Modulation of neurotrophic factors in the treatment of dementia, stroke and TBI: Effects of Cerebrolysin.

Neurotrophic factors (NTFs) are involved in the pathophysiology of neurological disorders such as dementia, stroke and traumatic brain injury (TBI), and constitute molecular targets of high interest for the therapy of these pathologies. In this review we provide an overview of current knowledge of the definition, discovery and mode of action of five NTFs, nerve growth factor, insulin-like growth factor 1, brain derived NTF, vascular endothelial growth factor and tumor necrosis factor alpha; as well as on their contribution to brain pathology and potential therapeutic use in dementia, stroke and TBI. Within the concept of NTFs in the treatment of these pathologies, we also review the neuropeptide preparation Cerebrolysin, which has been shown to resemble the activities of NTFs and to modulate the expression level of endogenous NTFs. Cerebrolysin has demonstrated beneficial treatment capabilities in vitro and in clinical studies, which are discussed within the context of the biochemistry of NTFs. The review focuses on the interactions of different NTFs, rather than addressing a single NTF, by outlining their signaling network and by reviewing their effect on clinical outcome in prevalent brain pathologies. The effects of the interactions of these NTFs and Cerebrolysin on neuroplasticity, neurogenesis, angiogenesis and inflammation, and their relevance for the treatment of dementia, stroke and TBI are summarized.

Depression and loneliness may predict work inefficiency among professionally active adults.

PURPOSE: Both depression and loneliness have been recognized as major public health issues, yet investigation into their role among young and middle-aged, professionally active persons is still required. The aim of the present study was to evaluate whether depression and loneliness may independently predict inefficiency at work among professionally active adults. METHODS: This is a cross-sectional study on a representative, nationwide sample. 1795 questionnaires were gathered from among professionally active adults from Poland from 1 to 31 July 2018 with a direct pen-and-paper interview. The sample was chosen by means of the stratified random method. The survey included a Patient Health Questionnaire (PHQ-9) to measure depression and questions, devised by the authors, relating to loneliness and inefficiency at work. Regression models were constructed with depression and loneliness as predictors of inefficiency at work, unadjusted and adjusted for selected sociodemographic, health- and work-related factors. RESULTS: In the unadjusted models, both depression and loneliness were independently associated with an increase of work inefficiency and absence from work, with effect sizes being higher for loneliness than for depression. After accounting for the control variables (i.e., sociodemographic, work- and health-related factors), the PHQ-9 score, but not the loneliness score, was associated with an increased probability of frequent thoughts about changing or leaving a job. CONCLUSION: Depression and loneliness independently predicted occupational functioning and differentially affect its various aspects. Counteracting depression and loneliness among employees should be regarded as a public health priority.

Comparison of Plasma, Saliva, and Hair Levetiracetam Concentrations.

BACKGROUND: Previous findings revealed high correlations between serum/plasma and saliva levetiracetam concentrations, indicating saliva as an alternative matrix for monitoring levetiracetam therapy. Levetiracetam concentration in the hair, which could reflect long-term drug exposure and patients' compliance, has not been systematically tested, as yet. The aim of this study was to determine the correlation between plasma, saliva, and hair levetiracetam concentrations in 47 patients with epilepsy. METHODS: Plasma, saliva, and hair levetiracetam concentrations were measured by liquid chromatography-tandem mass spectrometry with positive ionization. RESULTS: Levetiracetam saliva and plasma concentrations were highly correlated (r = 0.93). Plasma concentrations were not influenced by sex, age, and other concomitant antiepileptic drugs. Levetiracetam hair concentrations correlated with plasma concentrations (r = 0.36) but not daily dose (mg/kg). Drug hair concentrations were not influenced by hair color or treatment (dyed). CONCLUSIONS: The results tend to indicate that saliva may be a reliable alternative to plasma for monitoring levetiracetam concentrations. Levetiracetam can also be detected in human hair.

Personality traits, gender roles and sexual behaviours of young adult males.

BACKGROUND: Previous studies have shown that personality characteristics affect sexual functioning. The aim of this exploratory study was to assess and describe the relationship between global personality traits and the stereotypical femininity and masculinity levels with the broad aspects of sexual behaviours and attitudes in the group of 97 heterosexual young adult men aged 19-39 and living in Poland. METHODS: The 'Big Five' personality traits were measured with the NEO-FFI questionnaire; stereotypical femininity and masculinity with the Bem sex role inventory (BSRI); sexual disorders with the International index of erectile function (IIEF); socio-epidemiological data, sexual behaviours and attitudes towards sexuality with a self-constructed questionnaire. RESULTS: We identified weak to moderate associations with particular sexual behaviours and attitudes. Neuroticism correlated positively with lower sexual satisfaction, self-acceptance and more negative attitudes towards sexuality; extraversion with higher desire, frequency of sexual intercourses, their diversity, sexual satisfaction, masculinity level and lower report of erectile problems; openness to experience with better quality of partnership, more positive attitudes towards sexual activity and masculinity level; conscientiousness with later sexual initiation age, more frequent and diverse sexual behaviours (but lower interest in masturbation and coitus interruptus), overall sexual satisfaction, satisfaction with one's body and femininity level; agreeableness with a better quality of relationship with a partner, satisfaction from body, lower number of previous partners and more frequent sexual encounters (but less masturbation). Stereotypical masculinity, more so than femininity, was related to a wide range of positive aspects of sexuality. CONCLUSIONS: The Big Five personality traits and stereotypical femininity/masculinity dimensions were found to have a noticeable, but weak to moderate influence on sexual behaviour in young adult males.

Case control study of ANKK1 Taq 1A polymorphism in patients with alcohol dependence classified according to Lesch's typology.

OBJECTIVE: The aim of this study was to examine the association between the Taq 1A polymorphism of the ANKK1 gene in homogeneous subgroups of patients with alcohol dependence syndrome divided according to Lesch's typology. MATERIAL/METHODS: DNA was provided from alcohol-dependent (AD) patients (n = 373) and healthy control subjects (n = 168), all of Polish descent. The history of alcoholism was obtained using the Polish version of the SSAGA (Semi-Structured Assessment for the Genetics of Alcoholism). Samples were genotyped using the PCR method. RESULTS: We found no association between alcohol dependence and ANKK1 Taq 1A polymorphism. CONCLUSIONS: Lesch's typology is a clinical consequence of the disease, and its phenotypic description is too complex for simple genetic analysis.

Intensity and pleasantness of sucrose taste in patients with winter depression.

OBJECTIVES: Increased consumption of carbohydrates and craving for sweets are considered core features of winter depression. Unfortunately, little is known about neural and behavioral correlates of these symptoms. The primary aim of the present study was to evaluate taste responses to sucrose solutions in depressed patients with seasonal affective disorder (SAD). METHODS: Intensity and pleasantness ratings of sucrose solutions, electrogustometric thresholds, and taste identification abilities were assessed in depressed patients with SAD and non-seasonal affective disorder (non-SAD), and in non-depressed controls. RESULTS: Electrogustometric thresholds and identification abilities did not differ between the study groups. There were no differences between the groups in intensity or pleasantness ratings of sucrose solutions (1-30%). The proportion of 'sweet likers', i.e. subjects rating the highest sucrose concentration as most pleasant, was similar in the controls, SAD, and non-SAD patients. DISCUSSION: The present results suggest that: (i) winter depression is not associated with major alterations in gustatory function; and (ii) sweet craving and increased consumption of carbohydrates in patients with winter depression is not secondary to altered responses to sweet tastants. More studies are needed to characterize hedonic responses of patients with SAD to other sweet and non-sweet foods.

Retrospective comparison between the Prolift and Elevate anterior vaginal mesh procedures: 18-month clinical outcome.

INTRODUCTION AND HYPOTHESIS: There are few direct comparisons between the first-generation trocar-guided and the second-generation single-incision mesh systems in the treatment of anterior pelvic organ prolapse (POP). Hence, the purpose of this retrospective review was to compare 18-month operative success in female patients who had undergone POP surgery with the anterior Prolift (n = 52) or the anterior Elevate mesh (n = 62). METHODS: Subjective (bulge symptoms) and objective measures (absence of anterior or apical descent beyond the hymen, POP-Q anterior stage 0 or I, no retreatment for POP) were used as the measures of surgical efficacy. Postoperative pelvic floor pain, dyspareunia, de novo overactive bladder (OAB), de novo stress urinary incontinence (SUI), and mesh exposure were addressed as complications of POP surgery. RESULTS: The two groups did not differ with regard to the subjective and objective measures of the operative efficacy. There were no between-group differences in the proportion of women reporting postoperative pelvic floor pain, dyspareunia, de novo SUI, and de novo OAB symptoms (all p values >0.05). The proportion of patients with postoperative vaginal exposure was significantly higher in the Prolift group (7.7 %) than in the Elevate group (0.0 %; p = 0.02). CONCLUSIONS: In conclusion, our results suggest that the use of the Elevate system in patients with anterior compartment prolapse results in fewer mesh erosions, but similar efficacy, compared with the Prolift mesh.

Pharmacy switch of antipsychotic medications: patient's perspective.

BACKGROUND AND AIM: Several studies have raised concerns over consequences of brand-to-generic and generic-to-generic pharmacy-generated medication substitutions in psychiatric and non-psychiatric patients. The purpose of this retrospective study was to assess behavioral and emotional responses of patients with schizophrenia to antipsychotic medication substitution performed by pharmacies. METHODS: A group of Polish ambulatory patients with schizophrenia (n = 196) chronically treated with antipsychotic medications were asked whether antipsychotic medication substitution had been proposed by a pharmacist in the last 12 months. Ninety-nine patients answering positively were administered more questions addressing the patient's emotional and behavioral response to the pharmacy proposal. RESULTS: The most important findings of the present study can be summarized as follows: (1) approximately half of the patients were confronted with a pharmacy proposal to switch their antipsychotic medications in the last 12 months, (2) one quarter of these patients did not accept the pharmacy switch, (3) a substantial proportion of patients (>40 %) did not receive any explanation from a pharmacist offering medication substitution, (4) pharmacy-generated substitution proposals were mainly associated with negative patient attitudes and negative emotional responses, (5) substitution proposals provoked an unscheduled psychiatric visit in approx. 10 % of patients, (6) despite the negative attitudes reported by patients, the pharmacy switch rarely led to treatment discontinuation, but did provoke a change in drug dosing in 7 % of patients accepting the switch. CONCLUSIONS: A pharmacy proposal to switch their antipsychotic medications is a relatively common experience of Polish ambulatory patients with schizophrenia. Pharmacy-generated substitution proposals are mainly associated with negative patient attitudes, but rarely lead to antipsychotic treatment discontinuation in this group of patients.

[Towards better non-selectivity: the role of 5-HT7 receptors in therapeutic efficacy of a second-generation antipsychotic - lurasidone]. / W kierunku lepiej zaplanowanej nieselektywnosci: rola receptorów 5-HT7 w dzialaniu leku przeciwpsychotycznego II generacji, lurazydonu.

Effectiveness of currently available antipsychotic medications is far from satisfactory with many patients showing incomplete therapeutic response even after many trials with different antipsychotic drugs. Hence, there is an ongoing interest in searching for pharmacological mechanisms, which could potentiate therapeutic response to antipsychotic drugs and/or reduce its typical side effects. The primary aim of this mini-review is to summarize available evidence supporting the role of serotonin receptors, especially 5-HT7 receptors, in therapeutic effects of a second-generation antipsychotic drug, lurasidone.

[Guidelines for the use of second-generation long-acting antipsychotics]. / Wskazówki do stosowania leków przeciwpsychotycznych II generacji o przedluzonym dzialaniu.

Long-acting injectable antipsychotics constitute a valuable alternative for the treatment of psychotic disorders, mainly schizophrenia. They assure a more stable drug level, improve treatment compliance, and increase the chances for favorable and long-lasting improvement. Additionally, the long-acting second-generation antipsychotics combine the values of long-acting injectable drugs with the values of atypical antipsychotics. Four second generation long-acting antipsychotics have been described: risperidone, olanzapine, aripiprazole and paliperidone. The indications for their use, treatment strategy, tolerance, and potential interactions are discussed.

Genetics of alcohol dependence: a review of clinical studies.

BACKGROUND/AIMS: Alcohol dependence is a common severe psychiatric disorder with a multifactorial etiology. Since the completion of the human genome project and with the increased availability of high-throughput genotyping, multiple genetic risk factors for substance-related disorders, including alcohol dependence, have been identified, but not all results could be replicated. METHODS: We systematically review the clinical literature on genetic risk factors for alcohol dependence and alcohol-related phenotypes, including candidate gene-based studies, linkage studies and genome-wide association studies (GWAS). RESULTS: Irrespectively of the methodology employed, the most robust findings regarding genetic risk factors for alcohol dependence concern genetic variations that affect alcohol metabolism. GWAS confirm the importance of the alcohol dehydrogenase gene cluster on chromosome 4 in the genetic risk for alcohol dependence with multiple variants that exert a small, but cumulative influence. A single variant with strong influence on individual risk is the aldehyde dehydrogenase 2 ALDHD2*2 variant common in Asian populations. Other robust associations have been found with previously uncharacterized genes like KIAA0040, and such observations can lead to the identification of thus far unknown signaling pathways. Converging evidence also points to a role of glutamatergic, dopaminergic and serotonergic neurotransmitter signaling in the risk for alcohol dependence, but effects are small, and gene-environment interactions further increase the complexity. CONCLUSION: With few exceptions like ALDH2*2, the contribution of individual genetic variants to the risk for alcohol-related disorders is small. However, the concentration of risk variants within neurotransmitter signaling pathways may help to deepen our understanding of the underlying pathophysiology and thereby contribute to develop novel therapeutic strategies.

Marked elevation of adrenal steroids, especially androgens, in saliva of prepubertal autistic children.

Autism is diagnosed on the basis of behavioral manifestations, but its biomarkers are not well defined. A strong gender bias typifying autism (it is 4-5 times more prevalent in males) suggests involvement of steroid hormones in autism pathobiology. In order to evaluate the potential roles of such hormones in autism, we compared the salivary levels of 22 steroids in prepubertal autistic male and female children from two age groups (3-4 and 7-9 years old) with those in healthy controls. The steroids were analyzed using gas chromatography-mass spectrometry and radioimmunoassay. Statistical analysis (ANOVA) revealed that autistic children had significantly higher salivary concentrations of many steroid hormones (both C21 and C19) than control children. These anomalies were more prominent in older autistic children and in boys. The levels of androgens (androstenediol, dehydroepiandrosterone, androsterone and their polar conjugates) were especially increased, indicative of precocious adrenarche and predictive of early puberty. The concentrations of the steroid precursor, pregnenolone, and of several pregnanolones were also higher in autistic than in healthy children, but cortisol levels were not different. Some steroids, whose levels are raised in autism (allopregnanolone, androsterone, pregnenolone, dehydroepiandrosterone and their sulfate conjugates) are neuroactive and modulate GABA, glutamate, and opioid neurotransmission, affecting brain development and functioning. These steroids may contribute to autism pathobiology and symptoms such as elevated anxiety, sleep disturbances, sensory deficits, and stereotypies among others. We suggest that salivary levels of selected steroids may serve as biomarkers of autism pathology useful for monitoring the progress of therapy.

[Effectiveness of ketamine in depressed patients resistant to ECT or rTMS therapy]. / Skutecznosc zastosowania ketaminy u pacjentów z depresja oporna na leczenie elektrowstrzasowe lub rTMS.

OBJECTIVES: In the last decade several authors described a robust and clinically relevant alleviation of depressive symptoms after infusions of the uncompetitive N-methyl-D-aspartate (NMDA) glutamate receptor antagonist - ketamine. In the majority of published reports ketamine was administrated to patients with depression resistant to pharmacotherapy, but not to ECT. We present a series of 5 subjects suffering from multimodal treatment-resistant depression (including ECT or rTMS and various medications) treated with intravenous infusions of ketamine in a subanesthetic dose of 0.5 mg/kg in the naturalistic setting. To the best of our knowledge it is the first report on ketamine infusion in patient resistant to antidepressants and r TMS METHODS: Two subjects have been diagnosed with MDD, one with BD, two with severe depressive episode. The efficacy and possible adverse events were monitored using psychometric scales. Basic life parameters and ECG were observed. RESULTS: Ketamine's infusions showed transient antidepressant efficacy. Improvement rate in our group was significant lower than in previously reported. Ketamine was generally well tolerated. We noted transient BP variations and appearance of mild and transient dissociative symptoms. Low early response rate may be correlated with resistance to previous multimodal treatment, high rate of somatization and anxiety comorbidity or heterogeneity of our group. CONCLUSIONS: Our findings do not support the use of ketamine infusions as the monotherapy in the subgroup of patients with multimodal treatment resistant depression.

[The analysis of the polymorphic variations of the dopamine gen transporter (DAT1) and the serotonin transporter (5-HTTLPR) in patients with alcohol dependence syndrome with inclusion of the phenotypic feature of sweet liking preference]. / Analiza polimorficznych wariantów genu transportera dopaminy DAT1 i transportera serotoniny 5-HTTLPR u pacjentów z zespolem zaleznosci alkoholowej z uwzglednieniem fenotypowej cechy preferencji smaku slodkiego.

OBJECTIVES: The purpose of this study was to determine the relationship between sweet-liking phenotype and the variation of the gene sequence of the dopaminergic and serotonergic system. METHODS: The study recruited 100 probands. The participants were interviewed for addiction (SSAGA-Semi Structured Assessment for the Genetics of Alcoholism) and assessed with the questionnaires: MMSE, Beck Depression Inventory and Hamilton Anxiety, Snaith-Hamilton Pleasure Scale. The taste was analyzed with tests to assess sensitivity to sweet taste and also smell tests were performed. Patients preferring the highest glucose volumes were called sweet likers. Statistical analyses were performed (SPSS- Statistical Package for the Social Sciences). RESULTS: Links between sweet liking phenotype and polymorphic variant of DAT1 gene were determined. The presence of DAT1 9/10 genotype increased three fold time sweet liking phenotype (p = 0.015, odds ratio-3.00), the presence of DAT1 10/10 decreased two fold time the chance being sweet liker (p = 0.051, odds ratio-0.43). Genotype 10/10 was significantly more common among sweet dislikers 10/10 (68.18% vs 47.92%) i 9/9 (6.82% vs 2.08%). CONCLUSIONS; A genetically significant association between the presence of 9/10 DAT1 VNTR genotype and a sweet-liking phenotype in probands was determined.

The effect of selected polymorphisms of the dopamine receptor gene DRD2 and the ANKK-1 on the preference of concentrations of sucrose solutions in men with alcohol dependence.

BACKGROUND: The aim of the study was to determine the influence of DRD2 gene polymorphisms in exon 8 G/A (rs 6276) in the promoter region -141 C Ins/Del (rs1799732) and the influence of ANKK-1 gene Taq-1A polymorphism (rs 1800497) on the preference of increasing sucrose concentrations in men with alcohol dependence. SUBJECTS AND METHODS: 63 male patients with alcohol dependence were genotyped for the above polymorphisms. Their preference for increasing sucrose concentrations was tested and their taste intensity perception of sucrose solutions was assessed. The patients were tested with the 'Sniffin' Sticks' olfactory test. RESULTS: We found a statistically significant association between some alleles of ANKK 1 gene Taq 1A polymorphisms and sucrose preference in the subjects. The A1 Taq 1A allele determined hedonistic response to the two highest concentrations of sucrose. No association was found regarding the other two polymorphisms (in the promoter region and in the exon 8 of the DRD2 gene). CONCLUSIONS: Study results suggest Taq-1A polymorphism plays a role in the preference to high concentrations of sucrose and its potential association with alcohol dependence pathogenesis.

[Pharmacological features of naltrexone and its use in the treatment of alcohol dependence]. / Zastosowanie naltreksonu w terapii uzaleznienia od alkoholu - aspekty farmakologiczne.

Clinical studies performed over the last decades have indicated that combined therapy, involving pharmaco- and psychotherapy, is an optimal approach to alcohol dependence. Both pharmaco- and psychotherapy should be personalised with a careful balance between patient's needs and his/her clinical characteristics. The aim of the present article is to review the basic pharmacological features of naltrexone and its use in the treatment of alcohol dependence.

Treatment of insomnia in older adults. Recommendations of the Polish Sleep Research Society, Polish Society of Family Medicine and the Polish Psychiatric Association. / Leczenie bezsennosci osób w starszym wieku. Zalecenia Polskiego Towarzystwa Badan nad Snem, Polskiego Towarzystwa Medycyny Rodzinnej i Polskiego Towarzystwa Psychiatrycznego.

Insomnia is one of the most common health problems in developed countries. Its prevalence increases with age, with up to one in two people over the age of 65 experiencing symptoms of insomnia. The older people are also the patients who mostly commonly are among chronic sleep medication users. The aim of this article is to present the current recommendations for the management of insomnia in people over 65 years of age. The recommendations were prepared as a position of an expert panel, which included people from a number of clinical disciplines: family medicine, cardiology, psychiatry, sleep medicine and clinical psychopharmacology. The first step in treating sleep disorders is to establish proper diagnosis and, if possible, to initiate causal treatment. Moreover, cognitive and behavioural therapy for insomnia should also be used as the primary form of treatment, which can be supplemented, if not sufficiently effective, with pharmacological treatment. The main group of drugs used for treating insomnia are nonbenzodiazepine sedative hypnotics (zolpidem, zopiclone, eszopiclone, zaleplon). However, these drugs do not fully meet the needs of people over 65 years of age, primarily with regard to treatment safety. Therefore other classes of medicines, which are used for treatment of mental disorders, are prescribed off-label in this group of patients. Melatonin in a prolonged-release form is also indicated for this age group due to the high safety of the therapy. The management of insomnia in people over 65 years of age is a challenging task, given the need to seek compromise between treatment efficacy and safety. The treatment plan also has to take into account comorbidities as well as drugs used to treat them.

Attitudes towards the switching of anti-epileptic medications in pharmacies: the patients' perspective.

Purpose: A survey of epilepsy patients' experiences of and attitudes towards the pharmacy switching of anti-epileptic medications. Methods: A structured questionnaire was administered to a group of epilepsy patients treated at the Institute of Psychiatry and Neurology and the Medical University of Silesia, Poland. Two hundred and eleven patients (mean [± SD] age: 41.0 ± 15.6 years) were recruited; 60.6% were women. 68.2% had been treated for over 10 years. Results: Most individuals (63%) claimed that they had never bought a generic substitute medication. Among the patients who declared that a switch had been proposed to them at a pharmacy (~40%), only 68.7% received any explanation at all from a pharmacist. Some reported positive emotions mostly related to a lower price of the new drug but also to the explanations received. Most respondents who accepted the pharmacy switch (67.4%) did not notice any significant changes in the efficacy or tolerability of treatment, while the remaining subjects reported an increase in seizure frequency (23.2%) and deterioration in treatment tolerance (9%). Conclusions: Around 40% of Polish epilepsy patients have been confronted with a proposal to switch their anti-epileptic medications at a pharmacy. More of them report negative attitudes towards the pharmacist's proposal than do not. It is possible that one of the major reasons for this is the insufficient information provided by pharmacists. It remains to be established whether the reported decrease in seizure control could be accounted for by a low concentration of the anti-epileptic drug in the blood after the switch.

Letter to Editor. Position of the Polish Psychiatric Association on the use of benzodiazepine derivatives and drugs with a similar mechanism of action in the treatment of mental disorders. / List do Redakcji. Stanowisko Polskiego Towarzystwa Psychiatrycznego w sprawie stosowania pochodnych benzodiazepiny i leków o podobnym mechanizmie dzialania w leczeniu zaburzen psychicznych.

no summary.

Ethical dilemmas in contemporary psychiatry: Findings from a survey of National Psychiatric Associations in Europe.

BACKGROUND: The European Psychiatric Association (EPA) is an organization that speaks on behalf of its individual members and members of National Psychiatric Associations (NPAs). The aim of this study to identify and investigate current contents of ethical codes and practices in the countries belonging to EPA. METHODS: The study is an expert survey sent out to 44 representatives of 30 NPAs covering the following topics: the existence of national bodies dealing with ethical issues in psychiatry, the availability of documents relevant to ethical issues, the types of ethical issues addressed at the national level, and the current and envisaged ethical debates. RESULTS: Out of 44 experts invited to participate in the study, 31 NPAs from 30 countries responded (response rate 70.45%). In the majority of countries, the general mission statement serves as the main document covering ethical issues in psychiatry. Most frequently, internal documents were reported to address medical malpractice, workplace bullying, plagiarism, academic fraud, sexual abuse, and discrimination/racism. Furthermore, internal documents cover the ethical assessment of potentially controversial procedures, including psychosurgery, euthanasia, and pregnancy termination. The most important topics for debate at the level of NPAs/EPA were associated with violations of clinical practice standards and human rights. CONCLUSIONS: NPAs are active in the field of professional ethics, defining ethical standards related to interactions among professionals and services provided by mental health care professionals. Future collaboration of NPAs, under the umbrella of the EPA, could allow to develop a database of local ethical documents that would be translated into English and accessible to all EPA members.