Regarding the diagnosis of schizophrenia, a peak of onset of symptoms is considered at 25 years. The debut after 60 years is considered late onset and is rare, generating controversies in the diagnosis

We present the case of a 58-year-old patient with no personal or family history of mental health, who came to the emergency room for the first time, reporting feeling in danger. He comments itching on his skin, verbalizing seeing bugs running through it, relating this phenomenon to “witchcraft by my brothers”, he also refers to feeling like “they watch my thoughts and block it through a mobile application, they enter through my eye right and this gives me less vision and a headache. He also refers to having the ability to listen to how his brothers talk about how they are going to “hurt me.” Psychopathologically, we highlight that she is oriented in the three spheres, presenting delusional ideation with an experience of harm, a phenomenon of thought theft and auditory and tactile hallucinations.

Analytical and imaging tests, as well as toxins in urine, were negative.

Diagnosis of psychotic episode is made to see evolution. The clinic partially yields to treatment with atypical antipsychotics. At this time, the patient has no awareness of the disease.

Despite being a diagnosis that is scarcely prevalent, once organic disease has been ruled out.

None Declared

The primary aim of the present study was to compare the effects of agomelatine and venlafaxine XR on anhedonia in patients with Major Depressive Disorder. Secondary endpoints were to test its antidepressant and anxiolytic efficacy.

Sixty patients received randomly agomelatine (25–50 mg/day; N = 30) or venlafaxine XR (75-150 mg/day, N = 30). Psychopathological assessment was performed at baseline and over eight weeks of treatment with the Snaith Hamilton Rating Scale (SHAPS), the Hamilton Depression Rating Scale (HAM-D), the Hamilton Anxiety Rating Scale (HAM-A) and the Clinical Global Impression (CGI).

Both groups showed an overall significant reduction in times for SHAPS, HAM-D and HAM-A. A significant difference between times was observed for SHAPS scores in Agomelatine group: from baseline of 6.5 (T0) to 4 at week 1 (−2.5) (T1), 3.5 at week 2 (−3.0) (T2), and 3.4 at week 8 (−2.9) (T3). In the venlafaxine group, the reduction on SHAPS scores was not significant between visits (p = .08). At the last observation a significant difference between groups in favour of agomelatine was observed for SHAPS scores (D = 2.2; p < 0.05); moreover, only patients treated with agomelatine showed a significant improvement in CGI scores from baseline (D = 2.94, p < 0.05).

Agomelatine showed significantly greater efficacy on anhedonia and at least similar antidepressant efficacy to venlafaxine in patients with Major Depressive Disorder, with a better clinical improvement. Therefore, the efficacy of agomelatine on anhedonia, a potential trait marker of vulnerability for depression, holds particular importance in the treatment of patients with depressive features.

The COVID-19 pandemic has been causing relevant public health and psychosocial consequences.

To assess the impact of the COVID-19 pandemic on mental health, lifestyle and personal relationships in the Italian general population.

An online survey spread between May and June 2020 to collect socio-demographic, clinical, lifestyle, relationship, and mental health self-reported information. Mental disorder screening was performed by the Patient Health Questionnaire and PTSD Checklist for DSM-5.

Participants were 2003, 1504 of which (75%) completed the entire questionnaire (1157 females, 77%). Among the completers who have not had any mental disorder before (n=524, 35%), 263 (51.7%) met cut-off scores for psychiatric diagnoses on the self-report psychiatric screeners during the pandemic (i.e., Major Depressive Disorder, 11.3%, with death thoughts in approximately half of the cases; Panic Disorder, 1.1%; Generalized Anxiety Disorder, 13%.3, Obsessive-Compulsive Disorder, 13.2%, Post-Traumatic Stress Disorder, 7.3%; Alcohol Abuse, 5.5%). In line with this, 39% of completers complained of insomnia, while 12% and 10% started using anxiolytics and antidepressants, respectively. Approximately 7-8 % of completers started/increased alcohol and/or nicotine consumption, 33% quitted/decreased physical activity, and 40% declared decreased sexual satisfaction. Approximately 21% and 38% declared worsening in relationship with partner and difficulty in child-caring, respectively.

The COVID-19 pandemic appears to be a risk factor for new onset of mental disorders and worsening in lifestyle and familial relationships in the Italian population. These results should be confirmed by clinical interviews, and may represent a starting point for further monitoring of the medium and long-term consequences of the COVID-19 pandemic.

No significant relationships.

Psychoeducational interventions are promising long-term therapeutic options for bipolar disorder. We have developed a novel, web-based psychoeducational treatment for bipolar disorder, called “Beating Bipolar” www.BeatingBipolar.org. This was developed using an interative process involving several focus groups with patients, carers, families and professionals. The key areas covered in the package are: i) diagnosis; ii) causes; iii) medication; iv) lifestyle; v) relapse prevention and early intervention; vi) psychological approaches; vii) gender-specific considerations and viii) advice for family and carers. The 8 modules are delivered online on a fortnightly basis over a four-month period.

We aim to test the acceptability of the package to users and are currently conducting an exploratory randomised clinical trial (Trial registration: ISRCTN81375447).

The primary outcome measure will be quality of life, measured using the WHOQOL-Bref, and secondary outcome assessments will include scores on the Global Assessment of Functioning (GAF), the Functioning Assessment Short Test (FAST), the Schedule of Assessment of Insight (SAI), the Montgomery Asberg Depression Rating Scale (MADRS), the Young Mania Rating Scale (YMRS), and the number and severity of depressive and manic or hypomanic episodes experienced during the 10-month follow-up period. An assessment of costs and a detailed process evaluation involving qualitative interviews with participants will also be completed.

Initial findings will be presented during the symposium.

It is expected that findings from this exploratory trial will inform the design of a definitive randomised controlled trial of this intervention in the future.

There is strong association between depression and mortality rates among patients with CHF. Despite the massive burden of cardiac disease as well as that of depression in Pakistan, there is limited data regarding the prevalence of depression in patients suffering from CHF. The aim of this study was to assess prevalence of depression in patients with CHF and to compare the health related quality of life of depressed and non-depressed patients with CHF.

A total of 1009 patients diagnosed with CHF were recruited from different public hospitals in Karachi, Pakistan. Depression was assessed at baseline using the Beck Depression Inventory (BDI) and health related quality of life was assessed using Euro Qol (EQ-5D).

Of the 1009 participants recruited to the study, 66.4% (n = 670) met the threshold for depression using the BDI measure. Of the depressed patients, 66.7% (n = 447) were male. Preliminary results indicate that participants who were depressed at baseline had poorer health related quality of life on EQ-5D measures as compared to those who were non-depressed (mean EQ-5D descriptive score 10.45 in depressed patients vs 7.37 in non-depressed patients and mean EQ-5D visual scale score 35.09 in depressed patients vs 52.19 in non-depressed patients).

Considering the high prevalence of depression and its serious negative impact on quality of life of patients suffering from chronic physical illness, it is important to design and test culturally adapted psychosocial interventions to reduce depression and improve quality of life for these patients.

The authors have not supplied their declaration of competing interest.

Lithium was the first mood stabilizer and today continues to be a first-line treatment in the treatment of bipolar disorder despite its adverse effects, which make it important to monitor blood levels and control kidney function.

Presentation of a case of litium withdrawal and relapse in bipolar disorder. Literature review relating to the risk of relapse when lithium treatment is interrupted.

We present a clinical case of a patient who suffers a deterioration in renal function that requires the withdrawal of lithium and who consequently suffers a relapse. We conducted a bibliographic research of articles in Pubmed on this topic.

A 49-year-old male, with a history of multiple admissions to UHB since the age of 18 with a diagnosis of bipolar disorder and treatment with lithium. Decompensations towards the manic pole have always been related to interruptions in lithium treatment. On several occasions when the patient was feeling well emotionally, he believed himself to be “cured” and abandoned the treatment, triggering a manic episode, showing verbal aggression, increased self-esteem and delusional ideation of harm. Remission was usually achieved with the reintroduction of lithium and the addition of high-dose quetiapine. Between episodes, constant overvalued ideas of economic scarcity seemed to persist, which were accentuated in the form of delusional ideas of ruin in depressive decompensations. After 7 years of stability, control analysis showed blood litemia of 2.2 mEq/L with deterioration of kidney function and generalized tremor was observed, without improvement after serum therapy. He was admitted for dialysis and lithium was suspended. Treatment with valproate was started and a consultation scheduled in a week to adjust the dose. The patient did not attend that consultation and was admitted three days later to Psychiatry Hospitalization showing a challenging attitude, evident dysphoric mood, accelerated speech, with derailments and echolalia. Delusional ideation of harm with auditory hallucinations. Insomnia and hyporexia. Chronic renal failure persisted.

Lithium is a very effective drug but with a narrow therapeutic range that requires adequate monitoring due to the possible consequences of its use at different organs and systems of the body. when lithium is found in the blood at toxic levels with deterioration of kidney function and glomerular filtration fails to recover, lithium treatment should be suspended. Sudden withdrawal of lithium significantly increases the risk of relapse due to rebound effect. More than 50% of patients experience a recurrence within 10 weeks of withdrawal.

None Declared

Trazodone is a heterocyclic antidepressant that exerts its effect via the inhibition of selective serotonin reuptake and the antagonism of 5-HT2A and 5-HT2 C receptors. Antidepressant-induced gynecomastia and galactorrhea and increases in prolactin levels have rarely been reported.

A 73-year-old man presented to the psychiatric clinic with depressive symptoms and insomnia that was the reason that his GP introduced paroxetine 20 mg/day three months before. One month later because the insomnia persisted, trazodone (100 mg/day) was added to the treatment. At a 2-month follow-up, the patient reported improvement in depressive symptoms but also presented gynecomastia on the left side that is non-tender on palpation. No other medications were noted. Laboratory testing was within normal limits, with the exception of on elevated prolactin level (38.2 ng/mL). Ultrasonography indicated normal results. Treatment included the tapering and discontinuation of trazodone with continued paroxetine therapy. Lorazepam was initiated for the treatment of insomnia. Two weeks later, the prolactin level was 13.1 ng/mL and gynecomastia was practically resolved. Lorazepam was initiated for the treatment of insomnia.

Effects of trazodone on PRL are unclear, there is one study reported that trazodone increases the PRL level, and another one reported that trazodone reduces them, in our case, the trazodone use led to hyperprolactinemia via hypothalamic postsynaptic receptor stimulation and it should be remembered that gynecomastia and galactorrhea may appear as a rare side effect of trazodone.

The authors have not supplied their declaration of competing interest.

The grey matter heterotopias are a relatively common group of conditions characterized by interruption of normal neuronal migration from near the ventricle to the cortex. Subependymal grey matter heterotopia, also known as periventricular heterotopia, is the most common form.

To search a link between bipolar disorder and grey matter heterotopia

A case report of a woman with grey matter heterotopia who is diagnosed as bipolar

A 34 year old woman was admitted at Razi psychiatric hospital 3 months after childbirth. She was agitated, logorrheic with multiple projects and insomniac. The diagnosis was a manic episod with a marked score of 28/44 at The Bech-Rafaelsen Mania Scale (MAS). The patient was treated with 4 mg of risperidone and 1000 mg of sodium valproate with partial remission after two weeks. One month after her discharge, she had depressive mood, asthenia, anhedonia and insomnia. She had a score of 19 at Hamilton Depression Rating Scale (HDRS). She was switched from risperidone to olanzapine 15mg/j with partial remission after two weeks. In front of persistent symptoms with labile mood, she took lithium 1000 mg/j. She was complaining of a headache and a fluctuating heaviness of the right upper limb. At brain imaging, she had periventricular nodular heterotopia. The patient was adressed to neurology department.

Grey matter heterotopia can cause a variety of neuropsychiatrc symptoms which can lead to diagnosis difficulties. Therefore, in front of atypical symptoms or drug-resistance, patients should be referred for brain imaging.

No significant relationships.

Racism is present in most aspects of our society, including healthcare. Differences in health outcomes, and in the quality of mental health treatment for people coming from ethnic minority groups have been demonstrated in the literature. Psychiatry trainees are required to understand the impact of structural inequalities and power differences within mental health services, and to be able to deliver clinical care that is equitable for all.

To provide psychiatry trainees with a space to reflect on unconscious racial bias in clinical work and to explore potential barriers when talking about such topics.

A Race and Equality Reflective Group for psychiatry trainees was organised as an opportunity to discuss unconscious racial bias. Due to an insufficient number of registrations, the session was cancelled. An anonymous feedback questionnaire was sent to all trainees to understand reasons behind this, and to explore potential barriers to participation. The results were analysed and were brought back to a regular Balint group for further exploration.

Twelve trainees filled in the questionnaire. The main themes identified included this topic being a sensitive issue (5; 41.7%), discomfort in trainees (5; 41.7%), insufficient time to participate (4; 33%) and timetable clash (3; 25.9%). Barriers to discussing unconscious racial bias and inequality were identified in further exploration with trainees. The tendency for groups to adopt a split position that was observed, mirrors the dynamics seen in institutional racism.

This work has highlighted the need for ongoing focused, facilitated educational spaces where these issues can be openly discussed and reflected upon.

No significant relationships.

Inhibition capabilities have been shown to be a strong predictor of social and educational life outcomes (Mischel & Ebbesen, 1970; Shoda et al., 1990). Inhibition capabilities have an enormous impact on attention and impulsivity (Bari & Robbins, 2013). These two executive functions are associated with numerous psychiatric disorders but are not well understood in terms of white matter (WM) connectivity (Puiu et al., 2018). Novel techniques and statistical approaches in neuroimaging bring us closer to a biologically sustained model.

This research aims to: 1) identify WM connections associated with attention/impulsivity performance and 2) characterize the differences in WM microstructure associated with the variation of the performance.

157 children (GESTE cohort, 8-12 years, 27 Dx ADHD, 2 Dx ASD) with b=1500mm2/s, 2mm isotropic dMRI acquisitions were included. Tractography was performed with TractoFlow pipeline (Theaud et al., 2020). Dimensionality reduction of diffusion metrics yielded two components : microstructural complexity (DTI Metrics, AFD & NuFo) and axonal density (AFD_fixel) (Chamberland et al., 2019). Attention/impulsivity were evaluated with the CPT3. Multivariate linear regression was performed in python.

Lower microstructural complexity was associated with poorer attentional performance on regions of the parietal lobe to the occipital gyrus (P-O, p=0.044, R2=0.14, Figure 1.) and the Broadman’s area 8 to area 6 (SF8-SF6, p=0.002, R2=0.12, Figure 1.). Lower axonal density was associated with a less impulsive pattern on SF8-SF6 (p=0.001, R2=0.13, Figure 1.). Results remained significant when removing children with an ADHD or ASD diagnosis.

We identified underlying difference in WM microstructure that may be associated with the variation in attention/impulsivity performance in school-aged children.

No significant relationships.

Studies on psychiatric patients have shown that the presence of autistic traits affects the effectiveness of the treatment, decreasing the likelihood of positive clinical outcomes.

The aim of the present study is to investigate which are the areas of overlap between psychiatric symptoms and the traits of the autism spectrum using a bayesian approach.

A sample of 190 adult psychiatric patients, diagnosed with schizophrenia, bipolar disorder, major depression, and personality disorder participated in the study. The RAADS-R questionnaire was used to assess the presence of autistic traits. The severity of psychiatric symptoms was measured with the BPRS and PANSS scales, the perceived well-being and disability using the Whodas and Whoqol scales, the TOL and STROOP for the measurement of executive functions, the attentional matrices for visual-spatial attention, the Raven for general cognitive skills.

No difference emerged between the diagnoses regarding the presence of symptoms of the autism spectrum, which affects 64% of subjects. Logistic regression showed that the severity of symptoms measured as BPRS and PANSS predicted the probability of having autistic traits. Bayesian regression showed that specific autistic traits are indicative of executive functions deficits. Namely, motor impairment severity measured at RAADS is strongly predicted by rule violation with number of correct moves measured at TOL. The other executive functions seemed to be only moderately linked to autistic traits.

These results provide new information about the expression of comorbidity with autism in psychiatric patients.

More than 50% of women with endometriosis report that they suffer from sexual dysfunctions, the most significant of which is pain, which can subsequently be associated with stress, anxiety, depression. The aim of this study was to evaluate the relationship between sexual function, stress, anxiety and depression together with the values of stress hormones such as cortisol and prolactin in women with endometriosis.

Endometriosis can occur in up to 15% of women. A characteristic feature is the presence of tissue resembling the endometrium outside the uterine cavity. Endometriosis is an estrogen-dependent disease that is associated with fertility disorders (incidence up to 40%) and sexual dysfunction (up to 50% of patients). Endocrine and immune changes may be associated with chronic stress, anxiety and even depression.

A total of 92 patients with endometriosis were included in the study. Clinical examinations were focused on biochemical analysis of cortisol and prolactin. At the same time, sexual function, symptoms of stress, anxiety and depression were psychometrically evaluated in these patients.

In the mutual statistical assessment, positive correlations were found between the results of the Beck scale questionnaire for assessing the severity of depression (BDI-II) and PRL (R = 0.39), then confirmed by Mann-Whitney test (z-score is 5.98019, p value is <0.00001, result is significant at p <0.05). Furthermore, the correlation between BDI-II and HAM-A (R = 0.33), confirmed by the Mann-Whitney test (z-score is -8.55827, p value is <0.00001, the result is significant at p <0.05) (Fig.). Positive correlations were found between TSC-40 and FSDS-R (R = 0.30), confirmed by Mann-Whitney test (z-score is 3.89503, the value of p is 0., 0001, the result is significant at p <0.05). We also found a high correlation between PRL and HAM-A (R = 0.86). Cortisol levels did not show any positive correlation.

Sexual dysfunction usually accompanies up to 50% of patients with endometriosis. This in turn affects the mental health and well-being of not only the patients, but also their sexual partners. The results of this study are consistent with the hypothesis of possible relationships between stress, anxiety, depression and neuroendocrine markers in patients with endometriosis.

Women diagnosed with the symptoms of endometriosis should also be examined for psychosocial and psychiatric disorders at the same time. In this regard, it is important not to underestimate the psychological assessment of those patients who are at risk of developing symptoms of anxiety and depression and to provide them with appropriate psychological support.

None Declared

The pathological gambling (PG) is an impulse control disorder with clinical features common to other psychiatric disorders such as addictions and obsessive-compulsive disorder (OCD). The pathophysiology of PG is still unclear, but it is hypothesized that it might include environmental factors coupled with a genetic vulnerability and dysfunctions of different neurotransmitters such as norepinephrine, dopamine, glutamate and serotonin. The serotoninergic system seems to be primarily involved, as has been shown to regulate the impulsivity and aggression.

With this study we aim to assess the impulsivity in 26 PG as compared with a matched group of healthy controls (HC).

Twenty-six outpatients, with a diagnosis of PG according to DSM-IV criteria, and 26 HC were included in the study. The severity of symptoms was evaluated by the South Oaks Gambling Screen (SOGS) and the impulsivity was assessed by Barratt Impulsivity Scale, version 11 (BIS-11).

The results showed that the PG patients had a higher BIS-11 total score, as compared with HC, and higher scores of two factors of the same scale: the motor and attentional impulsivity. Even the motor and non-planning impulsivity subscales scores were higher in patients than in HC.

These results suggest that PG patients are more impulsive than control subjects. This feature could lead to a loss of control typical of PG.

It is well-known that depression is one of the significant risk factors for suicidality, but alone it is not sufficient.

Research has shown that the correlation between depression and suicidality became non-significant when hopelessness was statistically controlled, and that it is psychache that directly leads to suicide and mediates the effects of depression and hopelessness. We therefore explored depression, hopelessness and psychache (DHP) as a predictors of suicidality in patients diagnosed with psychotic disorders (PDs).

To identify patients at risk of suicidality.

The study sample consisted of 59 patients diagnosed with a PDs (schizophrenia spectrum and delusional disorders), mean age of 35.25 years (SD 8.25). Assessment instruments included the Beck Scale for Suicide Ideation, the Beck Depression Inventory II, the Beck Hopelessness Scale and The Psychache Scale.

There was a positive correlation between DHP and intensity of suicidality and factors of suicidal motivation and preparation. Regression analysis indicates that DHP contribute to 45,9% of the variance of intensity of suicidality (F=17,433, df=3, p 0,01), to 32.9% of the variance of suicidal motivation (F = 10.479, df = 3, p 0,01), and to 57.1% of the variance of suicidal preparation (F = 26.775, df = 3, p 0,01). Depression was the only significant predictor of intensity of suicidality and suicidal motivation, with hopelessness as the only significant predictor of suicidal preparation.

In patients diagnosed with PDs, depression was a significant predictor of intensity of suicidality and suicidal motivation, and hopelessness was a significant predictor of suicidal preparation.

Patient microaggressions and hate speech affect practitioners in all fields of healthcare. In some facilities, 100% of healthcare workers report experiencing harassment and hate speech, with the aggressors most frequently being patients. To date, there has been no systematic review of policies, recommendations and trainings on patient microaggressions and hate speech against healthcare professionals.

A systematic review was conducted to identify recommendations and solutions for healthcare professionals on responding to patient microaggressions and hate speech. Additionally, websites of major healthcare professional organizations and the 6 largest healthcare systems were checked for policy statements related to discrimination by patients towards healthcare providers.

A literature search of PubMed, PsycINFO, Medline, ERIC and MedEdPORTAL. Articles that contained recommendations and trainings for responding to microaggressions and hate speech were retained. 13 Leading professional organizations and 6 healthcare systems were checked for policies on discrimination by patients.

Our review identified 27 studies providing recommendations and trainings for healthcare professionals to address patient hate speech and microaggressions. Three professional organizations but no healthcare systems had policies on discrimination by patients.

Seven trainings that equip providers with tools to address patient microaggressions and hate speech were identified. Trainings included the ERASE framework; Stop, talk, and roll; interrupting microaggressions; and the OWTFD tool. Nineteen studies outlined recommendations for healthcare professionals and systems on how to respond to patient offenses. Professional organizations and healthcare systems need to create policies to support healthcare professionals who face microaggressions and hate speech.

According to international scientific literature, and as summarized in the guidelines of the International Society of Hypertension, lowering of blood pressure can prevent cardiovascular accidents. Some studies suggest that hypertension, anxiety, and depression might be inversely correlated.

To investigate whether blood pressure is associated with anxiety and depression.

Cross-sectional design. Male and female primary care patients were enrolled, aged 40–80. Criteria of exclusion adopted: use of antidepressants or antipsychotics; previous major cardiovascular event; psychosis or major depression; Type 1-DM; pregnancy and hereditary disease associated to obesity. Anxiety and depression symptoms were assessed using HADS. Waist circumference, hip circumference, blood pressure, HDL, triglycerides, blood sugar, hypertension, albumin concentrations and serum iron were also assessed.

Of the 210 subjects, 84 were men (40%), mean age was 60.88 (SD ± 10.88). Hypertension was found to correlate significantly to anxiety (OR = 0.38; 95% CI = 0.17–0.84), older age (OR = 3.96; 95% CI = 1.88–8.32), cigarette smoking (OR = 0.35; 95%CI = 0.13–0.94), high Body Mass Index (OR = 2.50; 95% CI = 1.24–5.01), Waist-hip ratio (OR = 0.09; 95% CI = 0.02–0.46) and the Index of comorbidity (OR = 16.93; 95% CI = 3.71–77.29).

An inverse association was found between anxiety and hypertension, suggesting the need to clinically manage these two dimensions in a coordinated way. Other findings are well known and already included in prevention campaigns. Further research is needed, also to better understand and explain the causative pathways of this correlation.

The authors have not supplied their declaration of competing interest.