In Southeast Europe (SEE) standard treatment of patients with psychosis is largely based on pharmacotherapy with psychosocial interventions rarely available. DIALOG+ is a digital psychosocial intervention designed to make routine care therapeutically effective. This trial simultaneously examined effectiveness of DIALOG+ versus standard care on clinical and social outcomes (Aim 1) and explored intervention fidelity (Aim 2).

A hybrid type II effectiveness–implementation, cluster-randomized trial was conducted in five SEE countries: Bosnia and Herzegovina, Kosovo*, Montenegro, North Macedonia, and Serbia. The intervention was offered to patients six times across 12 months instead of routine care. The outcomes were subjective quality of life (primary), clinical symptoms, satisfaction with services, and economic costs. Intervention fidelity was operationalized as adherence to the protocol in terms of frequency, duration, content, and coverage. Data were analyzed using multilevel regression.

A total of 81 clinicians and 468 patients with psychosis were randomized to DIALOG+ or standard care. The intervention was delivered with high fidelity. The average number of delivered sessions was 5.5 (SD = 2.3) across 12 months. Patients in the intervention arm had better quality of life (MANSA) at 6 months (p = 0.03). No difference was found for other outcomes at 6 months. Due to disruptions caused by the COVID-19 pandemic, 12-month data were not interpretable.

DIALOG+ improved subjective quality of life of individuals with psychosis at 6 months (after four sessions), albeit with small effect size. The intervention has the potential to contribute to holistic care of patients with psychosis.

Results of a co-morbid insomnia and depression study of eszopiclone and fluoxetine demonstrated that co-therapy produced greater improvements in sleep and depression than fluoxetine monotherapy. To determine if changes in the HAMD17 were due to sleep, individual HAMD17 items were evaluated.

Patients met DSM-IV criteria for MDD and insomnia, with screening HAMD17 >14. All patients received fluoxetine QAM for 10 weeks, and randomly received double-blind eszopiclone 3mg or placebo QHS for 8 weeks, followed by a single-blind placebo 2-week run-out. HAMD17 was completed at Weeks 4, 8, and 10. Individual items were compared with ANCOVA using an LOCF approach.

Mean baseline HAMD17 scores were 22 for each group. At Week 4, differences were noted between treatment groups in the total score, and the individual items of insight, the three insomnia items (p<0.02 vs monotherapy), with a trend for guilt (p=0.07). At Week 8, significant differences between groups were noted in total score (p=0.0005), in the clinician-administered Bech subscale (p<0.001), in the three insomnia items (p<0.001), guilt, work/activities, and anxiety psychic (p<0.05). At Week 10, the total score, guilt, the three insomnia items, work/activities, retardation, agitation, anxiety psychic, general somatic symptoms, and hypochondriasis demonstrated significant improvements (p<0.05 vs monotherapy) despite discontinuation of eszopiclone.

Eszopiclone/fluoxetine co-therapy resulted in significant improvements in the insomnia items of the HAMD17. In addition, several items related to core depressive symptoms were also improved with co-therapy compared with monotherapy.

Support for this study provided by Sepracor Inc.

Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed features experiences symptoms of both mood “poles” – mania and depression – simultaneously or in rapid sequence.

To review the nosological status of bipolar mixed states and its treatment.

Online search/review of the literature has been carried out, using Medline/Pubmed, concerning “mixed states”, “affective disorder”, “bipolar disorder”.

The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The presence of mixed features is associated with a worse clinical course and higher rates of comorbidities. There is ongoing debate about the role of antidepressants in the evolution of such states.

Clinical vigilance and careful evaluation are required to ensure mixed states are not missed in the clinical context. Atypical antipsychotics are emerging as the medications of choice in the pharmacological management of mixed states.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The author has not supplied his declaration of competing interest.

Postpartum depression affects around 12% of mothers in developed countries, with consequences for the whole family. Many women with depressive symptoms remain undetected and untreated. The aim of this study was to investigate to what extent women with depressive symptoms at 6 weeks postpartum are identified by the healthcare system, the interventions they received, and remission rates at 6 months postpartum.

Postpartum women scoring 12–30 on the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks after delivery (n = 697) were identified from the longitudinal cohort study “Biology, Affect, Stress, Imaging and Cognition” (BASIC) in Uppsala, Sweden. A total of 593 women were included. Background and remission information at 6 months was collected from the BASIC dataset. Medical records were examined to identify interventions received.

Most women (n = 349, 58.7%) were not identified by the healthcare system as having depressive symptoms and 89% lacked any record of interventions. Remission rates at 6 months postpartum were 69% in this group. Among women identified by the healthcare system, 90% received interventions and about 50% were in remission at 6 months postpartum. The EPDS reduction during the study period was largest in the group identified by the child health services (CHS, −5.15) compared to the non-identified (−4.24, p < 0.001).

Despite screening guidelines, many women with depressive symptoms had no documentation of screening or interventions by the healthcare system. Furthermore, a significant proportion did not achieve remission despite interventions. Being identified by CHS was associated with the largest reduction of symptoms. Research is needed to understand gaps in the healthcare processes, to better identify peripartum depression.

The comorbidity between cardiometabolic and psychotic disorders develops early. This is a crucial window of opportunity to reduce excess morbidity and mortality. Recently, a cardiometabolic risk prediction algorithm for young people with psychosis, the psychosis metabolic risk calculator (PsyMetRiC) was developed and externally validated in the UK. However, its international transportability is unknown.

We performed the first international validation study of PsyMetRiC in Lausanne, Switzerland, and examined whether additional variables (clinical and/or genetic) may improve the predictive performance of the algorithm

We included people aged 16-35y with psychosis from the PsyMetab cohort, who did not have MetS at baseline, and who had 1-6y follow-up data. The PsyMetRiC partial (age, sex, ethnicity, body mass index, smoking status, and prescription of a metabolically-active antipsychotic) and full (also including high-density lipoprotein and triglycerides) algorithms were applied. Predictive performance was assessed using measures of discrimination (C-statistic) and calibration (calibration plots). Recalibration steps included refitting the intercept and/or slope if necessary. Additional variables (e.g. speed of weight gain, polygenic risk scores) were added to the model and predictive performance was reassessed.

We included 545 participants. The discrimination performance of both PsyMetRiC algorithms was good (C>0.75), and calibration plots showed good agreement between observed and predicted risk. Additional analyses to be conducted.

PsyMetRiC is likely to be generalizable for use in Switzerland, suggesting that PsyMetRiC may also be suitable for use in other European populations. While additional international validations are required, these findings are an encouraging step toward an international cardiometabolic risk prediction algorithm for young people with psychosis.

No significant relationships.

Modulators of the brain renin-angiotensin system (RAS) have been shown to improve cognitive functioning in several animal models of neuropsychiatric disorders. Moreover, the brain RAS has been considered a new target for the treatment of Alzheimer's disease (AD). However, there are no population-based follow-up studies supporting this hypothesis.

Cross-sectional and prospective relationships between cognitive decline and ARB treatment were examined in the population-based Kuopio Ischemic Heart Disease Risk Factor Study.

To evaluate procognitive/antidementia capacity of orally delivered angiotensin II receptor blockers (ARB).

The study was conducted on a sample of 1774 subjects (920 females, 854 males; age range at baseline: 42–61 years) from Eastern Finland. An established cutoff score of at least 2-point decrease in the Mini Mental State Examination over a 9-year follow-up was used to detect age-related cognitive decline in the cross-sectional setting. In the prospective setting, a hospital discharge diagnosis of dementia/AD was used as outcome variable. Cross-sectional relationships were determined with logistic regression and prospective analyses were conducted with the Cox proportional hazards model (both adjusted for relevant background variables).

Cross-sectional analysis displayed a decrease of the odds of cognitive decline (n = 87; 4.9% of participants) in those with ARB treatment; OR = 0.445, 95% CI: 0.22–0.90, P = 0.024. Furthermore, in the prospective setting, the risk of dementia/AD diagnosis (n = 149; 8.4% of participants) was significantly reduced in ARB treated participants; HR = 0.621, 95% CI: 0.40–0.98, P = 0.038.

ARB treatment is associated with a decreased risk for age-related cognitive decline and dementia/AD manifestation.

The authors have not supplied their declaration of competing interest.

It is known that female reproductive events and hormonal treatments can impact the course of bipolar disorder (BD) in women, some of whom are more vulnerable to the development of mood instability under periods of hormonal fluctuation. The mechanisms involved are, however, largely unknown. The aim of this work is to review the impact of sexual hormones on the course of BD, regarding a clinical case.

To explore the role of sexual hormones in BD.

Literature review using Medline database.

This is a case of a 36-year-old woman with type 1 BD who develops a manic episode after starting oral contraception (OC). This episode remitted with suspension of the pill. Estrogen and progesterone are involved in various aspects of brain function, such as brain development, synaptic plasticity, and modulation of neurotransmitter systems. Studies indicate that there is a relationship between ovarian hormones and intracellular signaling systems involved in the pathophysiology of BD. However, research on OC use in patients with mood disorders is limited. Recent studies state that OC aren’t associated with a worse clinical course and don’t negatively influence BD, while other studies show there is a subgroup of bipolar women that improve with hormonal stability, while others get worse.

Further studies are needed to determine possible relationships between sexual hormones and BD, and it is essential to identify patients vulnerable to these risks by measuring baseline hormone levels, assessing hormone sensitivity through a history of mood changes during menstrual cycle and a history of previous mental health problems.

No significant relationships.

Depression is a debilitating mental disorder that often coexists with anxiety. The genetic mechanisms of depression and anxiety have considerable overlap, and studying depression in non-anxiety samples could help to discover novel gene. We assess the genetic variation of depression in non-anxiety samples, using genome-wide association studies (GWAS) and linkage disequilibrium score regression (LDSC).

The GWAS of depression score and self-reported depression were conducted using the UK Biobank samples, comprising 99,178 non-anxiety participants with anxiety score <5 and 86,503 non-anxiety participants without self-reported anxiety, respectively. Replication analysis was then performed using two large-scale GWAS summary data of depression from Psychiatric Genomics Consortium (PGC). LDSC was finally used to evaluate genetic correlations with 855 health-related traits based on the primary GWAS.

Two genome-wide significant loci for non-anxiety depression were identified: rs139702470 (p = 1.54 × 10−8, OR = 0.29) locate in PIEZO2, and rs6046722 (p = 2.52 × 10−8, OR = 1.09) locate in CFAP61. These associated genes were replicated in two GWAS of depression from PGC, such as rs1040582 (preplication GWAS1 = 0.02, preplication GWAS2 = 2.71 × 10−3) in CFAP61, and rs11661122 (preplication GWAS1 = 8.16 × 10−3, preplication GWAS2 = 8.08 × 10−3) in PIEZO2. LDSC identified 19 traits genetically associated with non-anxiety depression (p < 0.001), such as marital separation/divorce (rg = 0.45, SE = 0.15).

Our findings provide novel clues for understanding of the complex genetic architecture of depression.

“Viaje del Parnaso” is a volunteering project developed at the Day Center Aranjuez2 (CD2) for helping adults with SMI to get a satisfactory and responsible occupation through their implication in a volunteering work in the community, while involved in the maintenance of a green area in the city of Aranjuez.

The aim of this study was to evaluate the impact of the project on the volunteers’ lives in terms of personal growth and environment conservation and compare its results with non-volunteers also attended at the CD2.

The project was carried once a week during 45 weeks. 11 volunteers participated on the project, plus 5 non-volunteers were considered as cuasi-control group. The instruments applied were an item on “environment conservation” and 2 subscale items of “Personal Growth” from the Ryff Scales of psychological well-being. Measures were applied at baseline, 6 and 12 months after.

Significant differences were found on the environment conservation item between volunteers at baseline and 6 months after (P < 0.05). Results also revealed a significant difference (P < 0.05) between volunteers and non-volunteers at both variables (“environment conservation” and “Personal Growth”) in baseline and 6 months after treatment.

The data from this study suggest that a volunteering program seems to be an effective intervention for bringing about improvements in well-being of people with SMI, and also for increasing their environmental awareness. These improvements may also help to change the stigma of SMI reinforcing mental health patient's contributions to society.

The authors have not supplied their declaration of competing interest.

Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline.

The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-Åsberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression.

Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline.

Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

Mindfulness refers to a process that leads to a mental state characterized by non-judgmental awareness of the present moment experience, including one´s sensations, thoughts, bodily states, consciousness, and the environment, while encouraging openness, curiosity, and acceptance.

The purpose of this paper is to review the ways in which cognitive and behavioural treatments for depression and anxiety have been advanced by the application of mindfulness practices.

Brief non-systematic literature on the topic.

Mindfulness has spread rapidly in Western psychology research and practice, in large because of the success of standardized mindfulness-based interventions, consequently research on mindfulness based interventions (MBIs) has increased exponentially in the past decade. The most common include Mindfullness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), which incorporate the essence of Eastern mindfulness practices into the Western cognitive-behavioral practice. MBIs have showed efficacy in reducing the severity of anxiety and depressive symptoms in a broad range of treatment seeking individuals. MBIs have also been showed to perform with not so different results to cognitive-behavioral therapy (CBT).

MBIs have been showed to be important co-adjuvants to pharmacological treatment and psychotherapy of depression and anxiety. To prove this point without doubts and create adequate guidelines that include these forms of treatment more research needs to be done on the matter.

None Declared

During Covid-19 pandemic schools in Greece were closed and distance education instituted.

To find out whether the pandemic circumstances and the catholic internet access affected the time students spend on web activities other than educational duties.

Our sample consisted of 1213 parents with children from 4th, 5th, and 6th elementary school grades. They were collected with snowball sampling through internet, and they filled closed ended questions anonymous questionary.

During the pandemic the amount of time that children spent on the internet for purposes other than school obligations (social media, videogames, videos) was increasing by the time. On holidays and weekends this time was further increased. Parents mentioned reduced sleep time, reduced interest in hobbies and activities, as well as in person social communication with friends and loss of interest for school and educational matters. Children spend a lot of time on internet activities and sometimes they use it to avoid loneliness and negative situations. According to parents if their child doesn’t spend its preferrable time on the internet, get anxious, irritable, and sad. Often the child hides the time of internet use. Children from families with low socioeconomic, educational level, family income are more vulnerable to develop internet problematic use.

Social isolation, school closures, distance education, cancellation of after school activities and the facile internet access increased problematic internet use. This use is associated with behavioural, emotional and psychosocial problems. It is important to give information and implement educational programs for parents about how to control internet use of their children.

No significant relationships.

A traumatic brain injury (TBI) can cause numerous psychiatric complications. Humor and anxious disorders, personality disorders and psychoses are some of those possible problems. The diagnosis of psychosis due to traumatic brain injury (PDTBI), although controversial, has been subject of crescent debate and the idea that a TBI could cause a psychosis is gaining credibility. Diagnosing a PDTBI can be difficult. DSM-5 criteria are rather vague and there are many potential confounding factors due to similarities with other etiological psychosis.

Alert clinicians to the diagnosis of PDTBI, clarify this clinical entity and define features that may allow them to do the differential diagnosis with other etiologic psychotic disorders.

The authors performed a research in PubMed using the keywords psychosis and traumatic brain injury and selected the adequate articles to meet the objectives proposed.

Differential diagnosis of PDTBI should be done with schizophrenia, schizoaffective psychosis, delusional disorder, substance-induced psychosis, psychosis due to other medical condition and with posttraumatic stress disorder. Differentiating PDTBI and schizophrenia can be particularly difficult. Some features have been proposed in the literature as potentially differentiating, namely the presence of negative symptoms (more common in schizophrenia), findings in MRI/CT and EEG.

Establishing PDTBI diagnosis can be difficult. While awaiting new studies, clinicians should, in cases of TBI related psychosis, achieve a meticulous clinical history and mental exam, in order to ensure a correct diagnosis and, therefore, determine an appropriate intervention.

The author has not supplied his/her declaration of competing interest.

Deficient emotion regulation is a common and impairing area of difficulty among children and adolescents with externalizing disorders. Emotion focused cognitive behavioral therapy ECBT is a form of CBT that is suggested to be employed to improve dysregulation of anxiety and other kind of emotions in anxious youth.

Examine the efficacy of an Emotion-focused Cognitive-Behavioral Therapy (ECBT) inspired program on emotional regulation difficulties and behavioral problems in children and adolescents with externalizing disorders

We conducted a cross-sectional comparative experimental study. Subjects were 50 patients exhibiting behavioral disorders aged 9 to 18 years , with a diagnosis of attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).Participants were assigned to ECBT and control groups. ECBT group contributed in 12-h weekly sessions within ECBT-inspired program. The control group received standard care. To assess emotion-related competencies, children were administered the emotion regulation questionnaire (ERQ-CA) and the alexithymia questionnaire for children(AQC). Parents completed the Child Behavior Checklist(CBCL) to measure youth externalizing problems. Tests were administered in pre- and post-test to all subjects. Both groups were matched for age, sex and educationnal level. Comparison of pre- and post-test results was performed using the Student’s t-test.

ECBT demonstrated a significant difference in the reduction of behavioral problems. ECBT effectively increased adaptive emotion regulation strategies (cognitive reappraisal) in the post-test. ECBT also reduced alexithymia scores, particularly difficulty identifying feelings, and externally oriented thinking.

ECBT demonstrated promising initial effectiveness in addressing emotion regulation deficits of children with externalizing behaviors

No significant relationships.

There are only a few studies focusing on the religious delusion in relation to Schneider’s first rank symptoms, compared to the presence of these symptoms in paranoid delusions.

This study aims to explore the particularities of Schneider’s first rank symptoms in relation to religious delusion.

The study included 40 subjects with religious delusions. The cases were chosen from the Case Register of Psychoses of the Psychiatric Clinic in Timisoara and they have been followed longitudinally during a 15 year period. All of them had a stable 5 year ICD-10 diagnosis of Schizophrenia, Schizo-affective disorder or Persistent delusional disorder. The following variables were considered: demographic parameters (at onset and at present), clinical and evolutional aspects (including the number of relapses and the diagnostic stability) and psychopathological parameters regarding the variety of psychotic symptoms and the patient’s interpretation of Schneider’s first rank symptoms. The symptomatology was assessed using a method derived from the SCAN instrument and the data were analyzed qualitatively.

Differences between the subjects’ experiences of first rank symptoms in relation to paranoid delusions and religious delusions were observed. The subjects experiencing religious delusions often interpreted the first rank symptoms as being common, normal experiences.

In religious delusion, Schneider’s first rank symptoms are accepted and interpreted by the patient as common actions of supernatural beings, especially in schizo-affective episodes, being different from the interpretation of these symptoms when in relation to paranoid delusions.

Neuroleptic malignant syndrome (NMS) may be a life-threatening neurologic crisis primarily emerging as an idiosyncratic reaction to antipsychotic agent use, and characterized by a particular clinical syndrome of mental status alter, rigidity, fever and dysautonomia. Mortality results straightforwardly from the dysautonomic manifestations of the disease and from systemic complications.

To describe an unusual clinical case in order to determine the management regarding medication and electroconvulsive therapy (ECT), and provide an overview of NMS for the general practitioner with the most up-to-date information on etiology, workup, and management.

We report a case involving a 55-year-old man with paranoid schizophrenia disorder who presented with hyperthermia, hemodynamic instability, miosis, muscular rigidity, urinary incontinence, catatonic signs and mutism after combining several antipsychotics at the same time: long-acting injectable form of paliperidone, aripiprazol and haloperidol.

Guidelines for specific medical treatments in NMS are based upon case reports and clinical experience. Generally used agents are dantrolene, bromocriptine, and amantadine. A conceivable approach is to start with benzodiazepines along with dantrolene in moderate or severe cases, followed by the addition of bromocriptine or amantadine. ECT is generally reserved for patients not responding to other treatments.

NMS is an uncommon adverse drug reaction, with a multifactor pathophysiology and manifestation. Early diagnosis and interruption of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. ECT is an effective treatment when supportive treatment together with pharmacotherapy fails. It could be considered first line in severe life-threatening situations. It is advisable to consider maintenance ECT due to the high risk of relapse.

No significant relationships.