Criminality in Greece during the years of financial crisis: 2008-2014.

The link between poverty, unemployment and economic downturns and increases in crime rates has long been the subject of social science study. However, the relationships between these phenomena has not been studied sufficiently and through time in most European countries that suffered, or, like Greece, are still suffering the recent financial crisis. We examined if the recent financial crisis in Greece has coincided with an increase in crime, analyzing crime rates since the start of the financial crisis and over an extensive time period (7 years). Crime statistics were taken from the Greek Police. Repeated measures analyses of variance were performed to reveal potential differences in criminality for the years 2008, 2010, 2012 and 2014. There was a significant increase in global criminality rate per 100,000 residents (Wilks' Lambda=0.32, F (3,11)=7.93, p=0.004). There was a significant increase in illegal gun possession (Wilks' Lambda=0.16, F (3,11)=18.68, p=0.001), fraud (Wilks' Lambda=0.10, F (3,11)=32.35, p=0.001), extortion (Wilks' Lambda=0.38, F (3,11)=4.45, p=0.040), and beggary (Wilks' Lambda=0.33, F (3,11)=6.22, p=0.014). A reversed U shape was found for homicides, thefts and robberies, with rates peaking in 2010 and 2012 before dropping off in 2014. Narcotics and sexual exploitation crime rates remained unchanged. Surprisingly, the incidence of rape decreased (Wilks' Lambda=0.42, F (3,11)=5.14, p=0.018). Our results are in agreement with the results of previous broader studies as well as with criminological theories according to which in times of economic stress an increase in both property crimes and violent crimes is expected. As predicted, an increase in financial crime was observed (e.g. fraud and extortions) as well as petty crime related to financial hardship like beggary. Concerns regarding the escalation of white-collar crimes in times of economic downturns that have been raised in the literature warrant further investigation.

Psychiatry trainees' attitudes towards euthanasia and physician-assisted suicide.

We investigated the attitudes towards Euthanasia (EUT) and Physician-Assisted Suicide (PAS) in a sample of Greek Psychiatry trainees (PT), (n=120, mean age 32.01±0.21, male 60.0%) and compared these to those of medical trainees of other specialties (OMT), i.e. internal medicine, surgery, intensive care (n=154, mean age 32.97±1.17, male 57.1%). Most of the responders were for the acceptance of EUT and PAS under some circumstances. More often PT answer "never" in the question regarding the permission to withdraw life-sustaining medical treatment to hasten death, if that requested by a terminally ill patient (p<0.001) and also more often answer "never" to the question regarding the permission to hasten the death of a patient if that is requested by family members (p<0.01). On the other hand OMT were more often for the acceptance of EUT (p<0.001) and more often expressed a positive view in the case allowing PAS in patients with incurable-terminal illness and low expected quality of life (p<0.001). According to the results of this study there is a need for special education of PT on end of life decisions. Also, it is important for educators to have understanding the views of the trainees since soon in the future, the new generation of physicians will have to make end of life decisions.

Schizophrenia and type 2 diabetes mellitus.

Schizophrenia is associated with increased risk for type 2 diabetes mellitus, resulting in elevated cardiovascular risk and limited life expectancy, translated into a weighted average of 14.5 years of potential life lost and an overall weighted average life expectancy of 64.7 years. The exact prevalence of type 2 diabetes among people with schizophrenia varies across studies and ranges 2-5fold higher than in the general population, whereas the aetiology is complex and multifactorial. Besides common diabetogenic factors, applied similarly in the general population, such as obesity, hyperlipidemia, smoking, hypertension, poor diet and limited physical activity, the co-occurrence of schizophrenia and diabetes is also attributed to unique conditions. Specifically, excessive sedentary lifestyle, social determinants, adverse effects of antipsychotic drugs and limited access to medical care are considered aggravating factors for diabetes onset and low quality of diabetes management. Schizophrenia itself is further proposed as causal factor for diabetes, given the observed higher prevalence of diabetes in young patients, newly diagnosed with schizophrenia and unexposed to antipsychotics. Furthermore, studies support genetic predisposition to diabetes among people with schizophrenia, suggesting shared genetic risk and disclosing a number of overlapped risk loci. Therefore, special attention should be paid in preventing diabetes in people with schizophrenia, through intervention in all possible modifiable risk factors. Implementation of careful antipsychotic prescription, provision of adequate motivation for balanced diet and physical activity and facilitating access to primary health care, could serve in reducing diabetes prevalence. On the other hand, increasing calls are made for early diagnosis of diabetes, application of the appropriate anti-diabetic therapy and strict inspection of therapy adherence, to limit the excess mortality due to cardiovascular events in people with schizophrenia. Moreover, population health programs could help counseling and preventing diabetes risk, additionally to early screening and diagnosis set, aiming to reduce disparities in populations. Finally, mental health-care providers might greatly promote offered health services to patients with schizophrenia, through a holistic individualized approach, considering additionally the physical health of the patients and working closely, preventively and therapeutically, in collaboration with the physicians and diabetologists.

[Attenuated psychosis syndrome: A new diagnostic category for further study in DSM-5].

In recent years an increasing number of studies focus on the issue of early diagnosis and intervention. At the same time, a large number of special service units for early psychosis have been established around the world especially in Australia, USA, UK, Germany etc. Recently, similar units operate in Greece also. The Diagnostic Manual of Mental Disorders of the American Psychiatric Association in its latest edition in 2013 (DSM-5), introduced the category "Attenuated Psychosis Syndrome" (APS) for people with early psychotic experiences in the section: "Conditions for further study '. This new category has specific criteria and describes a situation, in which a person displays psychotic symptoms in an attenuated form, with quite unaffected reality testing, but not qualifying a diagnosis of schizophrenic spectrum. The clinical expression of APS should be differentiated with several well known psychiatric disorders such as: brief psychotic disorder, schizotypal personality disorder, major depression with psychotic features, adolescence adjustment disorders, drug use, etc. The "Attenuated Psychosis Syndrome" occurs mainly in adolescence and in young adulthood. The mean percentage of transition to psychosis for these individuals is estimated at 36%, three years after the onset of initial symptoms, while the risk of transition to psychosis, although smaller, seems to remain up to ten years later. For some other individuals, transition to other psychiatric disorders occurs, such as depression with psychotic elements, or bipolar disorder, while a significant number of them will not transmit to even more serious disorders. At the biological level, studies focused in brain's neuroimaging, suggest significant volumetric differences among people at high risk for psychosis who later develop psychosis compared to those who don't, while studies of psychophysiological indicators or / and genetic markers show promising results for the identification of relevant parameters indicating the transition to psychosis. Αlthough an heterogeneous population, people with APS, show significant difficulties in social, professional and cognitive level, that should be therapeutically addressed. In an attempt to improve the clinical status of these individuals, to delay or even to prevent a psychotic episode, a series of interventions have been used by psychiatrists. These interventions include: (a) administration of drugs, especially atypical antipsychotics or antidepressants in low dosage, (b) administration of non-pharmaceutical supplements (e.g. omega-3 ), (c) psychotherapeutic interventions, mainly cognitive behavior therapy and (d) a combination of the above. Many questions need to be answered such as, the period of therapeutic intervention, identification of indicators (biological or/and clinical) that may determine the most suited for the APS individuals therapeutic interventions or, that may foresee, to prevent the transition to psychosis. Thus, the continuation of research in populations of APS individuals in multiple levels is necessary.

Psychiatric specialty training in Greece.

The reform and development of psychiatric services require, in addition to financial resources, reserves in specialized human resources. The role of psychiatrists in this process, and at reducing the consequences of mental morbidity is evident. Psychiatrists are required to play a multifaceted role as clinicians, as experts in multidisciplinary team environments and as advisors in the recognition of public needs in mental health issues, as teachers and mentors for students and other health professionals, as researchers in order to enrich our knowledge in the scientific field of psychiatry, and as public health specialists in the development of the mental health services system. This multifaceted role requires the continuous education of modern psychiatrists, but above all a broad, substantial and comprehensive training regime in the initial stage of their professional career, that is to say during specialization. Training in Psychiatry, as indeed has happened in all other medical specialties, has evolved considerably in recent decades, both in the content of education due to scientific advances in the fields of neurobiology, cognitive neuroscience, genetics, psychopharmacology, epidemiology and psychiatric nosology, and also because of advances in the educational process itself. Simple apprenticeship next to an experienced clinician, despite its importance in the clinical training of young psychiatrists, is no longer sufficient to meet the increased demands of the modern role of psychiatrists, resulting in the creation of educational programs defined by setting and pursuing minimum, though comprehensive educational objectives. This development has created the global need to develop organizations intended to supervise training programs. These organizations have various forms worldwide. In the European Union, the competent supervising body for medical specialties is the UEMS (European Union of Medical Specialities) and particularly in the case of the psychiatric specialty, the European Board of Psychiatry. In the US, the supervising bodies are the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology, in the United Kingdom the Royal College of Psychiatrists, in Canada the Royal College of Physicians and Surgeons, etc. In our country, the debate on the need to reform the institutional framework for Psychiatric training has been underway since the mid-90s, with initiatives especially by the Hellenic Psychiatric Association, aiming to raise awareness and concern among psychiatrists while responding to requests from competent central bodies of the state, as well as establishing Panhellenic training programs for psychiatric trainees and continuing education programs. But what is the situation of the educational map in the country today, what would be the objectives, and how might we proceed? These questions we will try to answer in an effort initiated by Hellenic Psychiatric Association (HPA) and the journal "Psychiatriki" with the publication of thematic articles starting by presenting in the next issue of "Psychiatriki"a comparative study of the training in the specialty of psychiatry at two distinct periods of time (2000 and 2014). These time-frames are of great importance, since the first is a period that in retrospect can be considered as wealthier yet missing robust priorities, while the second, at the peak of the economic crisis, constitutes a difficult environment with limited resources. Already in the year 2000, psychiatric residency training in our country had major difficulties due to its outdated framework and its fragmentation. All areas in which training is assessed (clinical experience, theoretical training and training in psychotherapy exhibited inadequacies and limited convergence with European golden standards, in the absence of a plan and the implementation of a national education curriculum. Certain university clinics constituted an important exception, though the bulk of the country's future psychiatrists were lagging behind in educational opportunities. Fifteen years later and under the weight of the consequences of the financial crisis, the institutional framework has not yet changed, and the overall situation seems to have worsened dramatically. Nevertheless, there are positive aspects to be evaluated, reinforced, and utilized in order to minimize the adverse effects of the economic crisis and lay sound foundations for the future. Preparations of a national framework is imperative today more than ever and initiatives to amend the legislation on medical specialties as far as it concerns the field of Psychiatry, could benefit from the evidence, from the willingness of the trainers and trainees concerned, as well as from the elaborated proposals of the Hellenic Psychiatric Association (HPA).

Financial crisis and criminality in Greece: 2008 vs 2011.

Α number of previous articles have dealt with the negative impact of the Greek Economic crisis on public health, including significant increases in major depression prevalence and suicide and homicide rates. The mentally ill seem to represent a vulnerable social group, with particular difficulties in this context. The number of compulsory assessments and involuntary admissions was recorded by reviewing patient records in the Department of Psychiatry of the University Hospital of Patras, through years 2006-2013. Compulsory assessments increased from 176 in 2006 to 262 in 2009 and 354 in 2013, representing a 48.86% and 101.13% increase in the first and the fifth year of economic crisis, respectively. The assessments resulted in 160 involuntary admissions in 2006, which escalated to 262 admissions (63.75% rise) in 2013. Even though a rise in involuntary placements could be attributed to other factors as well, it may also partly represent a not so evident side of the Greek economic crisis.

Inter-rater reliability of the Greek version of CAARMS among two groups of mental health professionals.

There is increasing interest within the Greek psychiatric community in the early detection and prevention of psychotic disorders. To support this, there is a need for a valid and reliable tool to identify young people that may be at risk of developing a psychotic disorder. Our team has previously translated the Comprehensive Assessment of At-Risk Mental States (CAARMS). The validity of the CAARMS was ensured by the procedure of translation and the aim of the current study was to estimate the interrater reliability of the CAARMS Greek translation among residents in psychiatry and specialized mental health professionals. 43 mental health workers (27 residents in psychiatry and 16 specialized mental health professionals (i.e. 11 psychiatrists and 5 psychologist) participated in two seminars that covered theoretical information about the ultra high risk concept and training in the CAARMS. During the seminars, 10 vignettes with psychiatric history cases were presented, including healthy, ultra high risk and first episode psychosis. The mean correlated percentage of agreement with the correct answers regarding diagnosis of the presented history cases among all our subjects was 81.42, among specialized mental health professionals 77.88, and among residents 84.46. Intraclass correlation co-efficients were 0.994 for specialized mental health professionals and 0.997 for residents. The translated Greek version of CAARMS presents a satisfying interrater reliability when used by both residents and specialized mental health professionals. Residents declare even higher intraclass correlation co-efficients and mean correlated percentage of agreement than specialized mental health professionals, which indicate that residents are capable of using the CAARMS in early intervention units.

Early psychotic experiences: Interventions, problems and perspectives.

Psychotic or psychotic-like experiences and symptoms may precede and be indicative of later psychosis emergence. DSM-5 has introduced Attenuated Psychosis Syndrome (APS) as a condition for further study, arguing for its clinical validity and the need for identifying sub- threshold psychotic states. Early psychosis intervention has an already established role in reducing the Duration of Untreated Psychosis (DUP), delaying psychosis onset and relieving Ultra High Risk (UHR) individuals from their presenting symptoms. Pharmacological and mainly psycho-therapeutical approaches are suggested for this purpose. Cognitive Behavior Therapy (CBT) seems to have clear evidence of favorable outcome concerning transition to psychosis rates, omega-3 fatty acids lower but promising evidence, while low-dose antipsychotic medication or antidepressant treatment may seem beneficial, but it remains unclear if the reported favorable effects persist in the long term and how long intervention in UHR subjects should be given for. Case management and close monitoring based on principles of social psychiatry are considered key elements for the management of UHR individuals. However, the blazing case about early psychosis concerns the accurate specification of the prodromal stage of psychosis, which may set the basis for meaningful and effective early intervention. Although psychometric tools have been developed and provide a common criteria-based recognition method, debate is alive and well regarding "false positive" cases, since most UHR subjects will not finally develop psychosis. Moreover, transition rates to psychosis have been declining over the years, leading to fierce criticism over the validity of the UHR/ APS state and legitimacy of its treatment. On this framework, ethical issues of stigmatizing through unnecessary diagnosing and antipsychotics' prescribing are matters of serious questioning. Clinical heterogeneity and high comorbidity are further implications of the UHR state. Current research emphasizes on improving validity of inclusion criteria and formulating personalised and clinical stage- based intervention strategies. In order to do that, early psychosis recognition and intervention services are established throughout the world, trying to contribute in research by applying clinical, cognitive or neuropsychological criteria. Nevertheless, in the majority of so far conducted studies, samples sizes are considered small and duration of follow-up short, which are limitations yet to overcome. Other scientific voices argue that the UHR state might represent a non-specific risk factor for psychiatric disorders in general and not necessarily for psychosis and tend to examine the UHR and early intervention idea under the prism of subthreshold or early mental distress state. Either way, recognizing and intervening early in emerging psychiatric states, especially in those with psychotic or psychotic-like symptomatology, share indisputable benefits under the broader concept of prevention, setting a strong scientific-clinical rationale for service provision to help-seeking people and the possibility of changing the course for those with vulnerability to psychotic illnesses.

[Attempted suicide during the financial crisis in Athens].

Suicidal behavior is considered as the result of complex cognitive and emotional processes and it is a timeless, global and multifactorial phenomenon. Periods of financial crises in the past, such as the Great Depression in the USA in 1929 and the economic crises of Asia, Russia and Argentina in the late 1990s, have been associated with impairment of mental health of the economically affected. Unemployment, job insecurity, debts, poverty and social exclusion seems to lead to higher incidence of anxiety and depressive symptoms and increased suicidality. Alcohol and substance use and the reduction of the state budget for health services reinforce the negative effects of the economic recession on mental health. The financial crisis which currently affects many European countries began in 2008 and its impact on the mental health of European citizens is in progress. Greece is probably the most affected country by the European financial crisis. The aim of this study is to investigate the potential impact of the crisis' consequences on the attempted suicide rates in the Athens population and the differentiation of suicide attempters on social, demographic and clinical-psychopathological parameters during the crisis. A retrospective study was conducted. The semi-structured records of 165 attempters who were hospitalized in the Internal Medicine Clinics of the "Sotiria" General Hospital in Athens, after attempted suicide in the years 2007 and 2011, before and during the financial crisis respectively, were studied. Among suicide attempters 95(57.6%) were suffering from mental disorders. Most often diagnoses were these of mood disorders (n=60, 63.2%). Demographic data, current psychiatric disorder, previous suicide attempt and severity of psychopathology at the time of suicide attempt were recorded for each patient. Furthermore, the severity of each suicide attempt was estimated. Suicide attempts were 70 in 2007, before the financial crisis (mean age 36.9 years, 71% women) and 95 in 2011, during the financial crisis (mean age 41.0 years, women 65%). There is an increase of suicide attempts by 35.71%. There were no statistically significant differences between the two periods regarding the gender and age of attempters. There was a statistically significant increase of unemployed (p=0.004), as well as of married/widowed/divorced (p=0.02) suicide attempters during the crisis. There was not statistically significant difference in the severity of suicide attempts before and during the economic crisis or the severity of psychopathology of the attempters. The financial crisis is probably associated with upward trend in attempted suicide of the Athens population. Most affected are those who are unemployed, married, widowed, divorced. Suicide prevention programs are essential for the accurate and timely identification and the immediate and effective management of this special high risk group of attempters during the financial crisis.

Suicide in Greece: 2001-2011.

Since 2008 several European countries have fallen into a financial crisis. This crisis has mainly affected the Greek population. The lower of income and the increase of unemployment as consequences of crisis lead to negative effects on people's mental health. Usually, in periods of economic crisis there is an increase of suicidality of population. The aim of this study is to examine the changes of suicide rates in Greece during the last decade (2001-2011) with particular consideration in the recent period of economic crisis (2008-2011). Data regarding the greek general population and the crude data on suicides were obtained from the Hellenic Statistical Authority (ELSTAT). We assessed the specific suicide rate, i.e. the number of suicide cases per 100.000 inhabitants (SSR) using population data on the 2001 and 2011 census. Yearly and mean total, age and sex-SSR were calculated in five years age groups. There were no suicide cases among children under the age of fifteen. We compared total and male, female SSR during the period before the crisis (2001-2007) and during the crisis (2008-2011). During the decade 2001-2011 a total number of 4133 suicide cases were recorded. There were 3423 (82.8%) male suicides and 710 (17.2%) female suicides. During the decade 2001-2011 total SSR increased by 38.4%. In males increased by 33.1% and in females by 69.6%. In the period before the crisis (2001-2007) total SSR decreased by 3.9%. In males decreased by 8.4% but in females increased by 22.3%. During the period of crisis (2008-2011) total SSR increased by 27.2%. In males increased by 26.9% and in females by 28.5%. There was a statistically significant increase in total SSR during the crisis regarding subjects 50-54 years old (t=3.43, p=0.007) and in total SSR of males (t=2.31, p=0.047) as well as of the males age groups 50-54 (t=3.56, p=0.006), 45-49 (t=2.87, p=0.02), 30-34 (t=2.96, p=0.02). There were no statistically significant differences both in total SSR and in SSR of all age groups of females during the crisis. The most often used method of suicide all the year of this study was by hanging. In absolute count the total suicide cases for the year 2011 in Greece were 477 (SSR=4.22) and the male suicides 393 (SSR=7.02) which are the highest number of suicides observed in Greece during the last decades. Findings suggest an increase in suicide mortality in Greece during the financial crisis. Reorientation of the goals of the national mental health system as well as targeted interventions should be applied in high risk individuals, i.e. unemployed, poor, suffering from mental or/and physical illnesses, in order to prevent or to mitigate the impact of the financial crisis in the greek population.

A study of acculturation in psychotic and non-psychotic immigrants living in Athens.

BACKGROUND: Acculturation is the phenomenon that results when a group with one culture comes into continuous contact with a host culture. AIMS: To investigate the correlation between acculturation and psychotic symptomatology in a group of immigrants suffering from psychosis and to explore differences in demographic factors related with the acculturation process between individuals with and without psychosis. METHODS: Sixty-five patients and 317 non-psychotic immigrants were interviewed using the Immigrant Acculturation Scale (IAS) and a structured questionnaire for demographic data. The Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Global Assessment of Functioning (GAF) were also administered to all immigrants suffering from psychosis. RESULTS: Total IAS scores, as well as IAS everyday life scores, were positively correlated with GAF scores. IAS everyday life score in the patient group related with religion, marital status, gender and years in Greece, while in the non-psychosis group it was related with gender and years in Greece. IAS wishful orientation/nostos (the strong desire for one's homeland) related with religion in both groups. The IAS identity in the psychosis group did not show any significant relation with any of the variables, while in the non-patient group, it was related with marital status, gender and years in Greece. Age, duration of residence in Greece and higher adoption of Greek ethnic identity were the variables that differentiated the two groups of immigrants. CONCLUSION: Acculturation in immigrants suffering from psychosis could be seen as a process that does not correlate strongly with the severity of the symptomatology but is probably influenced by different set of factors.

Alexithymia, depression and serum lipids in suicide attempters.

Over the last decade several studies have discussed the association between serum cholesterol, depressive disorders and suicide. A specific psychological variable related to affect is alexithymia. Alexithymia has been linked to depression and suicidal behaviour. Concerning lipid levels there are several studies that suggest changes in serum lipid composition maybe related to depression and suicidal behaviour. In this study we examined the possible relationship between alexithymia, depression and serum lipids in suicide attempters. We studied 50 non-violent suicide attempters (drug overdosers) with a mean age of 35.0 (±12.2) years. Alexithymia was measured using the Shalling-Sifneos Personality Scale Revised (SSPS-R) and depression using the Montgomery-Asberg Depression Rating Scale (MADRS). Serum lipids concentrations were determined by enzymatic method within 24h of hospital admission. For the statistical evaluation Spearman's rank correlation coefficients were used. The mean serum lipid levels were: total serum cholesterol (TC) 175.2 (±29.6) mg/dL, highdensity lipoprotein cholesterol (H-DLC) 47.08 (±13.1) mg/dL, low density lipoprotein cholesterol (L-DLC) 109.5 (±23.5) mg/dL and the mean serum triglycerides (TR) level was 89.4 (±39.1) mg/dL. The mean scores on the questionnaires were: SSPS-R 10.3 (±3.7), MADRS 33.5 (±5.9). There were significant correlations between: (a) SSPS-R score and MADRS score (r=0.439, p<0.001), (b) SSPS-R score and TR level (r=0.323, p<0.05). There were no significant correlations between MADRS score and any of the lipid fractions measured. To our knowledge, only few studies have examined the association between alexithymia and clinical-psychopathological parameters in suicide attempters. There are no previous studies comparing serum lipid profile with alexithymia in suicide attempters. This is the first study to compare at the same time serum lipids, alexithymia and depression in suicide attempters. The results suggest that although there was a strong relationship between alexithymia and depression in suicide attempters only alexithymia was correlated to Serum triglyceride levels.

The approach to melancholy on 30.1 Aristotelian problem.

Τhe 30.1 Aristotelian problem is the most comprehensive and organized analysis of the phenomenon of melancholy in Aristotelian Corpus. Although, there are serious doubts if this text, as it was survived today, was written by Aristotle (384-322 B.C.) or by one of his followers -perhaps Theophrastus (372-287 B.C.)- nevertheless it is widely accepted that reflects the authentic ideas of Aristotle. The two counterbalancing sentiments, this of mirthfulness and this of moroseness, which are attributed in the text to the "melancholic" persons, introduce the primary difficulty, in order to be understood the unclear notion of melancholy in this work. All the previous approaches understood these sentiments, as diversity in the symptomatology of melancholy that is the ancient mental disorder which is similar to modern depression. But according to our point of view, this text is a study of pathological physiology, underling the significant role of black bile as the causative factor of the above two emotions in humans under the specific influence of temperature. Humor's overheat had as result the mirthfulness and its overcooling the moroseness. The reference to the healthy people and the graduation of the quantity of black bile in human body, as little, middle and massive, which is associated to the mentally ill persons, indicate that these two emotions were not only recognized as pathological manifestations of patients, but also as temperamental characteristics of healthy people, which arise from the same alteration of this humor, when its quantity is limited. Examining deeper the psychopathological aspect of this content, we may assume that, due to the fact mirthfulness was presented in the form of excessive enthusiasm, passion and courage and on the other hand moroseness by the distinctive elements of irrational fear, indolence and absurdity, the first one referred to mania and the second to melancholy, since their descriptions correspond to the basic features of each disease. Therefore, under the new reading, black bile should be perceived as the common source of the above two mental disorders, expressing the Aristotelian version of their correlation, which preoccupied many of the ancient Greek physicians as Themison (1st century B.C.) and his followers, Rufus of Ephesus (1st century A.D.), Galen (130-201 A.D.) and Aretaeus of Cappadocia (2nd century A.D.). This one probably derived from the difficulty to be fixed the limits between these two diseases, because anger and fear could be present in both situations provoking the confusion. Finally, we should reject the hypothesis of bipolar disorder's presentation, because text's generality does not allow the limitation to only one pathological phenomenon, while the absence of particular data on the duration and sequence of the two different emotional states acts as a deterrent for such a conclusion.

[Suicide rates and mental health services in Greece].

Some studies have shown that access to mental health services can have an impact on mental health outcomes, including the suicide rates. The aim of the present study was to examine the relationship between regional and prefecture suicide rates (suicides per 100.000 residents) and both the number of primary and mental health-care service providers and the number of mental health infrastructures in Greece. Data were taken mainly from the Hellenic Statistical Authority (EL.STAT.) and the Ministry of Health for the period 2002-2009. Spearman correlations were used to examine the relationship between primary health-care, mental health providers and suicide rates per 100,000 residents at the prefecture, administrative region and geographical region levels. Men showed significantly higher suicide rates than women (U=-7.20, p<0.001). For the period 2002-2009, the highest suicide rate at the prefecture level were in Rethymno (6.99), Rodopi (5.62) and Zakynthos (5.28). For the same period, the highest suicide rates at the geographical level were in Peloponnisos (4.01), Ionian Islands (4.03) and Grete (3.65). Increase in suicide rates (2009 vs 2002-2009) was observed in the following geographical regions of Greece: Crete (4.76 vs 3.65), Thrace (4.45 vs 2.02) Central Greece (3.61 vs 1.39) Aegean Islands (3.03 vs 1.28). The highest correlations between suiciderutes and health services at the geographic regional level were found to be during the period 2007-2009, where suicide rates showed a significant negative correlation with privately practicing psychiatrists (rho=-0.71, p<0.05), privately practicing psychologists (rho=-0.56, p<0.05), pathologists (rho=-0.73, p<0.01), and the number of the official mental health services (psychiatric clinics, day centers, mobile mental health units etc.) (rho=-0.73, p<0.01). In conclusion it was found that at all regional levels, suicide rates were reversely related to the number of primary health-care and mental health service providers, as well as the number of mental health infrastructures in Greece. It should be noted that the running financial crisis in Greece seems to have many effects on quality of life, since the most common effects of an economic crisis are unemployment, spending power cuts,general insecurity and public spending retrenchment, including health related budget cuts. Having in mind the above situation, further analyses are needed to determine the relationship between mental health-care services, suicide rates and other psychosocial indices, in order to provide a strategic plan for a better design of mental health-care policy in Greece.

[Psychotherapeutic interventions in stereotypies].

Stereotypies belong to the psychomotor disorders and they are found in many different disorders. This article refers to the international literature about the psychotherapeutic interventions in stereotypies and reviews the psychotherapeutic techniques that are already being used for these disorders. This study refers to four kinds of psychotherapeutic treatment: (a) Behavioral therapy, (b) Milieu therapy which can be combined successfully with an occupational therapy, (c) Family therapy and (d) Supportive or cognitive or dynamic psychotherapy. The method used for finding the articles for this review was the web research. The articles found were 44 in total, but only 25 were studied extensively since they were absolutely relative to the subject of this review. 12 of these articles were case studies, 7 theoretical papers and 5 of them were reviews. The last one was a research epidemiological study. According to most of the articles, behavioral therapy is considered to be the most effective psychotherapeutic treatment for attenuating stereotypies and relies on techniques like systematic desensitization, environmental enrichment, positive reinforcement of alternative behaviors and negative reinforcement of the "problematic" behaviors. The milieu therapy, combined with occupational therapy, endeavours to shape an appropriate environment where the patient can recover. Family therapy focuses on fully informing the relatives about the nature of stereotypies. Supportive psychotherapy focuses on the current problems in the patient's life. The cognitive psychotherapy tries to fix the dysfunctional thoughts of the patients. Finally, the dynamic psychotherapy is focused on the restoration or reinforcement of the patient's defensive mechanisms. It should be noted that there is a lack of systematic research in the field of stereotypies in general and, especially, regarding psychotherapeutic interventions.

Fatigue in female patients with major depression: the effect of comorbid anxiety disorders.

Several studies have investigated fatigue in the general population, in primary care facilities as well as in patients with fatigue-related physical diseases, but only marginally in patients with Major Depressive Disorder (MDD). Therefore, the investigation of correlates of depression-related fatigue is highly warranted and expected to facilitate the implementation of effective fatigue-specific treatment strategies. Depressed patients often suffer from comorbid anxiety disorders (CADs) or subthreshold anxiety symptoms. This study aimed to investigate the independent correlation of the severity of fatigue in female patients with MDD with the presence, number and type of CADs. We studied 70 consecutive female MDD patients (48.6% inpatients), aged 23-65 years (mean 48.2±10.6 years), currently in a Major Depressive Episode [17-item Hamilton Depression Rating Scale (HDRS) score≥17] and free of other fatigue-associated conditions. Diagnostic assessments were made with the short structured DSM-IV-based MINI version 5.0.0. Reported fatigue was assessed with the 14-item Chalder Fatigue Questionnaire (FQ). Correlations between the FQ score and age, inpatient status, HDRS score, presence and number of CADs were calculated. Then, stepwise multiple regression analyses were performed, with the FQ score as the dependent variable,so as to isolate independent predictors of the severity of fatigue. 92.9% of patients had clinically significant fatigue. 62.9% were suffering from at least one CAD (38.6% met criteria for one CAD,21.4% for two and 2.9% for three). 51.4% were diagnosed with generalized anxiety disorder (GAD),25.7% with panic disorder and/or agoraphobia (PD/AP), 17.1% with social anxiety disorder and 7.1%with obsessive-compulsive disorder. The FQ score was significantly correlated with the HDRS score(r=0.406, p<0.001), the presence of any CAD(s) (rho=0.4, p=0.001), the number of CADs (rho=0.393,p=0.001), the presence of GAD (rho=0.421, p<0.001) and the presence of PD/AP (rho=0.252, p=0.035).In multiple regression analyses, the presence and number of CADs and the presence of comorbid GAD turned out as significant independent predictors of the FQ score along with the HDRS score.The severity of fatigue in female MDD patients is independently correlated with the presence and number of CADs and, in specific, comorbid GAD. Our findings imply that: (1) this effect might in part account for greater impairment/disability and adverse prognosis for MDD with CADs; (2) high levels of fatigue, putatively clustering with anxiety symptoms, may be a marker of severity and anxiety disorders comorbidity for MDD and may define an "anxious-fatigued" subtype/phenotype in this population; (3) medications and psychotherapies for the management of severe depression-related fatigue should also target CADs.

Hospital anxiety and depression scale. A quantitative analysis in medical outpatients, psychiatric outpatients and normal subjects.

Depressive and anxiety symptomatology represent the most common psychiatric manifestations that complicate the management and prognosis of patients with somatic disorders. The Hospital Anxiety and Depression Scale (HADS) is a reliable, valid andpractical screening tool for identifying and quantifying anxiety and/or depression in non-psychiatric out patients. The aim of the present study was to compare the psychometric properties of the HADS among internal medicine outpatients, psychiatric outpatients and the generalpopulation. The present study involved 264 subjects: 95 internal medicine outpatients, 79 psychiatric outpatients and 90 normal controls. Psychiatric outpatients were diagnosed according to DSMIV-TR and inclusion criteria required the absence of any psychotic or organic psychiatric disorder. Patients with depressive disorders were divided in 3 groups: major depression, dysthymic disorderand adjustment disorder with mixed anxiety and depressed mood. All patients were administered the following psychometric tools: HADS, BDI and STAI. Subjects of the control group were administeredonly HADS. In all psychometric scales the psychiatric group presented significantly greater values than the internal medicine and the control group. In turn, the internal medicine group scoredsignificantly higher than the control group. Within the psychiatric outpatient group significantly higher HADS and HADS-D scores were observed in the major depression group followed by the dysthymicdisorder and the adjustment disorder with mixed anxiety and depressed mood group. HADS may be capable of identifying anxiety and depressive symptoms between psychiatric outpatients, internal medicine outpatients and subjects in the general population. In addition, the HADS-D subscaledifferentiates the main depressive disorders.

Association of serum BDNF and val66met polymorphism of the brain-derived neurotrophic factor in a sample of first psychotic episode patients.

Polymorphisms in the brain-derived neurotrophic factor (BDNF) gene have been indicated to be associated with schizophrenia. Previous studies have suggested that val66met polymorphism may increase the risk for schizophrenia, although other studies have not confirmed this association. Decreased BDNF levels in the brain and the serum of patients with psychotic disorders have been reported in first episode psychotic (FEP) patients. In our study we investigated the potential genetic association of this polymorphism with schizophrenia in a sample of 38 FEP patients with schizophrenia compared with a sample of 21 normal controls. Furthermore, we assessed serum BDNF levels and investigated whether there was an association between this polymorphism and alterations of serum BDNF levels between the investigated groups. There was a significant difference in genotyped frequencies between cases and controls (p=0.030). The homozygous carriers Met/Met were over-represented in the schizophrenia group (13/31, 41.9%), compared to controls (2/19, 10.5%). The serum BDNF levels in the sample of FEP patients was significantly reduced compared to controls (18.87±8.23 ng/mL vs 29.2±7.73ng/mL, U=140, p=0.0). No association was found between alterations of serum BDNF levels and Val66Met polymorphism in the group of patients (p=0.198). Negative correlations were shown between serum BDNF levels of the patients and the PANSS Negative subscale scores (p=0.015). There was found no significant difference between genotypes and memory scores in the sample of patients. Our findings indicate that serum BDNF levels at the onset of schizophrenia and BDNF Val66Met variant may be susceptibility risk factors for schizophrenia.

Fatigue and somatic anxiety in patients with major depression.

The objective this study aimed to investigate the independent contribution of somatic anxiety to the severity of depression-related fatigue. Seventy-six patients (85.5% female), aged 23-65 years (mean 48.7±10.6), diagnosed with major depressive disorder and currently in a major depressive episode (ΜΙΝΙ 5.0.0.) with a 17-item Hamilton Depression Rating Scale (HDRS) score ≥17, were studied. Forty-nine patients (64.5%) were concurrently suf fering from anxiety disorder(s). Patients with physical diseases or other fatigue-related conditions were excluded. Reported fatigue was measured with the 14-item Fatigue Questionnaire (FQ). Based on HDRS item 11 (somatic anxiety) scores, patients were divided into those with somatic anxiety (HDRS-11≥2) and those without (HDRS-11≤1). Pearson's (r) and Spearman's (rho) correlations between FQ score, age, gender, inpatient status, HDRS score and somatic anxiety status were calculated. A multiple regression analysis was then performed, with FQ as the dependent variable. Fifty-seven patients (75%) were rated as suffering from somatic anxiety (HDRS-11≥2). Patients with somatic anxiety had significantly higher HDRS and FQ scores. The FQ score significantly correlated with the HDRS score (r=0.36, p=0.001) and somatic anxiety status (rho=0.35, p=0.002). The FQ score was independently predicted by HDRS score and somatic anxiety status, with standardised beta coefficients of 0.259 (p=0.028) and 0.255 (p=0.031), respectively. R2 was 0.185. Both the severity of depression and the presence of somatic anxiety independently correlate with the severity of reported fatigue in patients with major depression. This finding has potential implications for the management of depression-related fatigue.