[Introduction of a risk assessment tool to evaluate the risk of aggressive behavior during acute psychiatric admission]. / Az agresszív magatartás rizikóját felméro skála alkalmazása akut pszichiátriai felvételre kerülo betegeken.

INTRODUCTION: Aggressive behavior among psychiatric patients occurs the most frequently during acute inpatient treatment causing significant safety risk for patients and staff. OBJECTIVE: As part of a risk-reducing project targeting the reduction of the frequency of physical aggression, a daily routine use of a risk evaluation tool was introduced in the acute psychiatric unit of the Jahn Ferenc South Pest Hospital. METHODS: Selection of the appropriate risk evaluation tool was based on a thorough search of the literature. After preparing the Hungarian translation of V-RISK-10, all acutely admitted patients were assessed with this rating scale completed by the duty psychiatrist. To evaluate the predictive validity of the scale, the authors retrospectively surveyed the number and length of necessary physical restraints due to aggressive behavior in the first week after admission. RESULTS: The mean score on V-RISK-10 was 6.78 ± 3.36 points and the time patients spent under restraints was 6.96 ± 17.21 hours. The sum score of the V-RISK-10 showed a moderate strength, and significant correlation with the time spent under restraint (r = 0.447; p = 0.001). DISCUSSION: The results confirmed that V-RISK-10 is an appropriate tool for predicting physical aggression necessitating restraints in the first days following an acute psychiatric admission. History of violent behavior, drug use, and a psychiatric diagnosis and suspiciousness among current symptoms had the strongest predictive value. CONCLUSION: The V-RISK-10 is a risk assessment tool that is user-friendly in the context of acute psychiatric inpatient care and has a moderate power for predicting aggressive behavior. Patients with high risk of aggression can be identified with this tool at the time of admission. With careful monitoring and timely initiation of aggression prevention strategies, the occurrence of aggressive behavior can be minimized. Orv Hetil. 2023; 164(8): 293-299.

[Accessibility of electroconvulsive therapy during COVID-19 pandemic in Hungary].

OBJECTIVES: A nationwide survey in Hungary found that 22 out of 58 psychiatric units performed ECT in 2014. Shortly after identifying the first COVID cases, strict control measures were introduced, and the hospital system was fundamentally transformed in the country that affected ECT provision as well. The aim of the current study was to survey the changes in ECT use in Hungary during the four waves of the COVID-19 pandemic. METHODS: All the psychiatric units that indicated they had performed ECT in 2014 were sent a semi-structured question naire requesting information about changes in ECT practice and the treatment profile of the unit. If there was no reply, a follow-up telephone call was made. RESULTS: There were only 3 centers where ECT was performed throughout all four waves of COVID. In nine centers (47%) ECT was suspended in all four waves. The main reason why ECT was halted during COVID was the restructuring of psychiatric inpatient care: six centers were fully transformed into general COVID units, and in the remaining 13 the number of psychiatric beds was reduced in favor of general COVID care. Staff shortage constituted another barrier to the provision of ECT. The number of infected patients in a wave of COVID-19 showed a significant negative correlation with the number of active ECT centers (p=0.05). No COVID-infected patient received ECT in Hungary. CONCLUSIONS: During the COVID pandemic in Hungary, nearly half of the ECT services were suspended and thus a number of patients missed out on receiving an effective treatment.

Changes in the Practice of Electroconvulsive Therapy in Poland: A Nationwide Survey Comparing Data Between 2005 and 2020.

BACKGROUND: The use and the characteristics of the practice of electroconvulsive therapy (ECT) in Poland have not been evaluated since 2005, when a nationwide survey revealed its rare utilization (0.11 patients/10,000 inhabitants/year). The aims of this study were to determine the current use of ECT and to compare the findings with those of the previous survey. METHODS: Two questionnaires were sent to all 48 inpatient psychiatric centers in Poland. The first one - to units providing ECT to explore its practice, and the second - to units not performing ECT to explore the reasons for not using this treatment. RESULTS: Nineteen (39.6%) of all psychiatric inpatient centers confirmed the use of ECT. The utilization rate was 0.13 patients/10,000 inhabitants. Similar to the findings from 2005, the main indications were affective disorders, and bitemporal electrode placement was the dominant method used for the delivery of ECT. Age-based and titration-based methods were applied exclusively in 50% and 25% of the centers, respectively (compared with 15% and 35% in 2005, respectively), while both methods were used in the remaining 25%. Improvements in safety were reflected by the use of comprehensive pre-ECT evaluation and treatment monitoring. None of the centers used sine-wave devices; this contrasts with their use by 29% of the centers in 2005. The main reasons for not using ECT were insufficient funding and a lack of experienced staff. CONCLUSION: The frequency of ECT use in Poland remains very low. In view of the improvement in the quality of health services in the past decade, such a markedly rare use of an effective treatment was unexpected. There is an urgent need of education to create more positive attitude towards ECT among health professionals and among public, and to increase the training of mental health professionals in ECT.

Hungarian Psychiatrists' Recognition, Knowledge, and Treatment of Catatonia.

DSM-5 introduced a number of modifications to the catatonic syndrome, which is now closer to Kahlbaum's original concept. The aim of the present study was to assess residents' and qualified psychiatrists' knowledge, experience and views about the treatment of catatonia in acute psychiatric care in Budapest, Hungary. Authors approached all psychiatric units that provide acute psychiatric care (N = 11) in Budapest and invited all psychiatrists and residents, who consented, to participate in the survey, completing a 13 items questionnaire. Ninety-eight fully qualified and trainee psychiatrists completed the questionnaire. Although 84.7% of the participants rated their knowledge of catatonia as moderate or significant, there were a number of obvious mistakes in their answers. Most catatonic signs and symptoms were not identified by almost 50% of the respondents and the frequency of catatonia was also underestimated. The views of the majority of the participants reflected the Kraepelinian concept, in which catatonia is primarily associated with schizophrenia. Although benzodiazepines are widely recommended as a first line treatment for catatonia, only 69.4% of participants chose them as a treatment option. In view of its clinical importance, catatonia deserves more attention in the education and training of medical students and psychiatric residents.

The prevalence of catatonic syndrome in acute psychiatric wards. / Rozpowszechnienie zespolów katatonicznych w ostroprzyjeciowych oddzialach psychiatrycznych.

OBJECTIVES: The aim of this prospective study was to determine the prevalence of the catatonic syndrome in a cohort of patients admitted to acute psychiatric units in Hungary. METHODS: Patients admitted to the acute inpatient unit of the Center of Psychiatry and Addiction Medicine, SzentIstván and SzentLászló Hospitals in a 4-month period were screened for catatonic signs and symptoms. Catatonic signs/symptoms were scored according to both the DSM-5 diagnostic criteria and the Bush-Francis Catatonia Rating Scale (BFCRS). Clinical diagnoses were established using the Structured Clinical Interview for DSM-IV Disorders (SCID), while cognitive performance was estimated with the Clock Drawing Test and the Mini-Mental State Examination (MMSE). RESULTS: During the study period, 342 patients were admitted to the above-mentioned acute inpatient units. The prevalence figures for the catatonic syndrome were 8.55% and 5.02% according to the BFCRS and the DSM-5, respectively. CONCLUSIONS: The prevalence of catatonic syndrome in an acute inpatient setting is within the broad range of figures reported in the literature. The difference between the standardized assessment (BFCRS) and routine clinical judgment (DSM-5) is noteworthy and suggests that a significant minority of catatonic patients might not be identified in clinical practice. As acute catatonia can be effectively treated, and early treatment could prevent potentially lifethreatening complications, recognition of catatonic symptoms is vitally important.

Schizophrenia with prominent catatonic features: A selective review.

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Catatonia as a putative nosological entity: A historical sketch.

Kahlbaum was the first to propose catatonia as a separate disease following the example of general paresis of the insane, which served as a model for establishing a nosological entity. However, Kahlbaum was uncertain about the nosological position of catatonia and considered it a syndrome, or "a temporary stage or a part of a complex picture of various disease forms". Until recently, the issue of catatonia as a separate diagnostic category was not entertained, mainly due to a misinterpretation of Kraepelin's influential views on catatonia as a subtype of schizophrenia. Kraepelin concluded that patients presenting with persistent catatonic symptoms, which he called "genuine catatonic morbid symptoms", particularly including negativism, bizarre mannerisms, and stereotypes, had a poor prognosis similar to those of paranoid and hebephrenic presentations. Accordingly, catatonia was classified as a subtype of dementia praecox/schizophrenia. Despite Kraepelin's influence on psychiatric nosology throughout the 20th century, there have only been isolated attempts to describe and classify catatonia outside of the Kraepelinian system. For example, the Wernicke-Kleist-Leonhard school attempted to comprehensively elucidate the complexities of psychomotor disturbances associated with major psychoses. However, the Leonhardian categories have never been subjected to the scrutiny of modern investigations. The first three editions of the DSM included the narrow and simplified version of Kraepelin's catatonia concept. Recent developments in catatonia research are reflected in DSM-5, which includes three diagnostic categories: Catatonic Disorder due to Another Medical Condition, Catatonia Associated with another Mental Disorder (Catatonia Specifier), and Unspecified Catatonia. Additionally, the traditional category of catatonic schizophrenia has been deleted. The Unspecified Catatonia category could encourage research exploring catatonia as an independent diagnostic entity.

Use of Electroconvulsive Therapy in Central-Eastern European Countries: an Overview.

Though a number of reports on the use of electroconvulsive therapy (ECT) has been published from the Central-Eastern European region over the past two decades, a systematic review of this literature has not been published. Thus the aim of this paper was to review recent trends in ECT practice in Central-Eastern Europe. Systematic literature search was undertaken using the Medline, PSYCHINFO and EMBASE databases covering the period between January 2000 and December 2013. Relevant publications were found from the following countries: Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovakia, Ukraine, but none from Albania and Moldova. ECT practice in the region shows a heterogeneous picture in terms of utilization rate, main indications, and the technical parameters of application. On one end of the spectrum is Slovakia where the majority of psychiatric facilities offer ECT, on the other end is Slovenia, where ECT is banned. In about half of the countries schizophrenia is the main indication for ECT. In Ukraine, unmodified ECT is still in use. Clinical training is generally lacking in the region and only 3 countries have a national ECT protocol. Possible ways of improving ECT practice in the region are briefly discussed.

Catatonia in disulfiram intoxication - a case report and a brief overview of the literature.

Catatonic syndromes could accompany a variety of psychiatric and medical conditions. The most common conditions underlying catatonia are affective disorders followed by schizophrenia, but several medical conditions including intoxications affecting the central nervous system can also present with catatonic signs and symptoms. Therapeutic doses of disulfiram could induce catatonia with or without accompanying psychosis or mood disorder. A case of disulfiram intoxication manifesting with catatonia is reported here together with a brief overview of the literature. A patient was admitted to the toxicology ward after a suicide attempt with approximately 20 g of disulfiram. On transfer to the psychiatric ward, she was sitting still, in a semi-stuporous state and displayed motiveless resistance to instructions or attempts to move (active negativism). She was unresponsive to most of the questions (mutism), occasionally verbigerated 1-2 words and stared for more than 20 seconds between shifting attention. After developing a comatosus state her treatment continued at the toxicology ward, where a contrast-enhanced computer tomography scan revealed bilateral emollition of 1.5 cm diameter in both nucleus lentiformis at the level of the third ventricle. Following treatment her condition improved and she benefited of rehabilitation facility and a second psychiatric treatment. She was discharged free of neurological and psychiatric symptoms. In conclusion, we underscore the importance of accurate diagnosis of the underlying psychiatric or medical condition when encountering a fast emerging catatonic syndrome and focus first on treating the causative condition while simultaneously attempting symptomatic treatment of catatonia.

Reasons for acute psychiatric admission of patients with dementia.

INTRODUCTION: The estimated number of patients living with dementia in Hungary is between 150,000 and 300,000. Hungary's prevalence of vascular dementia is much higher than that of other countries. Patients with dementia can be admitted to psychiatric hospitals for several reasons, the least common of which is cognitive decline. Comorbid psychiatric disorders or dementia-related behavioral disturbances are much more common reasons. AIM: To examine the reasons for the acute psychiatric admission of patients suffering from dementia in a psychiatric center in Budapest. MATERIALS AND METHODS: In this retrospective survey the data of dementia patients who were referred to the Centre for Psychiatry and Addiction Medicine (CPAM) at Szent István and Szent László Hospitals between August 1 and October 31, 2014 were analyzed with special attention paid to the reasons for hospitalization. RESULTS: Altogether 302 patients were admitted to the CPAM over the study period and 26.15% of them suffered from dementia. The distribution of dementia subtypes was as follows: 43% mixed type (vascular and neurodegenerative), 40.5% vascular type, 11.4% Alzheimer's disease, and 5.1% other types. A small percentage (12.7%) of patients had mild dementia, while 34.2% and 53.2% suffered from moderate and severe dementia, respectively. The major causes of hospitalization were aggressive behavior (34.2%), delirium (19%), and divagation and confusion 15.2% each. They were mainly associated with moderate and severe dementia. Suicide attempt was the reason for admission in 10.1% of cases, and delusions in 6.3%. With regard to admission outcome, 44.3% of patients were transferred to a medical ward, 12% within 3 days of psychiatric admission. Nearly 9% of patients required extended hospitalization, 21.5% were discharged home, 20.3% were transferred to a nursing home and 5.1% died while in hospital. More than half of the patients were rated on the CGI-C scale; 59% of them scored 2 points (much improved), 25% scored 1 point (very much improved) and 16% scored 3 points (moderate improvement). DISCUSSION: A high proportion of dementia patients acutely admitted to a psychiatric ward was medically compromised and either died soon after admission (5%) or was transferred to a medical ward for further treatment. This highlights the importance of a thorough medical work-up including physical examination and laboratory investigations for dementia patients requiring acute psychiatric admission. It is of note that only a small number of patients could be discharged home or to a nursing home. These figures underscore the need for more nursing home places and a better functioning social care system in this field.

Lamotrigine in the treatment of psychotic depression associated with hereditary coproporphyria -- case report and a brief review of the literature.

OBJECTIVE: We report a successful treatment with lamotrigine of a patient with hereditary coproporphyria presenting with affective and psychotic symptoms. CASE REPORT: M.F., a 38-year-old, single woman was admitted to an acute psychiatric ward because of suddenly emerging psychosis. Ms F's hereditary coproporphyria was diagnosed 9 years before the current admission. While on treatment with olanzapine (20mg/day) the psychotic symptoms have gradually disappeared. In view of her significant mood fluctuations predominantly with depressed phases, lamotrigine was started and titrated up to 125 mg/day. Ms F's mood gradually became euthymic, suicidal ideations and anxiety disappeared. At 5-month follow-up, while still on lamotrigine, her porphyria was asymptomatic. CONCLUSION: To the best of our knowledge, this is the first report about the safe administration of lamotrigine in hereditary coproporphyria. Lamotrigine did not trigger an acute porphyric attack as confirmed by clinical and laboratory findings.

Electroconvulsive therapy in a Hungarian academic centre (1999-2010).

BACKGROUND: Since the 1930s, the Department of Psychiatry and Psychotherapy at Semmelweis University (DPPSU) in Budapest has played a leading role in convulsive therapy in Hungary. The aim of this study was to describe the pattern of ECT use at the DPPSU over an 11-year period. SUBJECTS AND METHODS: Analysis of the medical notes of all patients treated with ECT in this academic centre between 1999 and 2009. RESULTS: During the study period, 28,230 patients were admitted to the DPPSU, of whom 457 (1.6%) received ECT. More than 50% of patients receiving ECT were diagnosed with schizophrenia. The percentage of female patients receiving ECT significantly exceeded that of the male patients, above what was expected in view of the diagnostic mix. CONCLUSION: The data indicate that in the first decade of the 21(th) century, ECT use shows a declining tendency in this Hungarian academic centre. The mean number of treatment sessions was relatively low and nearly the same across diagnostic groups. ECT was mainly used as a last resort for treatment-resistant patients. In the majority of cases, bifronto-temporal brief pulse stimulation was applied. Seizures were monitored with EEG and EMG.

When do psychiatric side effects emerge during antiviral treatment of hepatitis C?

BACKGROUND: This retrospective study aimed to determine the time-frame regarding the first appearance of psychiatric side effects in the course of antiviral treatment and the subsequent referral to consultation-liaison psychiatric services. SUBJECTS AND METHODS: Medical records of patients receiving combined antiviral treatment with alpha interferon and ribavirin for hepatitis C at a hepatology outpatient clinic and referred to psychiatric consultation between April 2000 and July 2011 were scrutinized. RESULTS: Time between the initiation of antiviral treatment and the first appearance of psychiatric symptoms was 10.64±10.68 weeks. Patients were referred to psychiatric examination 16.1±12.7 weeks after antiviral treatment had been commenced. The time frame of the emergence of psychiatric symptoms and the referral for psychiatric consultation did not correlate with the patients' age or sex. No relationship between substance/alcohol abuse and psychiatric history and the timing of psychiatric side effects and their assessment were found. CONCLUSIONS: This study confirmed that psychiatric side effects appear late in the course of combined antiviral treatment arising after 10.64±10.68 weeks the treatment started. The results also showed that some patients' psychiatric symptoms appeared immediately after the beginning of the antiviral therapy. This finding underlines the importance of monitoring patients' psychiatric condition as soon as antiviral treatment commences.

Safety of the electroconvulsive therapy and amisulpride combination.

BACKGROUND: Electroconvulsive therapy is frequently considered when pharmacotherapy is ineffective. In such cases the combination of the two treatment modalities are commonly used. Amisulpiride, a second generation antipsychotic drug is used in the treatment of schizophrenia and psychotic depression. When amisulpiride is ineffective as a monotherapy, combination with ECT could be an option to enhance its efficacy. To the best of our knowledge, to date there have been no data about the safety of this combination. SUBJECTS AND METHODS: Medical notes of all patients who were given ECT while on amisulpiride were selected from the archives of the Department of Psychiatry, Semmelweis University Medical School, Budapest, covering a 10-year period. A randomly selected matched control group was formed from patients who underwent ECT but were not taking amisulpiride. Patients in both groups also received a variety of psychotropic drugs other than amisulpide. Side effects were compared between the two groups of patients. RESULTS: Twenty patients received amisulpride with ECT. The most common side effects were headache, hypertension, tachycardia, nausea, dizziness, confusion, psychomotor agitation, sialorrhea, and prolonged seizure activity. All adverse effects resolved within 24 hours. No side effects of any kind were observed in 7 and 8 cases in the study and control groups, respectively. CONCLUSIONS: This was the first study that examined the safety of amisulpride-ECT combination in schizophrenia. Comparing the side-effects between the study and control groups, no significant differences were detected in terms of their types or frequency. The amisulpiride-ECT combination appears to be a safe treatment option.

Electroconvulsive therapy on Hungarian websites.

BACKGROUND: Although there are several similarities in terms of their equipment and the way they are performed, the social perception and public attitudes towards electroconvulsive therapy (ECT) and electric cardioversion (ECV) is entirely different. The aim of this study was to assess and compare the information on Hungarian Internet sites on ECT and ECV with respect to their depiction and acceptance by the public. SUBJECTS AND METHODS: An Internet search was undertaken with the Google search engine using the terms "ECT", "electroconvulsive therapy", "electroshock", "defibrillator" and "electric cardioversion". The search was restricted to information published in the Hungarian language from 1 January 2000 to 31 December 2010. All communications were classified into negative, neutral and positive groups depending on their attitude towards the aforementioned treatment methods. Professional or non-professional categories were also distinguished. RESULTS: The total number of communications, which appeared between 2000 and 2010 and contained one of the search words for ECT was 66. The majority of them portrayed ECT in a negative (24; 36.4%) or neutral (25; 37.9%) fashion. Most of the websites (139; 95.2%) related to ECV were reflected positive (120; 82.2%) and neutral opinions (19; 13.0%). CONCLUSIONS: Hungarian-language Internet sites mainly view ECT as negative or neutral in contrast to ECV cardioversion, which has almost entirely a positive reputation. Although the effectiveness of both therapies is equally well established, their public image as manifested on the Internet differs significantly. This may have a major impact on the frequency of their use.

The practice of consenting to electroconvulsive therapy in the European Union.

OBJECTIVES: To survey major aspects of obtaining informed consent to electroconvulsive therapy (ECT) in the countries of the European Union. METHODS: Leading professionals in the field of biological psychiatry in all European Union countries and Norway and Switzerland were approached by e-mail asking about the national practice of obtaining consent to ECT including the form of consent, the legality of consent by proxy, and consent to anesthesia and maintenance treatment. RESULTS: A considerable diversity was found across Europe regarding consent to ECT. In Slovenia and Luxembourg, ECT is not available at all. Informed consent is needed in written form in most European countries except for Sweden, Denmark, Finland, and Slovakia, where verbal consent is sufficient. Italy, Ireland, and Latvia are stricter in their approach because separate written consent is required before each ECT session. CONCLUSION: The practice of obtaining informed consent varies from country to country reflecting the individual European Union countries' jurisdiction and their sociocultural traditions as well as their different development of psychiatric services. In line with the increasing cooperation in health care, developing a unified way of obtaining consent for ECT is recommended.

[The optimal combination of ECT with pharmacotherapy]. / Az akut elektrokonvulzív kezeléssel párhuzamosan alkalmazott pszichofarmakoterápia optimalizálásának szempontjai.

The main indications for the electroconvulsive therapy (ECT) - psychotropic drug combination are pharmacotherapy-resistant, severe schizophrenic or affective psychoses. In such instances, a careful evaluation of the possible interactions between ECT and psychotropic drugs should precede the initiation of treatment in order to prevent adverse side effects. In this respect, the issues to be considered include the impact of concomittant pharmacotherapy on the seizure parameters of the ECT as well as the efficacy of the combined treatment relative to ECT or pharmacotherapy administered alone. This paper reviews the current literature on the use of benzodiazepines, mood stabilizers, antidepressants, antipsychotics together with ECT with the aim of providing recommendations for clinical practice.