A commentary on of the new mental health act for the Maltese Islands

Legal notice 276, published in September 2013, has set out the time windows for the implementation of the Mental Health Act, which was approved by parliament in 2012. The changes are expected to be rolled out over a period of one year, with the totality of the Act being in force by 10th October 2014. The first set of changes, implemented last November, brings in effect the first half of the provisions of the Mental Health Act. Overall the proposed Mental Health Act is much improved on the previous Act; it reads well and brings the law up to date with modern psychiatry practice. At first glance the Maltese Mental Health Act seems to stem from the basis of the UK 1983 Mental Health Act as amended in 2007, although the authors are not familiar with other EU Mental Health Acts, therefore they could not comment on whether there are resemblances to other Acts. In this article, the authors will discuss and make comments on some of the seminal parts of the new Mental Health Act.peer-reviewe

ADHD : from childhood into adulthood

This is an overview of the some of the most recent and seminal research done on Attention Deficit Hyperactivity Disorders (ADHD). ADHD is currently one of the most common reasons for referral to child mental health services and still is under-recognised both in children (5.29%) and adults (2.5%). ADHD is a highly heritable disorder with a mulitifactorial pattern of inheritance. Parents, siblings and parents of a child with ADHD are 4-5 times more likely to have ADHD. Environmental factors also play a role in elucidating this disorder. Untreated ADHD leads to numerous co-morbidities, and longer term morbidity. Methylphenidate is suggested as the first line pharmacological treatment. ADHD is easy to treat, 80% of correctly diagnosed patients (children or adults) respond favourably to methylphenidate. All child and general adult psychiatrists should be aware of this disorder, comfortable with making the diagnosis and treating adults with ADHD. The purpose of the overview is to cover the epidemiology, aetiology, diagnostic criteria and different managements of ADHD.peer-reviewe

Cannabis use and age of admission to a psychiatric unit for first episode of psychosis

Background: Research has implicated that cannabis has an aetiological role in psychosis, and thus one can hypothesize that the onset of psychosis in patients who use cannabis occurs earlier in life than those who do not use cannabis Aim: The aim of this study is to assess the possible influence of cannabis on the age of onset of patients with first episode of psychotic illness admitted to a psychiatric unit in the Maltese Islands. Methods and sample: This study is a one year prospective study that includes all ICD-10 first episode psychosis patients admitted to a psychiatric hospital in the Maltese Islands. Age of admission to hospital was used as proxy for age of onset of psychosis. Use of cannabis prior to admission was ascertained by urine testing. Results: The mean age of admission to hospital for first onset psychosis for patients whose urine was positive to cannabis was 24.63 years old, and for patients whose urine was negative to cannabis was 44.63 years old. This difference was statistically significant, using the Mann Whitney-U test p=0.001. Conclusion: The results indicate that cannabis use can precipitate an earlier onset of psychotic illness. Considering the widespread use of cannabis, and that earlier age of onset of psychosis is associated with worse prognosis, this issue is of public health concern.peer-reviewe

Problems associated with the diagnosis and the prescribing of anti-psychotic medication in children and adolescents for psychiatric conditions, by non-psychiatric specialists

Aim: The objective of this study is to assess the accuracy of the diagnosis and appropriateness of antipsychotic medication prescribed to children and adolescents referred to child guidance clinic, and how many of these remained on the said medication after consultant psychiatrist and multidisciplinary team review. Method: A retrospective case notes review of all the children referred to a child guidance clinic in the period June 2005 to July 2006 were analysed, looking specifically at the referral tickets, the treatment on first interview with a member of the multidisciplinary team at the clinic, the working diagnosis of the team, and the management plan after at least six months of follow up at child guidance clinic. There was very good interrater reliability between the two observers looking at the case notes. Results: One hundred and fifty four (63.1%) out of a total of 244 children who were referred carried an admission diagnosis, which differed from the working diagnosis after 6 months. A total of 66 children (27%) were started on various types of psychiatric treatment prior to referral. Thirty (45.5%) of these were prescribed sulpiride, an atypical neuroleptic. Following review by the multi-disciplinary team, the medication of 25 (83.3%) of these children was terminated or altered. Conclusion: This report highlights the need of consultation liaison with general practitioners and also Continued Medical Education courses for general practice management in child and adolescent psychiatry. It is advisable that non psychiatric specialists limit the use of antipsychotic medication to children and adolescents without expert advice and in addition, should refer all such children with urgency.peer-reviewe

User satisfaction of Children and Young People’s Service, Malta

Background Few published studies have evaluated the service users’ satisfaction of a Children and Young People Service (CYPS). An association between child and carers’ satisfaction and their attendance to CYPS exists. The aims of this study were to evaluate the service users’ views of the national CYPS, Malta and disseminate findings to policy makers to inform service development. Method Young People (YP) attending CYPS from 1st to 30th November 2014 were invited to fill in an anonymized Charleston psychiatric outpatient satisfaction scale in Maltese or English. The quantitative data was collected from 13 questions using a Likert scale and analysed using statistical correlations. The qualitative data was collected from three open ended questions and analysed using a thematic analysis. Results The sample population was 211 (97.7% response rate), average age 9.97 years (SD 3.34, CI ± 0.45). Overall quality of care was significantly (p<0.001) correlated with; 'respect shown for YP’s treatment opinions’ (r=0.539), 'matching treatment plan to YP’s individual needs' (r=0.320), and 'helpfulness of the services received' (r=0.618). Thematic analysis findings included; waiting lists and the interval between reviews were perceived as too long, difficultly establishing a therapeutic relationship, and lack of age appropriate environment which hindered attendance. Conclusions This is the first service user satisfaction evaluation for CYPS, Malta. Increasing staff to reduce waiting times and having reviews by the same clinician would ensure continuity of care and improve the therapeutic relationship. Better communication between services is required through school visits and paediatricians. Extending opening times, facilitating the referral process and improving accessibility may decrease barriers to service. Artwork and a well-lit environment could help engagement. Despite the above, YP still felt that overall CYPS provided an individualised treatment plan where staff work collaboratively to scaffold YP and meet their needs.peer-reviewe

Risk factors for adolescents developing substance use disorders; what should our prevention programs be targeting?

This review identifies the main risk factors and high risk groups of adolescents with substance use disorders (SUD). Furthermore it presents the epidemiological data on SUDs in Malta and discusses possible ways of tackling prevention, whilst offering suggestions based seminal studies from published literature to service developers. Adolescence is a developmental period a high risk, more than half individuals with SUDs identify that the problem began before the age of 20. 18% of adolescents in Europe have reported a lifetime use of illicit drugs, the prevalence rates in Malta are similar. Risk factors for SUDs include; heritable factors; familial patterns and psychiatric disorders. Environmental factors include; family functioning, parenting practices, child maltreatment, peer influences, substance availability and consumption opportunities. One predictive phenotype for SUDs is psychological dysregulation characterised by cognitive, behavioural and emotional difficulties with daily challenges in childhood. The regular use of substances is associated with depression, anxiety, PTSD, behaviour problems. Highest risk groups as those having two parents with a SUD, living with single parents, sexual orientation differences, early use of substances, psychological dysregulation and an attitude of ambivalence towards the use of substances. Over 70% of adolescents receiving treatment for SUD had a history of trauma. Parental practices such as knowledge, communication and awareness are an important protective factor which may help reduce the influential negative influence from peers on substance use. Focusing on abstinence alone in treatment is insufficient as adolescents present with; lower problem recognition, higher rates of binge use and co-morbid psychiatric problems compared to adults. Preventative measures targeted to high risk adolescents were correcting misperceptions is a primary focus may have important benefits. This may reduce the general ambivalence with regards to drug use, thereby reducing the influence from friends. Secondly, correcting misconceptions may lead to adolescents changing the assumption that one’s friends are all positively predisposed to substance use. It’s estimated that for every dollar invested in addiction treatment, $4-7 are saved in drug related crime, theft and criminal justice costs.peer-reviewe

Pediatric Bipolar disorder, in Malta is it under-diagnosed?

The objective of this retrospective study was to determine the frequency of Bipolar Disorder in children and adolescents referred to the Child Guidance Clinic (CGC), St. Luke’s Hospital, Malta, over a year. Diagnostic criteria were analyzed and compared to current literature. Of 141 children, none were diagnosed with Bipolar Disorder. Further awareness of clinicians is advised, to identify Bipolar Disorder, thus limiting its long term morbidity and mortality.peer-reviewe

Socioeconomic status and its impact on the prevalence of severe ADHD in the Maltese Islands

Attention deficit hyperactivity disorder (ADHD) is a common disorder associated with hyperactivity, impulsivity and reduced attention. If left untreated this may possibly lead to various impairments in other areas, such as lack of educational attainment, increased risk of accident-prone behaviour, substance misuse and antisocial behaviours. Although the exact aetiology is still not fully understood, various studies have demonstrated the presence of both a genetic and an environmental component. ADHD is highly hereditable, demonstrating a strong genetic component. Furthermore, increased rates of ADHD have been linked with a low socioeconomic status. The islands of Malta have traditionally been divided for statistical purposes into 6 districts, with certain districts more often being associated with low socioeconomic demographics. The main aim of this study was to assess whether higher prevalence rates of ADHD were present in the districts, which are classically associated with a low socioeconomic status. All persons aged 0 to 18 years attending the governmental clinics, having a documented diagnosis of severe ADHD and therefore being prescribed pharmacotherapy were identified and included in this study. 9 youngsters were living in institutional care and were therefore excluded from the study. A significant difference (p<0.0001) in the point prevalence of ADHD between the 6 Malta districts was found, with higher rates of ADHD occurring in the harbour districts. Though not statistically significant, a positive correlation was demonstrated between the ADHD prevalence and a number of socioeconomic variables, these included; the rate of smoking (p=0.111), number of people classified as at-risk-of-poverty per district (p=0.397), and number of people with no schooling per district (p=0.156). The overall point prevalence for ADHD in Malta obtained was 0.85, a value which is less than the average prevalence noted worldwide. The authors believe this value is an underestimation since the data collection in this study did not include ADHD cases off pharmacological treatment and any ADHD cases assessed and treated in the private sector.peer-reviewe

A case control and follow up study of 'hard to reach' young people who also suffered from multiple complex mental disorders

PhD ThesisIntroduction: The Innovations project 15 to 25 years (IP) was a new multidisciplinary team based within an inner city area, walk-in health centre, in the North East of England (funded from January to December 2011) developed to provide a service to identify, assess and treat HTRYP. This research project draws data from the IP and compares them to data collected from a Community Mental Health Team (CMHT) in the North East of England. Aims: Initial Phase: to describe the mental health and evaluate the outcomes (mental disorder and social function) of the HTRYP who attended the IP. Phase 1: to compare the baseline demographics (Time Point 1 (TP1)) between a matched sample of IP and a sample of YP from CMHT. Phase 2: to identify and compare the indices for severity, complexity, engagement and response to treatment in a matched sample of IP and CMHT sample at TP1 and pre-discharge (TP2). Phase 3: to assess the mental state and social function of a group of individuals from the IP and CMHT samples who were retraced and agreed to be interviewed (24 months after discharge), TP3. Methods: Phase 1 and 2: a retrospective review of the clinical case notes of the YP who attended the IP (HTRYP) and CMHT was conducted. For Phase 1 the CMHT were matched to the HTRYP on age and date of discharge. The demographic characteristics of the two samples at TP1 were compared. For Phase 2 the samples were additionally matched for; gender, highest level of educational attainment and socioeconomic status. For phase 2 the focus was on severity of mental disorder and service input and change from TP1 to TP2 and between both services. Data were analysed using SPSS version 21. Phase 3 provided a follow up evaluation of the mental state and social function of YP who attended IP and CMHT (change was assessed using the Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and the Children’s Global Assessment Scale (CGAS). For this phase the samples used for retracing were further matched for primary diagnosis and severity of mental disorder at TP1. Results: Forty referrals were received by the IP service from a variety of agencies. Four referrals were not appropriate. An assessment was offered to 36, five refused. Of the 31 (86%) YP who were assessed all met the criteria for HTRYP, nine repeatedly missed appointments and seven were judged not to be suffering from complex mental disorders and were signposted to local community services. 15 (48%) were then offered individually tailored therapy. In Phase 1 significant differences at TP1 were found between the 36 HTRYP and 115 CMHT samples. The IP group experienced significantly more severe deprivation (t142= -5.6, p=<0.0001), higher rates A case control and follow up study of ‘Hard to Reach’ young people who also suffered from multiple complex mental disorders v Dr Nigel Camilleri of unemployment (χ²2 =16.696, p<0.0002) and homelessness (Wx= 1, 23.812, p<0.001) and achieved poorer educational attainment (Wx=4, 27.485, p<0.001) compared to the CMHT sample. In Phase 2, at baseline the HTRYP (median 3, CMHT median 1, χ24= 31.58, P<0.001) had more mental disorders, higher severity scores and lower levels of social function than YP attending CMHT (HTRYP HoNOSCA mean score: 19.1 and CMHT mean score: 11.2 t91= 5.53, P= <0.001, and HTRYP CGAS mean score: 51.0, CMHT mean score 58.9, t47= -2.0, P= 0.05). In terms of service input; the clinic time offered to HTRYP (1538 minutes) was significantly greater (t100= 3.79, P= <0.001) than the CMHT sample (518 minutes). Changes in outcome measures scores between TP1 and TP2 showed that the HTRYP made significantly greater improvement compared to CMHT YP; (HoNOSCA scores t54= 4.81, P= <0.001 and the CGAS scores t20= -3.61, P= <0.002). In Phase 3, only 16 (57%) of 28 HTRYP and 23 (43%) of 54 CMHT were successfully contacted. 13 HTRYP (46%) of 28 attended the follow up review compared with 9 (17%) of 54 CMHT. These YP were shown to be representative of the target populations from which they were selected. At follow up review the HTRYP, (HoNOSCA, Wx=13, p=0.031 and CGAS Wx=13, p=0.013) showed a greater clinical improvement in mental state from TP1 to TP3 compared to YP from CMHT (HoNOSCA, Wx=9, p=0.674 and CGAS, Wx=2, p=0.655). At TP3 the CMHT YP had maintained a higher overall level of social function and had lower level of deprivation than the HTRYP. However there was great variability in terms of social function between the YP within each sample (HTRYP and CMHT). Conclusion: The IP identified a high risk group of YP. They came from more deprived backgrounds and carried more burden of mental illness compared to YP attending the CMHT. Engaging the HTRYP required more clinical hours and they received a different care package to YP who attended the CMHT. The sub-set of HTRYP who received the IP therapeutic intervention, made a significant clinical improvement when compared to the YP attending the CMHT. The findings of this study suggest that HTRYP may benefit from a flexible, individualised resource intense service that includes an outreach capability to maximise engagement, assessment and intervention planning. However the sample size was small and the resource implications for this type of clinical provision are considerable. Further clinical research is needed to investigate what might be the most resource efficient and effective in terms of ways of working with this high risk group of YP to help reduce the immediate and long term burden of mental disorders.Malta Government Postgraduate Scholarship Scheme and received support as a portfolio study by the National Institute Health Research (NIHR) Clinical Research Network

Socio-economic status and population density risk factors for psychosis : prospective incidence study in the Maltese Islands

The aim of the study is to determine the incidence of patients suffering from psychosis and requiring admission to hospital. The study also intended to gain further epidemiological information, specifically in relation to population density and socio-economic status, as well as ethnicity, and to examine any differences between the six districts of the Maltese Islands. Based on the evidence from previous studies, Professionals hypothesized that a higher incidence of psychosis would be found in the lower socio-economic region, the more densely populated regions and among ‘irregular’ migrants.This was a prospective cross-sectional study of the incidence of psychosis in patients requiring admission to hospital. The sample comprised all patients newly admitted, with a diagnosis of psychosis, to a psychiatric ward at any of the three government hospitals between 1 May 2007 and 30 April 2008. There were no exclusion criteria related to age, gender or ethnicity.peer-reviewe