Vol 2, No 1 (2021)

The future of psychiatry
Sartorius N.

Since the Second World War mental health programmes and psychiatry have made significant advances. Countries, as well as the United Nations, have recognized the magnitude and severity of mental health problems, and numerous national programmes have been launched to deal with them. Technology relating to the treatment of mental disorders has advanced and significant progress has been made in terms of knowledge regarding the functioning of the brain. The awareness of the need to protect the human rights of those with mental illness has increased. National and regional programmes against stigma and the consequent discrimination of those with mental illness, have been launched in many countries. Associations bringing together those who have experienced mental illness and their relatives, have come into existence in many countries.

While these are great steps forward, more work is necessary to complete these advances. In low- and middle-income countries, the vast majority of people with mental disorders do not receive adequate treatment. Even in highly industrialized countries, a third of people with severe forms of mental illness are not receiving the appropriate therapy. Laws concerning mental health are outdated in many countries. The protection of the human rights of the mentally ill is incomplete and imperfect. The emphasis on economic gain and the digitalization of medicine in recent years has not helped. On occasions, this has even slowed down the development of mental health services, and the provision of mental healthcare. Thus, psychiatry must still deal with the challenges of the past century, while facing new demands and tasks.

Among the new tasks for psychiatry are undoubtedly reforms which will allow (i) the provision of appropriate care of people with comorbid mental and physical disorders, (ii) the application of interventions leading to the primary prevention of mental and neurological disorders, and (iii) a radical reform of the education of psychiatrists and other mental health workers, dealing with mental illness. Collaboration with other stakeholders in the field of mental health and medicine, will be of crucial importance in relation to all these tasks.

Consortium Psychiatricum. 2021;2(1):3-7
Emotional Response to Humour Perception and Gelotophobia Among Healthy Individuals and Patients with Schizophrenia and Depression, with Signs of a High Clinical Risk of Psychosis
Volovik D.D., Omelchenko M.A., Ivanova A.M.

Introduction. Investigating early changes in the emotional sphere within the schizophrenia course is a perspective direction in clinical psychology and psychiatry. Intactness of positive emotions, in particular, humour perception, may be a very important resource for patients. At the same time, humour perception is very sensitive to pathological conditions, such as the fear of being laughed at, known as “gelotophobia”. Those with gelotophobia perceive laughter as dangerous, rather than pleasant, and they can hardly distinguish between teasing and ridicule. Gelotophobia was confirmed to be expressed among people with mental disorders. Nonetheless, knowledge relating to the fear of being laughed at, was mostly generated among the non-clinical samples.

Objectives. Thus, the aim of the study was to provide more clinical data on gelotophobia manifestations associated with schizophrenia spectrum disorders; the emotional response and facial expression of patients with gelotophobia were studied, in particular, regarding their perception of humour, including during the early stages of disorders, by comparison with healthy individuals.

Methods. n=30 controls and n=32 patients with schizophrenia and with depression with signs of a high clinical risk of psychosis took part. Two short videos, comic and neutral, were shown to the participants, while videotaping their facial expression, followed each by a self-reported measure of emotional responses. Participants also completed the State-Trait Anxiety Inventory, the PhoPhiKat<30> and the Toronto Alexithymia Scale.

Results. Gelotophobia was significantly higher within the clinical group. It correlated with a lower frequency of grins among the patients during the comic video, while this was not the case in the control group. Gelotophobia was related to state and trait anxiety in both groups, but only in the clinical group did state anxiety increase after watching the comic video. Gelotophobia correlated with alexithymia and was twice higher among the patients compared to the controls.

Conclusion. Thus, gelotophobia has not only quantitative, but also qualitative specifics in patients with schizophrenia, and those with depression with signs of a clinically high risk of psychosis, compared to healthy controls.

Consortium Psychiatricum. 2021;2(1):8-17
Immunoinflammatory Profile in Patients with Episodic and Continuous Paranoid Schizophrenia
Malashenkova I.K., Krynskiy S.A., Ogurtsov D.P., Hailov N.A., Zakharova N.V., Bravve L.V., Kaydan M.A., Chekulaeva E.I., Andreyuk D.S., Ushakov V.L., Didkovsky N.A., Kostyuk G.P.

Introduction. Associations of disturbances in innate and adaptive immunity during the clinical course of schizophrenia have been found in a number of studies. Yet, the relationship of immune parameters and systemic inflammation in relation to the clinical course of the disease and its prognosis, remains poorly understood, which highlights an interesting topic for further research. The goal of this study was to research the immuno-inflammatory changes in patients with clinical continuous and episodic paranoid schizophrenia, to assess the pathogenetic significance of these changes.

Methods. Thirty-six patients with paranoid schizophrenia, of which 20 had episodic symptoms and 16 had continuous symptoms, consented to participate in the study, together with 30 healthy volunteers. In the study we assessed the parameters of innate immune response (serum levels of key pro-inflammatory and anti-inflammatory cytokines, C-reactive protein) and the adaptive immune response, including humoral-mediated immunity (serum immunoglobulins IgA, IgM, IgG, circulating immune complexes), as well as the cell link of adaptive immunity (key lymphocyte subpopulations). Positive and negative symptoms were assessed with the positive and negative symptoms scale; frontal dysfunction was assessed by Frontal Assessment Battery (FAB).

Results. Both patient groups had higher than normal levels of C-reactive protein and IL-8. There was a significant elevation of circulating immune complexes among patients with continuous symptoms of schizophrenia, compared to patients with episodic symptoms and healthy controls. Levels of CD45+CD3+ lymphocytes (T-cells) differed between clinical groups, with higher values identified among patients with episodic symptoms and lower values among those with continuous symptoms. In addition, patients with episodic symptoms had significantly increased levels of CD45+CD3+CD4+CD25+CD127- regulatory T-cells. Finally, the level of CD45+CD3-CD19+ B-cells was significantly higher among patients with continuous symptoms vs. patients with episodic symptoms and the control groups. Markers of activation of humoral immunity were associated with the severity of frontal disorders in these patients.

Discussion. Comprehensive data on the serum level of cytokines and the parameters of adaptive immunity among individuals with continuous schizophrenia, by comparison with patients with episodic schizophrenia, are practically absent in the literature. We have shown that among those with continuous schizophrenia, there are signs of systemic inflammation and chronic activation of the adaptive humoral immune response, while among patients with episodic symptoms of the disease, there are signs of systemic inflammation and certain activation of cell-mediated immunity, without significant changes in the humoral link of adaptive immunity.

Conclusion. More studies are needed, but the data obtained in this study are important for subsequent clinical studies of new treatment methods, based on various immunophenotypes of schizophrenia.

Consortium Psychiatricum. 2021;2(1):19-31
Suicides in the COVID-19 Pandemic — Are We Well Informed Regarding Current Risks and Future Prospects?
Rozanov V.A., Semenova N.V., Vuks A.J., Freize V.V., Isakov V.D., Yagmurov O.D., Neznanov N.G.

Background. Suicides are predicted to drop in the acute phase of any crisis that poses a threat to the entire population, though data on this are inconsistent. A pandemic is the most severe global crisis one can imagine. There is an urgent need to identify objective trends in suicide rates across countries and populations in a real-time manner in order to be better informed regarding prospects and adaptation of preventive strategies.

Objectives. To evaluate suicidal behaviour in a metropolis immediately after the introduction of severe containment measures due to the pandemic.

Methods. Cases of completed suicides in St. Petersburg were obtained from the local city Bureau of Forensic Medical Examinations for the period 1 January 2016 to 31 July 2020. Data were accurately collected and monthly frequencies per 100,000 of the population in April-May 2020 (introduction of the most severe “stay at home” measures) were compared with corresponding data from 2016-2019. Confidence intervals were calculated according to Wilson.

Results. Suicide frequencies in the population of St. Petersburg in April 2020 did not go up, in contrast, they were 30.3% lower than the average for the previous four years. The decrease in April was more pronounced in males than in females (36.3% and12.4%, respectively). When looking at age groups it was found that the biggest drop in suicides was in older males (> 55 years). In this group, suicide indices were 58.5% lower than average for the previous four years. However, in females, there was a 50% rise in suicides in June, while in young males (15-34 years) there was an 87.9% rise in May. Total number of suicides for the first half of 2020 was very close to the average seen in previous years. None of the registered changes were statistically significant.

Conclusions. The analysis is preliminary and does not account for possible seasonality, however, we consider that the reduction in completed suicides immediately after crisis exposure deserves attention. It supports views that in the acute phase of the crisis, suicidal behaviour may decline, which may be quickly replaced by a rise. Such a rise in females and younger males points on possible risk groups and requires a response from society. More studies are needed to have a clearer picture of suicide dynamics in Russia during the different waves of the pandemic, and prevention should be prioritized regardless of the tendencies.

Consortium Psychiatricum. 2021;2(1):32-39
Mental Health in Australia and the Challenge of Community Mental Health Reform
Rosenberg S., Harvey C.

Australia was one of the first countries to develop and implement a national mental health plan, 30 years ago. This national approach belied the country’s federal structure, in which the federal government takes responsibility for primary care while state and territory governments manage acute and hospital mental health care. This arrangement has led to significant variations across jurisdictions. It has also left secondary care, often provided in the community, outside of this governance arrangement. This article explores this dilemma and its implications for community mental health, and suggests key steps towards more effective reform of this vital element of mental health care.

Consortium Psychiatricum. 2021;2(1):40-46
Community-based Mental Health Services in Norway
Ruud T., Friis S.

Community-based mental healthcare in Norway consists of local community mental health centres (CMHCs) collaborating with general practitioners and primary mental healthcare in the municipalities, and with psychiatrists and psychologists working in private practices. The CMHCs were developed from the 1980s to give a broad range of comprehensive mental health services in local catchment areas. The CMHCs have outpatient clinics, mobile teams, and inpatient wards. They serve the larger group of patients needing specialized mental healthcare, and they also collaborate with the hospital-based mental health services. Both CMHCs and hospitals are operated by 19 health trusts with public funding.

Increasing resources in community-based mental healthcare was a major aim in a national plan for mental health between 1999 and 2008. The number of beds has decreased in CMHCs the last decade, while there has been an increase in mobile teams including crisis resolution teams (CRTs), early intervention teams for psychosis and assertive community treatment teams (ACT teams). Team-based care for mental health problems is also part of primary care, including care for patients with severe mental illnesses. Involuntary inpatient admissions mainly take place at hospitals, but CMHCs may continue such admissions and give community treatment orders for involuntary treatment in the community.

The increasing specialization of mental health services are considered to have improved services. However, this may also have resulted in more fragmented services and less continuity of care from service providers whom the patients know and trust. This can be a particular problem for patients with severe mental illnesses. As the outcomes of routine mental health services are usually not measured, the effects of community-based mental care for the patients and their families, are mostly unknown.

Consortium Psychiatricum. 2021;2(1):47-54
Organization of Community Psychiatric Services in Finland
Korkeila J.

Background. The Finnish psychiatric treatment system has undergone a rapid transformation from operating in institutional settings to a adopting a community-based approach, through implementation of national plans; this process was carried out quickly, due to a severe economic recession in the early 1990s.

Methods. This paper is a narrative review, based on relevant documents by national authorities, academic dissertations and published scientific literature, between 1984 and 2018, as well as the interviews of key experts in 2019.

Results. The municipality is currently the primary organization, responsible for all health services. Municipalities may also work together in organizing the services, either through “unions of municipalities” or hospital districts. Services are to a great extent outpatient-oriented. The number of beds is one fifth of the previous number, around four decades ago, despite the increase in population. In 2017, 191,895 patients in total (<4% of Finns) had used outpatient psychiatric services, and the number of visits totalled 2.25 million. Psychotherapy is mainly carried out in the private sector by licensed psychotherapists. Homelessness in relation to discharged psychiatric patients has not been in evidence in Finland and deinstitutionalization has not caused an increase in the mortality rate among individuals with severe mental disorders.

Conclusion. Psychiatric patients have, in general, benefitted greatly from the shift from institutions to the community. This does not preclude the fact that there are also shortcomings. The development of community care has, to date, focused too heavily on resource allocation, at the expense of strategic planning, and too little on methods of treatment.

Consortium Psychiatricum. 2021;2(1):55-64

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