A Case of Panic Disorder Misdiagnosed as Epilepsy for 9 Years in a Young Male.

Panic disorder can be misdiagnosed as epilepsy and vice versa, which, in turn, can impact the patient, their family, and the healthcare system. Here, we describe a rare case of a 22-year-old male with a 9-year history of misdiagnosed drug-resistant epilepsy. On presentation to our hospital, the patient's physical examination and other investigations were unremarkable. The attacks were reported to last for about 5-10 minutes and were related to interfamilial distress. He reported feeling anxious about having an attack, experiencing palpitations and sweating before and during episodes, feeling chest tightness, derealization, and fearing loss of control, based on which a diagnosis of panic disorder was made. The patient was treated with 12 sessions of cognitive behavioral therapy, following which all his antiepileptic medications were stopped over 8 weeks. The dose of sertraline was increased and maintained at 200 mg once daily and was gradually stopped after 6 months of remission. This case highlights that panic disorder should be considered as a differential diagnosis of epilepsy. This can be done through a cross-specialty referral, especially given that the clinical manifestations of hyperventilation syndrome can be diagnosed differently by neurologists, psychiatrists, and other specialists.

Therapeutic antischizophrenic activity of prodigiosin and selenium co-supplementation against amphetamine hydrochloride-induced behavioural changes and oxidative, inflammatory, and apoptotic challenges in rats.

Schizophrenia (SCZ), a multifactorial neuropsychiatric disorder, is treated with inefficient antipsychotics and linked to poor treatment outcomes. This study, therefore, investigated the combined administration of prodigiosin (PDG) and selenium (Na2SeO3) against SCZ induced by amphetamine (AMPH) in rats. Animals were allocated into four groups corresponding to their respective 7-day treatments: control, AMPH (2 mg/kg), PDG (300 mg/kg) + Na2SeO3 (2 mg/kg), and AMPH + PDG + Na2SeO3. The model group exhibited biochemical, molecular, and histopathological changes similar to those of the SCZ group. Contrastingly, co-administration of PDG and Na2SeO3 significantly increased the time for social interaction and decreased AChE and dopamine. It also downregulated the gene expression of NMDAR1 and restored neurotrophin (BDNF and NGF) levels. Further, PDG combined with Na2SeO3 improved the antioxidant defence of the hippocampus by boosting the activities of SOD, CAT, GPx, and GR. These findings were accompanied by an increased GSH, alongside decreased MDA and NO levels. Furthermore, schizophrenic rats having received PDG and Na2SeO3 displayed markedly lower IL-1ß and TNF-α levels compared to the model group. Interestingly, remarkable declines in the Bax (pro-apoptotic) and increases in Bcl-2 (anti-apoptotic) levels were observed in the SCZ group that received PDG and Na2SeO3. The hippocampal histological examination confirmed these changes. Collectively, these findings show that the co-administration of PDG and Na2SeO3 may have a promising therapeutic effect for SCZ. This is mediated by mechanisms related to the modulation of cholinergic, dopaminergic, and glutaric neurotransmission and neurotrophic factors, alongside the suppression of oxidative damage, neuroinflammation, and apoptosis machinery.

Cultural adaptation and validation of the mental illness associated stigma scale for Arabic-speaking population in Saudi Arabia.

Objective: This research aimed to culturally adapt and validate the MIAS scale for Arabic-speaking individuals within the Saudi Arabian general population, with an emphasis on cultural, societal, and individual nuances. Methods: An initial pilot testing with a small group ensured the scale's clarity. Subsequently, two cross-sectional studies involving 189 participants to assess structural validity of the Arabic MIAS scale, and 38 participants to assess the test-retest reliability. Descriptive statistics, Cronbach's α, Intraclass Correlation Coefficient (ICC), and Confirmatory Factor Analysis (CFA) were employed for data analysis. Results: The Arabic MIAS scale demonstrated good internal consistency and acceptable test-retest reliability (ICC α = 0.631). A three-factor model emerged (CFI = 0.890, TLI = 0.845, RMSEA = 0.094), including "Outcomes," "Negative Stereotypes," and "Recovery," closely mirroring the original study's structure. one item was excluded from the model since it didn't align with any of the three factors. Conclusion: The study contributes a culturally adapted, validated, non-condition-specific tool to gauge public attitudes toward mental health stigma in an Arabic context. It highlights the need for culturally sensitive stigma research and interventions and underscores the importance of improving such tools for cross-cultural applicability and comparability.

Attempting to Increase the Effectiveness of the Antidepressant Trazodone Hydrochloride Drug Using π-Acceptors.

Major depressive disorder is a prevalent mood illness that is mildly heritable. Cases with the highest familial risk had recurrence and onset at a young age. Trazodone hydrochloride is an antidepressant medicine that affects the chemical messengers in the brain known as neurotransmitters, which include acetylcholine, norepinephrine, dopamine, and serotonin. In the present research, in solid and liquid phases, the 1:1 charge-transfer complexes between trazodone hydrochloride (TZD) and six different π-acceptors were synthesized and investigated using different microscopic techniques. The relation of dative ion pairs [TZD+, A-], where A is the acceptor, was inferred via intermolecular charge-transfer complexes. Additionally, a molecular docking examination was utilized to compare the interactions of protein receptors (serotonin-6BQH) with the TZD alone or in combination with the six distinct acceptor charge-transfer complexes. To refine the docking results acquired from AutoDock Vina and to better examine the molecular mechanisms of receptor-ligand interactions, a 100 ns run of molecular dynamics simulation was used. All the results obtained in this study prove that the 2,6-dichloroquinone-4-chloroimide (DCQ)/TZD complex interacts with serotonin receptors more efficiently than reactant donor TZD only and that [(TZD)(DCQ)]-serotonin has the highest binding energy value of all π-acceptor complexes.

Multispectral and Molecular Docking Studies Reveal Potential Effectiveness of Antidepressant Fluoxetine by Forming π-Acceptor Complexes.

Poor mood, lack of pleasure, reduced focus, remorse, unpleasant thoughts, and sleep difficulties are all symptoms of depression. The only approved treatment for children and adolescents with major depressive disorder (MDD) is fluoxetine hydrochloride (FXN), a serotonin selective reuptake inhibitor antidepressant. MDD is the most common cause of disability worldwide. In the present research, picric acid (PA); dinitrobenzene; p-nitro benzoic acid; 2,6-dichloroquinone-4-chloroimide; 2,6-dibromoquinone-4-chloroimide; and 7,7',8,8'-tetracyanoquinodimethane were used to make 1:1 FXN charge-transfer compounds in solid and liquid forms. The isolated complexes were then characterized by elemental analysis, conductivity, infrared, Raman, and 1H-NMR spectra, thermogravimetric analysis, scanning electron microscopy, and X-ray powder diffraction. Additionally, a molecular docking investigation was conducted on the donor moiety using FXN alone and the resulting charge transfer complex [(FXN)(PA)] as an acceptor to examine the interactions against two protein receptors (serotonin or dopamine). Interestingly, the [(FXN)(PA)] complex binds to both serotonin and dopamine more effectively than the FXN drug alone. Furthermore, [(FXN)(PA)]-serotonin had a greater binding energy than [FXN]-serotonin. Theoretical data were also generated by density functional theory simulations, which aided the molecular geometry investigation and could be beneficial to researchers in the future.

Spectroscopic and Molecular Docking Studies of Cu(II), Ni(II), Co(II), and Mn(II) Complexes with Anticonvulsant Therapeutic Agent Gabapentin.

New Cu(II), Ni(II), Co(II), and Mn(II) complexes of the gabapentin (Gpn) bidentate drug ligand were synthesized and studied using elemental analyses, melting temperatures, molar conductivity, UV-Vis, magnetic measurements, FTIR, and surface morphology (scanning (SEM) and transmission (TEM) electron microscopes).The gabapentin ligand was shown to form monobasic metal:ligand (1:1) stoichiometry complexes with the metal ions Cu(II), Ni(II), Co(II), and Mn(II). Molar conductance measurements in dimethyl-sulfoxide solvent with a concentration of 10-3 M correlated to a non-electrolytic character for all of the produced complexes. A deformed octahedral environment was proposed for all metal complexes. Through the nitrogen atom of the -NH2 group and the oxygen atom of the carboxylate group, the Gpn drug chelated as a bidentate ligand toward the Mn2+, Co2+, Ni2+, and Cu2+ metal ions. This coordination behavior was validated by spectroscopic, magnetic, and electronic spectra using the formulas of the [M(Gpn)(H2O)3(Cl)]·nH2O complexes (where n = 2-6).Transmission electron microscopy was used to examine the nanostructure of the produced gabapentin complexes. Molecular docking was utilized to investigate the comparative interaction between the Gpn drug and its four metal [Cu(II), Ni(II), Co(II), and Mn(II)] complexes as ligands using serotonin (6BQH) and dopamine (6CM4) receptors. AutoDock Vina results were further refined through molecular dynamics simulation, and molecular processes for receptor-ligand interactions were also studied. The B3LYP level of theory and LanL2DZ basis set was used for DFT (density functional theory) studies. The optimized geometries, along with the MEP map and HOMO → LUMO of the metal complexes, were studied.

Increasing the Efficacy of Seproxetine as an Antidepressant Using Charge-Transfer Complexes.

The charge transfer interactions between the seproxetine (SRX) donor and π-electron acceptors [picric acid (PA), dinitrobenzene (DNB), p-nitrobenzoic acid (p-NBA), 2,6-dichloroquinone-4-chloroimide (DCQ), 2,6-dibromoquinone-4-chloroimide (DBQ), and 7,7',8,8'-tetracyanoquinodi methane (TCNQ)] were studied in a liquid medium, and the solid form was isolated and characterized. The spectrophotometric analysis confirmed that the charge-transfer interactions between the electrons of the donor and acceptors were 1:1 (SRX: π-acceptor). To study the comparative interactions between SRX and the other π-electron acceptors, molecular docking calculations were performed between SRX and the charge transfer (CT) complexes against three receptors (serotonin, dopamine, and TrkB kinase receptor). According to molecular docking, the CT complex [(SRX)(TCNQ)] binds with all three receptors more efficiently than SRX alone, and [(SRX)(TCNQ)]-dopamine (CTcD) has the highest binding energy value. The results of AutoDock Vina revealed that the molecular dynamics simulation of the 100 ns run revealed that both the SRX-dopamine and CTcD complexes had a stable conformation; however, the CTcD complex was more stable. The optimized structure of the CT complexes was obtained using density functional theory (B-3LYP/6-311G++) and was compared.

Enhancement of Haloperidol Binding Affinity to Dopamine Receptor via Forming a Charge-Transfer Complex with Picric Acid and 7,7,8,8-Tetracyanoquinodimethane for Improvement of the Antipsychotic Efficacy.

Haloperidol (HPL) is a typical antipsychotic drug used to treat acute psychotic conditions, delirium, and schizophrenia. Solid charge transfer (CT) products of HPL with 7,7,8,8-tetracyanoquinodimethane (TCNQ) and picric acid (PA) have not been reported till date. Therefore, we conducted this study to investigate the donor-acceptor CT interactions between HPL (donor) and TCNQ and PA (π-acceptors) in liquid and solid states. The complete spectroscopic and analytical analyses deduced that the stoichiometry of these synthesized complexes was 1:1 molar ratio. Molecular docking calculations were performed for HPL as a donor and the resulting CT complexes with TCNQ and PA as acceptors with two protein receptors, serotonin and dopamine, to study the comparative interactions among them, as they are important neurotransmitters that play a large role in mental health. A molecular dynamics simulation was ran for 100 ns with the output from AutoDock Vina to refine docking results and better examine the molecular processes of receptor-ligand interactions. When compared to the reactant donor, the CT complex [(HPL)(TCNQ)] interacted with serotonin and dopamine more efficiently than HPL only. CT complex [(HPL)(TCNQ)] with dopamine (CTtD) showed the greatest binding energy value among all. Additionally, CTtD complex established more a stable interaction with dopamine than HPL-dopamine.

Investigating Predictors of Psychological Distress for Healthcare Workers in a Major Saudi COVID-19 Center.

This study investigated the relationship between fear of COVID-19, previous exposure to COVID-19, perceived vulnerability to disease, sleep quality, and psychological distress among healthcare workers (HCWs) in Taif city in Saudi Arabia, which has a population of 702,000 people. A cross-sectional study design was adopted. HCWs (n = 202) completed a survey containing the Fear of COVID-19 Scale (FCV-19S), Perceived Vulnerability to Disease (PVD), Pittsburgh Sleep Quality Index (PSQI), and Depression, Anxiety, and Stress Scale (DASS-21). FCV-19S and sleep quality were significant predictors for psychological distress. Female gender was a significant predictor for depression and stress. Single, divorced, and widowed marital status were predictive for anxiety. FCV-19S was weakly correlated with PVD but moderately with depression, anxiety, and stress. Of the two PVD subscales, perceived infectability was weakly correlated with psychological distress. PVD and previous experience with COVID-19 were not significant predictors. Sleep quality and FCV-19S were major predictors of psychological distress. Findings indicated that poor sleep quality was strongly associated with psychological distress, while fear of COVID-19 had a moderate association. Such results support the need to design and implement psychological programs to assist HCWs in dealing with the psychological impact of this ongoing pandemic.

Enhancing the Antipsychotic Effect of Risperidone by Increasing Its Binding Affinity to Serotonin Receptor via Picric Acid: A Molecular Dynamics Simulation.

The aim of this study was to assess the utility of inexpensive techniques in evaluating the interactions of risperidone (Ris) with different traditional π-acceptors, with subsequent application of the findings into a Ris pharmaceutical formulation with improved therapeutic properties. Molecular docking calculations were performed using Ris and its different charge-transfer complexes (CT) with picric acid (PA), 2,3-dichloro-5,6-dicyanop-benzoquinon (DDQ), tetracyanoquinodimethane (TCNQ), tetracyano ethylene (TCNE), tetrabromo-pquinon (BL), and tetrachloro-p-quinon (CL), as donors, and three receptors (serotonin, dopamine, and adrenergic) as acceptors to study the comparative interactions among them. To refine the docking results and further investigate the molecular processes of receptor-ligand interactions, a molecular dynamics simulation was run with output obtained from AutoDock Vina. Among all investigated complexes, the [(Ris) (PA)]-serotonin (CTcS) complex showed the highest binding energy. Molecular dynamics simulation of the 100 ns run revealed that both the Ris-serotonin (RisS) and CTcS complexes had a stable conformation; however, the CTcS complex was more stable.

Selenium Nanoparticles with Prodigiosin Rescue Hippocampal Damage Associated with Epileptic Seizures Induced by Pentylenetetrazole in Rats.

BACKGROUND: Prodigiosin (PDG) is a red pigment synthesized by bacterial species with important pharmaceutical and biological activities. Here, we investigated the neuroprotective and anticonvulsant activities of green biosynthesized selenium formulations with PDG (SeNPs-PDG) versus pentylenetetrazole (PTZ)-induced epileptic seizures. METHODS: Rats were assigned into six experimental groups: control; PTZ (60 mg/kg, epileptic model); sodium valproate (200 mg/kg) + PTZ; PDG (300 mg/kg) + PTZ; sodium selenite (0.5 mg/kg) + PTZ; and SeNPs-PDG (0.5 mg/kg) + PTZ. The treatment duration is extended to 28 days. RESULTS: SeNPs-PDG pre-treatment delayed seizures onset and reduced duration upon PTZ injection. Additionally, SeNPs-PDG enhanced the antioxidant capacity of hippocampal tissue by activating the expression of nuclear factor erythroid 2-related factor 2 and innate antioxidants (glutathione and glutathione derivatives, in addition to superoxide dismutase and catalase) and decreasing the levels of pro-oxidants (lipoperoxidation products and nitric oxide). SeNPs-PDG administration inhibited inflammatory reactions associated with epileptic seizure development by suppressing the production and activity of glial fibrillary acidic protein and pro-inflammatory mediators, including interleukin-1 beta, tumor necrosis factor-alpha, cyclooxygenase-2, inducible nitric oxide synthase, and nuclear factor kappa B. Moreover, SeNPs-PDG protected against hippocampal cell loss following PTZ injection by decreasing the levels of cytosolic cytochrome c, Bax, and caspase-3 and enhancing the expression of anti-apoptotic Bcl-2. Interestingly, SeNPs-PDG restored the PTZ-induced imbalance between excitatory and inhibitory amino acids and improved monoaminergic and cholinergic transmission. CONCLUSIONS: These promising antioxidative, anti-inflammatory, anti-apoptotic, and neuromodulatory activities indicate that SeNPs-PDG might serve as a naturally derived anticonvulsant agent.

Capsule Machine Validation.

Instrumentation has become an integral function for any compounding operation, particularly for hard-gelatin capsules. This study examined the use of a capsule machine in a simulated compounding operation. It is an instrument that is reasonably priced and can deliver 24 capsules within ten minutes of operation. Capsule Connection LLC suggests the use of this machine for filling capsules with herbal or vitamin preparations. Moreover, this instrument may be used for training pharmacy students in a pharmaceutics/compounding laboratory. The main objective of the research was to calibrate and validate a capsule formulation for acetaminophen using the Capsule Machine from Capsule Connection LLC. Twenty Capsule Machines were purchased from Capsule Connection LLC. The machines were first calibrated and then validated using spray-dried lactose monohydrate powder. Based on the results obtained from the calibration and validation process, a powder mixture containing acetaminophen was prepared by mixing acetaminophen with lactose in a glass mortar using the geometric dilution method. The labeled amount of acetaminophen per capsule was 81 mg. Capsules generated from this compounding operation were tested using the United States Pharmacopeia content uniformity test. The calibration and validation processes were repeated twice with lactose monohydrate. The overall average weights for size-0 capsule shells and lactose-filled capsules were 94.61 mg and 545.77 mg, respectively. On average, the content of a capsule was estimated to be 451.16 mg of powder. A powder mixture was prepared to make 480 capsules (20 machines, each producing 24 capsules). This mixture was made of 38.88 g of acetaminophen and 177.68 g of lactose. A 3% amount of additional powder was added to account for the powder loss during the operation. All capsule machines passed the United States Pharmacopeia content uniformity test. The average amount of acetaminophen per capsule was 98.91% of the labeled amount. Only less than 5% of the capsules were lost during the filling operation of lactose in capsules and none lost with the acetaminophen capsules. The Capsule Machine from Capsule Connection LLC produced capsules containing acetaminophen with high reproducibility and accuracy.

Depression and suicidal ideation among dental students of Southern Saudi Arabia: A cross sectional study.

PURPOSE: To assess depression and suicidal ideation among dental students at King Khalid University College of Dentistry, Abha, Saudi Arabia. METHODS: A cross-sectional questionnaire-based study was carried out among dental students between January and March 2020. The Arabic version of the Patient Health Questionnaire (PHQ-9) was used to assess depression, while suicidal ideation was assessed using three questions related to suicidal behaviors drawn from the literature. RESULTS: A total of 218 participants completed the questionnaires. More than 40% of the participants experienced depression while the prevalence of suicidal ideation was 48.2%; around a third of the sample had suicidal ideation, and half of which made a suicidal attempt in the preceding year (p < 0.05). There was a lack of association between depression severity and suicidal ideation. CONCLUSION: A large proportion of dental students experienced depression and suicidal ideation. These findings invite in depth analysis of the causative and contributing factors for such high rates as well as ways for addressing them.

Effects of Fear of COVID-19 on Mental Well-Being and Quality of Life among Saudi Adults: A Path Analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has been very disruptive, and thus is likely to result in substantial challenges to mental health. OBJECTIVES: This study aimed to investigate the effects of fear of COVID-19 on the mental well-being and quality of life among Saudi adult population and to evaluate the impact of perceived social support. MATERIALS AND METHODS: This cross-sectional study used an anonymous online survey, where participants were administered the Fear of COVID-19 Scale, Hospital Anxiety and Depression Scale, European Health Interview Survey-Quality of Life and Medical Outcomes Study Social Support Survey. A path analysis was used to investigate the proposed theoretical domain structure linking fear of COVID-19 with perceived social support, mental well-being and quality of life. RESULTS: A total of 1029 Saudi adults with a mean age of 33.7 years (SD 11.5) responded to the survey. Descriptive analysis showed that this sample was fearful of COVID-19, anxious and depressed but, at the same time, reported high quality of life and perceived social support scores. Path analysis indicated that increased fear of COVID-19 was directly associated with diminished mental well-being, which in turn was associated with lower quality of life. The beneficial effects of perceived social support were stronger on quality of life than on mental well-being. No direct link was found between fear of COVID-19 and quality of life. CONCLUSION: These findings emphasize the importance of having effective social systems in place to minimize the impact of the COVID-19 pandemic on mental well-being and quality of life.

Psychometric Evaluation of the Arabic Version of the Fear of COVID-19 Scale.

Fear is a central emotional response to imminent threats such as the coronavirus-19 disease (COVID-19). The Fear of COVID-19 Scale (FCV-19S) assesses the severity of fear towards COVID-19. The present study examined the psychometric properties of the Arabic version of the FCV-19S. Using a forward-backward translation, the FCV-19S was translated into Arabic. An online survey using the Arabic versions of FCV-19S and the Hospital Anxiety and Depression Scale (HADS) was administered. Reliability and concurrent and confirmatory validity were examined. The dataset consisted of 693 Saudi participants. The internal consistency of the Arabic FCV-19S was satisfactory (α = .88), with sound concurrent validity indicated by significant and positive correlations with HADS (r = .66). The unidimensional structure of the FCV-19S was confirmed. The Arabic version of the FCV-19S is psychometrically robust and can be used in research assessing the psychological impact of COVID-19 among a Saudi adult population.

Impact of Using a 3D Visual Metaphor Serious Game to Teach History-Taking Content to Medical Students: Longitudinal Mixed Methods Pilot Study.

BACKGROUND: History taking is a key component of clinical practice; however, this skill is often poorly performed by students and doctors. OBJECTIVE: The study aimed to determine whether Metaphoria, a 3D serious game (SG), is superior to another electronic medium (PDF text file) in learning the history-taking content of a single organ system (cardiac). METHODS: In 2015, a longitudinal mixed methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) on a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). In total, 1 participant left the PDF group after allocation was revealed and was excluded. A total of 24 students in the game group and 14 students in the PDF group completed follow-up 7 weeks later. Using an iterative design process for over a year, with input from a variety of clinical disciplines, a cardiac history-taking game and PDF file were designed and informed by Cognitive Load Theory. Each group completed its intervention in 40 min. A total of 3 levels of Kirkpatrick training evaluation model were examined using validated questionnaires: affective (perception and satisfaction), cognitive (knowledge gains and cognitive load), and behavioral attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated before data collection. RESULTS: Compared with baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (P<.001). Apart from the game group having a statistically significant difference in terms of satisfaction (P<.001), there were no significant differences between groups in knowledge gain, self-efficacy, cognitive load, ease of use, acceptability, or objective structured clinical examination scores. However, qualitative findings indicated that the game was more engaging and enjoyable, and it served as a visual aid compared with the PDF file. CONCLUSIONS: Students favored learning through utilization of an SG with regard to cardiac history taking. This may be relevant to other areas of medicine, and this highlights the importance of innovative methods of teaching the next generation of medical students.

Social anxiety apps: a systematic review and assessment of app descriptors across mobile store platforms.

QUESTION: The aim of this systematic review is twofold: (1) to characterise the purpose and description of available social anxiety apps and (2) to review the evidence on the effectiveness of social anxiety apps. STUDY SELECTION AND ANALYSIS: A search was conducted on three major mobile platforms: Apple iTunes, Google Play and Windows Store. Apps were included if they addressed social anxiety and used an English language interface. A systematic review of the literature from MEDLINE, EMBASE, PsycINFO, Cochrane, Scopus and Web of Science to identify evidence-based evaluations of social anxiety apps was also undertaken. FINDINGS: Of the 1154 apps identified, 38 apps met the inclusion criteria: iTunes (n=18), Google Play (n=16) and Windows Store (n=4). Over 60% of apps were exclusively focused on social anxiety, while the remainder targeted social anxiety and related conditions. Most developers did not provide information on their organisational affiliations or their content source. Most apps used multimedia while 17 apps used text only. Finally, although the systematic review of the literature identified 94 articles, none of which met inclusion criteria. CONCLUSIONS: Social anxiety apps have the potential to overcome barriers to accessing treatment; however, none of the apps identified have had studies on their effectiveness published. As the evidence base is lacking, it is therefore not currently possible to recommend their use.