Patients with OCD usually require higher dosages of serotonin reuptake inhibiting (SRI) drugs than is used for the treatment of depression. This observation resulted in treatment-refractory patients being occasional prescribed selective SRI drugs above the normal upper limit of prescribing. Previous studies have shown that these high doses are well tolerated.

We decided to investigate the blood levels of patients on dosages of sertraline that were above the normal therapeutic range.

Successive patients treated by the National Inpatient Service for OCD/BDD who were treatment refractory and prescribed > 200 mg sertraline per day were included. All had previously received 2+ trials of different SRIs for > 3months each as well as been offered augmentation with dopamine blockers and at 2+ trials of exposure and response-prevention. All patients scored in the profoundly ill range of the Yale Brown Obsessive Compulsive Scale.

Sertraline was titrated in 50 mg increases every 2–4 weeks up to a maximum of 400 mg. Blood samples were taken after their morning dose. This was after the patients had stabilised for at least 2 weeks on the higher doses.

Seventeen patients were included in the study and received sertraline dosages ranging from 225 mg to 400 mg per day. Blood levels were within therapeutic range or below for all patients. Following treatment within the service, these patients generally showed an improvement of an average of improvement of 43% on the YBOCS.

A subgroup of patients with profound refractory OCD seem to either malabsorb or rapidly metabolise sertraline resulting in lower than therapeutic blood levels.

The authors have not supplied their declaration of competing interest.

To analyze the qualitative answers profile of an anonymous standardized survey, with qualitative and quantitative questions, about the Brazilian psychiatrists' perceptions on their use of the multiaxial diagnostic systems ICD 10 and DSM-IV and on their expectations about future revisions of these classifications (ICD-11 and DSM-V).

the questionnaire, elaborated by Graham Mellsop (New Zealand), was translated into Portuguese and sent through mail to 1050 psychiatrists affiliated to the Brazilian Psychiatry Association. The quantitative analysis is presented elsewhere.

One hundred and sixty questionaries returned (15,2%). From these, 71,1% of the open questions where answered. The most needed and/or desirable qualities in a psychiatric classification were found to be: simplicity, criteria clarity, objectivity, comprehensibility, reliability and ease to use. The axis I of the ICD-10 was reported to be the most used due to its instrumental character in addition to being the official classification, including for legal and bureaucratic purposes. The DSM-IV was also used in the everyday practice, mostly for education and research purposes, by psychiatrists with academic affiliations. The less frequent use of the multiaxial systems was justified by the lack of training and familiarity, the overload of information and by the fact they are not mandatory. It was evaluated that some diagnostic categories must be reviewed, like: mental retardation, eating disorders, personality disorders, sleeping disorders, child and adolescence disorders, affective and schizoaffective disorders.

This material offers a systematic panorama about the psychiatrists' opinions and expectations concerning the diagnostic instruments used in the daily practice.

Somatization is a common symptom of depression. Somatization is also related to sleep problem including insomnia.Depression is the one of the most common cuase of insomnia. Therefore, it would be needed to investigate the interaction between depression, insomnia and somatization.

To investigate the independent effects of major depressive disorder (MDD) and insomnia on somatization.

To compare somatization of primary insomnia, MDD with insomnia, MDD without insomnia, and normal controls.

A total of 181 participants without serious medical problem were recruited. Subjects were divided into 4 groups based on the SCID-IV and ICD-10 insomnia criteria:

1. 1) normal controls,

2. 2) primary insomnia,

3. 3) MDD without insomnia, and

4. 4) MDD with insomnia.

The somatization subscores of the SCL-90-R were completed by participants.

There were significant between-group differences in somatization (F=25.30, p< 0.001). MDD with insomnia showed higher somatization compared to normal controls (p< 0.001), primary insomnia (p=0.01), or MDD without insomnia (p< 0.001). Primary insomnia had higher somatization than normal controls (p< 0.01), while there was no significant difference between MDD without insomnia and normal controls. Presence of insomnia predicted higher somatization (beta=0.44, p< 0.001), while there was only non-significant association between MDD and somatization (beta=0.14, p=0.08).

In the current study, insomnia was associated with somatization independently from major depression. Subjects with primary insomnia showed higher somatization. Within MDD patients, presence of insomnia was related to higher somatization. Our finding suggests that insomnia may partly mediate the relationship between depression and somatization.

Ginkgo biloba extract EGb 761® improved neuropsychiatric symptoms (NPS) in patients with dementia in a series of trials.

To explore the effects of EGb 761® on NPS in patients with mild cognitive impairment (MCI).

A randomized, placebo-controlled, double-blind, 24-week, multi-center trial was conducted, including 160 patients with MCI who scored at least 6 on the 12-item Neuropsychiatric Inventory (NPI). Effects on NPS were assessed using the NPI, the state sub-score of the State-Trait Anxiety Inventory (STAI-X1) and the Geriatric Depression Scale (GDS). Further outcome measures were the Trail-Making Test (TMT, Forms A and B) and global ratings of change. Descriptive statistical analyses followed the intention-to-treat principle.

The NPI composite score decreased by 7.0 ± 4.5 (mean, standard deviation) points in the EGb 761®-treated group and by 5.5 ± 5.2 points in the placebo group (p = 0.001). Improvement by at least 4 points was found in 78.8% of patients treated with EGb 761® and in 55.7% of those receiving placebo (p = 0.002). Significant superiority of EGb 761® over placebo was also found for the STAI-X1 score, the informants' global impression of change and both TMT scores. There were statistical trends favoring EGb 761® in the GDS and the patients' global impression of change. Adverse events were reported by 37 patients taking EGb 761® and 36 patients receiving placebo; there were no serious adverse events.

EGb 761® improved NPS and cognitive performance in patients with MCI. The drug was safe and well tolerated.

Prevalence of autistic disorder (AD) has increased dramatically in the last three decades. The comorbidity of the disorder with attention deficit hyperactivity disorder (ADHD) is well established, but current diagnostic criteria do not allow a dual diagnosis. In Greece, neither the prevalence of autism nor its comorbidity has been adequately examined.

The aim of the present study was to explore the prevalence of AD in schoolchildren in Crete and to assess its comorbidity with ADHD.

The initial sample was consisted of 7,661 children randomly selected. The study was conducted in two stages. Screening was based on school records. Only children with diagnosis of autism from the formal child psychiatric diagnostic centers were included in the sample. For each autistic child, the Teachers Report Form and the ADHD-IV scale were applied.

Out of 7,661 children, 25 (0.3%) had AD. The estimated prevalence was 0.5% for boys and 0.1% for girls (p< 0.0001). Ten children (40%) fulfilled DSM-IV diagnostic criteria for ADHD. Age and gender were found to be associated significantly with the presence of ADHD. The most prevalent co-occurrent subtype of ADHD was the combined. There was not significant evidence of an association between academic impairment of autistic children and the presence of ADHD.

The prevalence of AD in schoolchildren in Crete, the risk factors and its comorbidity with ADHD were comparable to those reported in other countries worldwide. Younger age and male gender seems to be associated with the presence of ADHD in autistic children.

There is little known about the extent to which men and women with mental disorders are at increased risk of being a victim of domestic violence. We therefore aimed to estimate the prevalence and risk of domestic violence victimisation among men and women with depressive and anxiety disorders, post-traumatic stress disorder, eating disorders, psychotic disorders, and among psychiatric service users.

We searched 18 biomedical and social sciences databases (including MEDLINE, EMBASE and PsycINFO) and supplemented the search by hand searching of key journals and reference lists of included articles, citation tracking, expert recommendations, and updating a systematic review on victimisation among people with mental disorders. We included cross sectional, cohort and experimental studies that reported on the prevalence and/or risk of adulthood domestic violence victimisation among people meeting either ICD or DSM diagnostic criteria for a mental disorder. Two reviewers independently extracted data and appraised study quality. Random effects meta-analysis was used to pool data where possible.

High quality papers reported a median prevalence of adult lifetime domestic violence in mental health service users of 30% (IQR 26% - 39%) in female inpatients and 33% (IQR 31%-53%) in female outpatients. There was an increased risk of experiencing domestic violence in all diagnostic groups and in men and women but there were few high quality studies for men.

Mental disorder is associated with a high prevalence and increased risk of being a victim of domestic violence in both men and women.

Hyper-sexuality is an increased sexual activity that causes stress the individual at social levels. There are studies that support the theory that neurophysiological abnormalities of individuals appear in this disorder and do not overlap with the alterations found in substance addictions. However, it is doubtful whether addiction to other substances can trigger behavior in the sexual sphere.

To report a case of abuse of alcohol as a trigger relapse in terms of sexual alterations in a patient diagnosed with alcohol abuse, stimulants dependence and hyper-sexuality.

Here we report a married gentleman in the fourth decade of his life that presents behavior and sexual activity level compatible with a case of hyper-sexuality. After conducting motivational interviews with the psychologist to aim a sustained abstinence of amphetamines and a lack of alterations on the sexual sphere, the patient achieved clinical stability over several years. However, it is referred for psychiatric consultation as he presented recently abusive alcohol consumption associated with Speed. He relapsed in the sexual sphere by increasing sexual desire and impulsiveness. It was decided to prescribe oral nalmefene (1 tablet daily) for two months and then stop treatment regularly (taken PRN in case of high risk situations). As a result, he has had sustained remission for over 6 months.

Although, there are studies suggesting that neurobiological changes among the pathologies described are different, the treatment of alcohol abuse can be beneficial in other diseases such as hyper-sexuality as disinhibition associated with alcohol intoxication.

The authors have not supplied their declaration of competing interest.

Quincke-edema has been specifically associated with using certain drugs including chlorpromazine as detailed through two clinical cases.

Illustration of two clinical cases about angioedema induced by Chlorpromazine.

We reviewed clinical data from two patients who committed a suicide attempt and then transferred to the psychiatry department after their somatic stabilization: the first was 27-year-old followed in psychiatry since childhood for intellectual deficiency and admitted to the emergency department for the suicide attempt by taking 14 tablets of chlorpromazine 100 mg and the second was a 20-year-old patient, admitted to the emergency department for suicide attempt by Raticid.

The first patient presented a delusional persecution-themed syndrome with auditory hallucinations. Therefore, he was initially put on injectable treatment with Haloperidol 15mg and Diazepam 30mg then oral relay after 48h by Risperidone 4 mg and Chlorpromazine 200 mg. On the fourthday of his hospitalization, he presented a Quincke edema without laryngeal impairment. We stopped chlorpromazine and eliminated the other causes of this edema, resulting in a gradual regression of symptomatology. The second patient was put on chlorpromazine. On the second day, the patient presented a Quincke edema without laryngeal impairment. Somatic examination and biological exploration did not reveal any abnormalities. We stopped chlorpromazine and put the patient on Dexamethasone 3 days in a row resulting in a good outcome.

These two cases identified a Quincke-edema reaction associated with the use of Chlorpromazine, this complication can lead to life-threatening manifestations and warrants greater awareness of the potential for recurrence.

Patients with severe mental illness have significantly reduced lifespans. Excepting suicide, cardiovascular risk is the biggest cause. The problem is exacerbated by psychotropic medication and poor primary care engagement. Therefore psychiatrists should maximise every opportunity to promote physical health.

We audited physical examination, investigations, and documentation of past medical history (PMH) & assessments in inpatients. We used the Royal College of Psychiatrist's Physical Health in Mental Health Scoping Group 2009 guidelines as our standard.

We audited notes of all 125 patients admitted to four wards at Ladywell unit over two months (01/07/2011- 31/08/2011). We surveyed trainees to identify training and resource needs and facilitate focussed interventions.

Physical Examination: 102/125(82%) received physical examination, 60/125(48%) on admission. Average delay before examination 12 days.

Blood tests/Investigations: 89/125(71%) received blood tests: 50/125(40%) thyroid function, 67/125(54%) liver function, 28/125(22%) glucose, 1/125(0.8%) HbA1c, 38/125(30%) lipid profile. 48/125(38%) had urine drug screening, 55/125(44%) ECG.

Documentation: The following was documented: 102/125(82%) PMH, 82/125(66%) allergies, 90/125(72%) smoking status. The following was scanned into records: 23/55(42%) ECG, 72/125(58%) physical observation chart.

Survey: The trainee survey highlighted need for training updates on physical health and problems in equipment provision.

Physical assessment is inconsistent, neglecting metabolic screening. Admission is a vital window for screening/modifying physical health.

Focussed assessment guidelines should be formulated. Following the survey, teaching led by consultant physicians has been organised on identified topics including metabolic syndrome. Lack of equipment will be addressed by creation of comprehensive equipment lists, to be distributed to ward administrators.

Despite the perception that doctors should be ‘invincible’, mental illness is common in this population. Doctors and medical students have low levels of help-seeking for their own mental health problems often only presenting to mental health services once a crisis arises. Fear of exposure to stigmatization is a crucial factor to symptom concealment.

‘The Wounded Healer’ is an anti-stigma intervention that has been described as an innovative method of pedagogy that blends science with the humanities. The Wounded Healer has been delivered to more than 5000 medical students and doctors in countries all over the world.

We conducted a cross-sectional, mixed methods study. Immediately following the intervention we distributed paper questionnaires to participants who attended the Wounded Healer that contained stigma constructs. Answers were on a Likert-type scale and there was also space for free-text comments.

303/378 (80%) of participants recruited for the study responded. 246/303 (81%) of respondents either agreed or strongly agreed that the talk made them more accepting of medics suffering from psychopathology. 223/303 (73%) of respondents either agreed or strongly agreed that they were more aware of the importance of engaging in help-seeking behavior when under mental distress.

Many respondents reported in the free-text comments that the Wounded Healer was inspirational and that every medical student should receive this intervention.

A majority of respondents responded positively to the stigma constructs. This may have implications for medical students and doctors in mental distress by helping to reduce stigma and by encouraging help-seeking behavior.

Burnout is prevalent in residents and coping is one of the important modifying factors.

This study aimed to investigate coping strategies, burnout, and their relationship among residents.

A cross-sectional descriptive study was conducted among residents from October 2019 to April 2020 in Thailand. The Brief COPE Inventory Thai version and The Maslach Burnout Inventory Thai version were used, and the associations between coping strategies and burnout were examined.

The number of 280 residents replied the questionnaire (response rate 41.5%). The most favored copings were self-distraction and acceptance and the least common were denial and substance use. Most residents had high level of emotional exhaustion (n = 113, 40.4%) and moderate level of reduced personal accomplishment (n = 99, 35.4%). However, low degree of depersonalization was reported predominantly (n = 164, 58.6%). The coping of venting, behavioral disengagement and self-blame independently predicted emotional exhaustion and depersonalization. Behavioral disengagement was the only predictor of burnout in all dimensions, whereas positive reframing is the only strategy that had independent and protective effect against burnout in all dimensions.Table 1

Multivariate analysis of factors associated with emotional exhaustion

A large number of residents had emotional exhaustion. Behavioral disengagement and positive reframing were the most influential coping strategies related to burnout. This study might inform residency training program of some specific approaches for burnout prevention.

None Declared

Suicide is an important public health problem worldwide. The aim of this study was to describe the epidemiology of suicide and attempted suicide in Iran.

A retrospective study from March 2001 to March 2008 examined some characteristics of cases of suicide and attempted suicide in the Islamic Republic of Iran based on the health system database of 41 medical universities.

A total of 53 100 cases of suicide and attempted suicide were analysed. Just over half were among women (55.0%). The most favoured method of attempted suicide among both males and females was drug overdose. Self-burning was more frequent in females (5.8%) while hanging (4.5%), cutting (2.8%) and firearms (0.5%) were more common in males. There were 3883 (7.3%) completed (fatal) suicides. Hanging had the highest case fatality rate (76.5%) and drug overdose the lowest (2.3%). Older people had a higher mortality rate.

Suicide and attempted suicides increased from 8.3 per 100 000 population in 2001 to 19.4 in 2005, then declined to 16.3 in 2008.

Acute intermittent porphyria (AIP) is a rare autosomal dominant inherited metabolic disease characterized by mutations in the porphobilinogen deaminase gene. This mutation may provoke neurotoxic levels of delta-aminolevulinic-acid and porphobilinogen, potentially resulting in an acute life-threatening clinical syndrome, characterized by psychiatric, in particular atypical psychotic, symptoms as well as severe neurological and gastrointestinal symptoms. Since the clinical presentation varies and symptoms are nonspecific, diagnosis is often made late.

Naming of alarm symptoms based on a recent case study.

Description of a recent case supplemented with data from the literature.

The patient is a 46 year old woman who was admitted in 2007 with abdominal pain, an epileptic seizure and weakness, interpreted as a Guillain-Barre syndrome. In 2011 she was readmitted with severe abdominal pain, diarrhea, volatile psychotic symptoms and seizures, following a short period of excessive alcohol consumption. During admission she developed progressive weakness in the upper arms, shooting pains in the limbs and a feeling of tightness. Impaired abdominal breathing was suspected. Again, Guillain-Barré syndrome was considered, but additional studies did not support this diagnosis. Because of the recurrent character of symptomatology following alcohol abuse, acute (intermittent) porphyria was considered diagnostically. The dark-colored urine indeed contained significantly increased delta-aminolevulinic-acid and porphobilinogen concentrations. Additional (genetic) diagnosis follows.

A recurrent disease course with severe gastrointestinal, neurological and psychiatric symptoms, following alcoholabuse, is suspect for AIP.

Despite the availability of an ever-expanding range of typical and atypical antipsychotics, a substantial proportion of patients with schizophrenia show a partial or total lack of response to antipsychotic mono therapy. This study was done to evaluate the effect of purslane on psychologic symptoms of schizophrenic patients.

This randomized clinical trial study was carried out on 60 chronic schizophrenic patients in Sina hospital Shahrekord, Iran during 2011-12. Subjects were randomly divided into intervention and control groups. The control group received Risperidone up to 6mg/day and Biperiden 4mg/day for 8 weeks. The Patients in interventional group received 1gr extract of purslane daily with the same regimen for 8 weeks. The scales for assessment of positive symptoms (SAPS) and assessment of negative symptoms (SANS) were recorded in prior and 8th weeks. In addition, CRP and MDA level of patients were assessed in two stage of study.

At the end of study, the mean score of positive symptoms were 47.93±18.56 and 57.1±14.83 in intervention and control groups, respectively (P< 0.05), and the mean score of negative symptoms were 40.83±11.03 and 46.13± 9.34 (P< 0.05).The CRP levels of patients in intervention and control groups were .53±.55 and 1.72±.73 at 8 week respectively (P< .05) and the MDA levels were 3.25±1.25 and 5.43± 1.76 respectively (P< .05).

According to findings of this study, the use of purslane as an adjunct to Respridone can improve psychological condition of chronic schizophrenic patients and decrease MDA and CRP levels of them.

Cancer is a leading cause of death worldwide and India is no exception to this. The controversies and necessity of assessing the prevalence of psychological morbidity with validated instruments in cancer patients, which can have important ramifications, in service delivery led to the present study.

To study the Prevalence and correlates of psychiatric morbidity in cancer patients and find the factors associated with psychiatric illness in cancer patients in a tertiary care centre.

Patients admitted in Radiotherapy ward of Medical College Trivandrum who met inclusion and exclusion criteria were assessed using translated and validated MINI 6.0, delirium rating scale and Adjustment disorder questionnaire after obtaining informed consent.

Of the 384 patients assessed the prevalence of Psychiatric disorders was 41.7% with adjustment disorders contributing to 22.6%, major depressive disorders 10.9%, delirium 6.5%, and hypomania 1.6% and age, past history of chemotherapy, past history of radiotherapy, & surgical treatment of carcinomas were significantly associated with psychiatric disorders.

Cancer is associated with Psychiatric disorders and affects patients. Psychological interventions can alleviate the distress of these persons and provisions of psychological support should be is an important component in the care of these patients.

Relapse rate among patients with schizophrenia can determinate outcome of illness. Up to 40% of patients with first psychosis responds well to treatment. Despite this fact relapse rate is still high, in particular if treatment is discontinuated. Frequent use of first generation antipsychotics (FGA) in underdeveloped countries can be one of possible reasons for treatment discontinuation and consequent relapse.

To analyse rehospitalisation rate in patients with first and multiple episodes of schizophrenia, and compare it with medication choice.

Retrospective analysis of medical records of patients with schizophrenia hospitalised in Psychiatry Clinic of University Clinical Center Tuzla in period from year 2011 to 2013.

During the two-year period, 37 patients with first episode of schizophrenia were hospitalised. Second generation antipsychotics (SGA) were used in 40.5%, and first generation in 13.5%, long acting injectibles - first generation (LAI) were used in 8.1%, and combination of FGA's and SGA's in 5.4% of cases. In the same period, 121 patients with multiple episodes of schizophrenia were hospitalised. SGA were used in 21.4%, FGA in 33%, LAI's in 47.1%, and combination FGA's and SGA's in 35.5% of cases. Relapse rate in the first year after discharge was 16.2% in group with first psychotic episode, and 33% in the group with multiple episodes of schizophrenia.

High relapse rate in group with multiple episodes can be explained with nonadherence regarding the side effects of too frequent use of FGA's.

The authors have not supplied their declaration of competing interest.

It has been estimated that around 10-20% of all pregnant women suffer from antenatal depressive or anxiety symptoms. These symptoms have been associated with multiple adverse child outcomes including obstetric problems, e.g. preterm delivery, Apgar score and low birth weight. Therefore, considerable health gains may be achieved if depression and anxiety during the perinatal period are adequately treated. Nevertheless, to date, no previous trials have published on the effects of Cognitive Behavioral Therapy (CBT) during pregnancy on child outcomes.

The ´Pregnancy Outcomes After a Maternity Intervention for Stressful Emotions´ (PROMISES) trial is a randomized controlled trial, which compares the effects of CBT vs. care as usual (CAU) during pregnancy among a group of women with (sub)clinically depressive and/or anxiety symptoms (n=226) on both maternal and child outcomes. Child outcomes comprise a range of obstetric outcomes including birth weight, Apgar score, and gestational age. Independent samples t-tests were performed to investigate differences in mean values.

No significant differences were found between the CBT- and the CAU-groups, in gestational age (39+0 vs 39+2 weeks+days, p=.99), birth weight (3447 vs 3509 grams, p=.24), or Apgar score at 1 (8.6 vs 8.6, p=.99), 5 (9.5 vs 9.6, p=.31), and 10 minutes (9.7 vs 9.8, p=.26).

Although CBT as early treatment of antenatal depression and anxiety is most likely to be effective for prevention of postpartum depression, CBT seems to have no effect on major obstetric outcomes.

In this study we aimed to explore the role of inflammation in subjects with mild Alzheimer dementia (AD), mild cognitive impairment (MCI) and subjective cognitive decline (SCD) via new potential inflammation markers of Neutrophil-lymphocyte ratio (NLR) and Platelet-lymphocyte ratio (PLR). NLR and PLR are useful and cost-effective biomarkers, showing peripheral systemic inflammation, were previously shown in neuropsychiatric disorders [1].

In screening phase the patients were assessed with mini-mental state examination, clinical dementia rating scale (CDR), geriatric depression scale (GDS) and Hachinski Ischemic Scale (HIS) after unstructured psychiatric interview according to diagnostic and statistical manual of mental disorder, Text Revised (DSM-IV, TR). Spectrum of cognitive decline includes 31 patients with mild Alzheimer's disease, 30 subjects with mild cognitive impairment, 31 individuals with subjective cognitive decline. Thirty-one healthy controls enrolled to the study.

NLR value of patients with AD was 2.38 ± 0.81, subjects with MCI was 2.48 ± 1.19, SCD group was 2.24 ± 1.11 and control group was 1.85 ± 0.80. NLR was significantly higher in AD and MCI groups when compared with control group (P = 0.006, P = 0.03, respectively). Platelet-lymphocyte ratio was not correlated with cognitive impairment. Neutrophil counts were indifferent when comparing either of groups. Lymphocyte levels were significantly lower in each of cognitive decline groups when compared to healthy controls.

The present findings suggest that systemic inflammation may have a role in developing Alzheimer's Disease.

The authors have not supplied their declaration of competing interest.