The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment.

AIMS: A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. METHODS: This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). RESULTS: We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys.

BACKGROUND: To examine cross-national patterns and correlates of lifetime and 12-month comorbid DSM-IV anxiety disorders among people with lifetime and 12-month DSM-IV major depressive disorder (MDD). METHOD: Nationally or regionally representative epidemiological interviews were administered to 74 045 adults in 27 surveys across 24 countries in the WHO World Mental Health (WMH) Surveys. DSM-IV MDD, a wide range of comorbid DSM-IV anxiety disorders, and a number of correlates were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: 45.7% of respondents with lifetime MDD (32.0-46.5% inter-quartile range (IQR) across surveys) had one of more lifetime anxiety disorders. A slightly higher proportion of respondents with 12-month MDD had lifetime anxiety disorders (51.7%, 37.8-54.0% IQR) and only slightly lower proportions of respondents with 12-month MDD had 12-month anxiety disorders (41.6%, 29.9-47.2% IQR). Two-thirds (68%) of respondents with lifetime comorbid anxiety disorders and MDD reported an earlier age-of-onset (AOO) of their first anxiety disorder than their MDD, while 13.5% reported an earlier AOO of MDD and the remaining 18.5% reported the same AOO of both disorders. Women and previously married people had consistently elevated rates of lifetime and 12-month MDD as well as comorbid anxiety disorders. Consistently higher proportions of respondents with 12-month anxious than non-anxious MDD reported severe role impairment (64.4 v. 46.0%; χ 2 1 = 187.0, p < 0.001) and suicide ideation (19.5 v. 8.9%; χ 2 1 = 71.6, p < 0.001). Significantly more respondents with 12-month anxious than non-anxious MDD received treatment for their depression in the 12 months before interview, but this difference was more pronounced in high-income countries (68.8 v. 45.4%; χ 2 1 = 108.8, p < 0.001) than low/middle-income countries (30.3 v. 20.6%; χ 2 1 = 11.7, p < 0.001). CONCLUSIONS: Patterns and correlates of comorbid DSM-IV anxiety disorders among people with DSM-IV MDD are similar across WMH countries. The narrow IQR of the proportion of respondents with temporally prior AOO of anxiety disorders than comorbid MDD (69.6-74.7%) is especially noteworthy. However, the fact that these proportions are not higher among respondents with 12-month than lifetime comorbidity means that temporal priority between lifetime anxiety disorders and MDD is not related to MDD persistence among people with anxious MDD. This, in turn, raises complex questions about the relative importance of temporally primary anxiety disorders as risk markers v. causal risk factors for subsequent MDD onset and persistence, including the possibility that anxiety disorders might primarily be risk markers for MDD onset and causal risk factors for MDD persistence.

Evolution of the mental health care system in Poland.

OBJECTIVE: The aim of this paper is to trace evolution of mental health system in Poland. METHOD: Available Polish literature and fundamental policy documents including mental health legislation are reviewed and major milestones in this evolution identified and then discussed against the background of political and social developments. RESULTS: The mental health system evolved since the beginning of the 1970s from large hospitals towards community-based care. It was found that the changes were rather slow due to financial shortages and lack of clear demand from users. Recent transitions offer opportunities to increase impact of users and their families. On the other hand, however, introduction of health insurance system reduces prospects for well co-ordinated mental health policy and may lead to inequalities in access to services. CONCLUSION: It can be concluded that evolution of mental health services has been influenced by prevailing ideologies as much as by technical and professional considerations.

Malczyce, Poland: a multifaceted community action project in eastern Europe in a time of rapid economic change.

The major focus of this paper is the sustainability of a one-year demonstration project on drug misuse prevention, which was implemented in a local community affected by acute economic crisis and high unemployment. The project was initiated by the Institute of Psychiatry and Neurology, and supported by the European Commission. The primary goal of the project was to demonstrate that community-based prevention is possible and feasible within the context of current transitions in Poland. Its major outcome was a community prevention package consisting of a number of booklets and videos to assist other communities in their prevention efforts. Experiences from this study suggest that factors contributing to the sustainability of a community prevention project can be identified and emphasized through simple analysis of community surveys, as well as focus group discussion.

The supply of alcoholic beverages in transitional conditions: the case of Central and Eastern Europe.

Three periods are distinguished and applied to describe the dynamics of changes in the system of supply of alcoholic beverages in Central and Eastern Europe since 1980. The distinction of these three periods is based on changes in the regulation of the supply. The period of the old regulation ended in most countries around the 1990s. A deregulation took place in the early 1990s. The first steps toward a reregulation were visible in attempts to create a new order in the alcohol market in the last years of the 1990s. The analysis builds mainly on developments in Poland and Russia, with more scattered information from other countries. In each period the role of different actors (the state, the enterprises, organized crime, civil organizations and individuals), different interests (economic development, state finances, political order, public order, public health and various symbolic interests) and different public measures to regulate the supply (licensing, taxation and preventive actions and treatment) are considered. The analysis shows how the state lost its dominant position to private firms and is slowly regaining it again, how interest in state finances, overall economic development and later in profit-making dominate all three periods, and how the old system of regulations was ruined, to become rebuilt in very small steps with many conflicts and complications. Public health interests and also civil society interests were weak in comparison with economic interests. From the public health perspective, changes in the supply system have had significant consequences, but a more comprehensive regulation of supply does not necessarily lead to diminished alcohol-related harm.

Alcohol misuse as a health and social issue in the Baltic Sea region. A summary of findings from the Baltica Study.

The Baltic Sea region today is a scene of a double transition: the eastern transformation and the western integration. As a consequence, alcohol-related issues are undergoing extensive changes. As part of a study of prevalence and perception of social problems around the Baltic Sea (the Baltica Study), alcohol issues have been studied from four perspectives: official statistics, mass media, public opinion and views of influential groups. The Baltic Sea region contains countries from the top and from the bottom of the European statistics on alcohol consumption (Latvia and Sweden respectively). Alcohol has been an important political issue in the transition of many countries (Russia and Poland just before the transition, Sweden and also Finland in their processes of European Union integration). For the medically oriented alcohol research community, the most important finding is that the medical profession and medical and epidemiological arguments play a secondary role in most of the countries when it comes to the definition of the problem.

What does science have to say?

This plenary session had particular character. Ten representatives of the research world briefly presented what science has to say on different aspects of alcohol policy. Major research-based generalizations from a variety of policy experiences were brought to the discussion. The panel's composition reflected the global map of alcohol studies; the group consisted of four people from English-speaking countries, four from northern Europe and the Nordic countries and two from the Mediterranean part of Europe. The session focused on population-orientated strategies including political and economic controls on the availability of alcohol, advertising and public information campaigns. There was discussion of drink driving measures, and of how individual treatment interventions relate to the broad field of public health. Contributions from the world of nutrition and tobacco control policy were also drawn into the debate.

[Mortality of narcotic addicts using injections]. / Umieralnosc osób uzaleznionych od narkotyków przyjmowanych w iniekcjach.

The paper presents and discusses results of a longitudinal study on mortality of injecting drug users from detoxification unit of the Institute of Psychiatry and Neurology, Warsaw, Poland. The study was a part of an international project initiated by the World Health Organization and co-ordinated by Department of Epidemiology Lazio Region, Rome, Italy. Nine centers from six countries participated in the project. All infecting drug users attending treatment in the 1983-1992 period were enrolled. In Warsaw cohort, direct mortality rate for men was 25.7 per 1000 person-years and 14.3 per 1000 person-years for women. As compared with general population the risk of death was 11 times higher among males and 20 times higher among female drug users. Poisson's regression model showed that risk of dyeing (rate ratio) is particularly high during first year after last treatment. Almost 40% of deaths were classified as sudden deaths, cause unknown (code 798 of ICD IX) while close to one third as injuries and poisonings (800-999).

Lessons to be learnt from Poland's attempt at moderating its consumption of alcohol.

This paper analyses the interplay between alcohol policy and research in Poland during the last two decades. It was a period of profound political and economic changes that strongly influenced the alcohol scene. In the 1970s alcohol was treated as a secret issue. Despite a rapid growth of alcohol consumption neither the authorities nor media expressed any concern about the growing wave of related problems. Funding allocated to research was very low and only a few devoted individuals continued their studies, albeit on a reduced scale. The beginning of the 1980s saw a sudden politicization of the alcohol issue. The government was blamed for pushing alcohol. In response to this challenge, alcohol controls were tightened. A huge programme of alcohol research was initiated to accumulate knowledge and evidence for further alcohol policy, as well as to symbolize a high priority of the alcohol issue. In following years, however, the political significance of alcohol decreased. The system established for its control was eroded, and finally collapsed in the late 1980s and early 1990s. The huge research evidence that was accumulated during the 1980s is not being applied to alcohol policy, which itself has virtually ceased to exist.