were employed to determine changes in trends of financing, health manpower policy and use of services before and after 1993 health care reforms. The qualitative part of research (e.g., cross-sectional and cross-national comparison of trends) was used to compare the significance of a reduction in the number of home visits as well as how its pattern fitted into the international trends (outburst of home visits in the USA and stagnation or decrease in the UK).

[Barber-Johnson analysis of bed utilization in hospital-based health care in the Croatian Republic during peace and war:1986-1991]. / Barber-Johnsonove analize koristenja kreveta u sustavu stacionarne zdravstvene zastite Republike Hrvatske u mirnodopskim i ratnim uvjetima: 1986-1991. godine.

Intensity of bed utilization in Croatia's hospitals in the peace-time period 1986-90 and the war year of 1991 was evaluated. The study covered 32 general-and-teaching hospitals disposing with 21,300 beds in 1986-90 and 27 of these hospitals with 19.000 beds in 1991. Basic information derives from hospital's statistical reports analyses by the Barber-Johnson's technique. While length of stay was reduced in the 1986-90 period, average number of discharges and deaths per available beds increased (1986/26.1; 1990/26.9). In the peace year of 1990 the performances of 11 of the 32 hospitals grouped in a zone limited to 10.0-12.9 days for the length of stays and 1.1-2.5 days for turnover interval. In the war year of 1991 the performances of 10 of the 27 hospitals were grouped in a zone defined by 8.5-10.9 days for length of stay and by 3.1 and 6.2 days for turnover interval. The Barber-Johnson's analysis provides key information in the decision making about hospital beds utilization, as well as in the evaluation of such decisions.

Fatalities in the war in Croatia, 1991 and 1992. Underlying and external causes of death.

OBJECTIVE: To show the underlying and external causes of death and selected characteristics of those killed in the war in Croatia between March 1991 and December 1992. DESIGN: Analysis of 4339 fatalities recorded on two national mortality statistics documents that specified war operations as the cause of death: a demography mortality statistical form and a death certificate. MAIN OUTCOME MEASURES: The frequency of clinical causes of death and their association with methods of wounding, length of survival, and attendant diagnoses. RESULTS: Half of those killed were men aged 21 to 35 years. Among women killed, the majority were aged 61 to 75 years. Skull fracture with intracranial injuries was the leading cause of death (28.9%), followed by multiple traumas and injuries of unspecified site (17.9%), and thoracic wounds with lung and heart injuries (17.6%). The most common methods of wounding were bombs and fragments of other explosive devices involving 1907 persons (43.9%), followed by deaths from bullet wounds (33.0%). More than 50% of those killed had sustained multiple injuries. In 78.6% of the cases, death immediately followed the wounding.

A profile of NFP acceptors in Egypt.

PIP: A follow-up studies of Egyptian women who attended a class on natural family planning indicates that the women who completed the course and were motivated to avoid or delay pregnancy were successful at it. Begun in 1982, the Natural Family Planning (Billings)/Egypt (NFPB/Egypt) program offers training in the Ovulation (Billings) Method, which can be used to both achieve and avoid pregnancy. To complete the course, women needed to have charted 6 menstrual cycles. In 1985, the program decided to conduct a follow-study, and it contacted 203 of the approximately 500 women who had attended at least some of the classes. Of the 203 women, 41% (84) had taken the classes to achieve pregnancy, 18% (36) to space or delay pregnancy, and 41% (83) to avoid pregnancy. 76% of this group had actually completed the course. While 15 of the women who had dropped out of the course did so because they had become pregnant, all of the unwanted pregnancies in this group were among women who were breastfeeding or in the post-pill period. Among the women who had finished the course and whose aim was to delay or avoid pregnancy, 8 had become pregnancies, but 4 of the women said that they had in fact wanted the pregnancy. The other 4 were unwanted pregnancies. NFPB/Egypt also conducted interviews with 25 of the women. 19 of them continued to use the Billings Method, 13 of whom were using it to avoid pregnancy. Of the 6 women no longer practicing the Billings Method, 3 had had an IUD inserted, and the other 3 were trying to achieve pregnancy.^ieng