Predictors of Chronic Combat-Related Post-Traumatic Stress Disorder Group Psychotherapy Favorable Outcomes; A Prospective Cohort Study in Croatia.

BACKGROUND: Combat-related chronic post-traumatic stress disorder (PTSD) is a therapeutically resistant disorder of the fluctuating course. The success of a group psychotherapy is partial. The aim of this paper is to determine baseline characteristics of veterans for whom a group psychotherapy will be the effective psychotherapeutic treatment. SUBJECTS AND METHODS: We performed this prospective cohort study in two geographically distant institutions: Regional Psychotrauma Center at the Psychiatric Clinic Split, and the Daily Hospital of the Psychiatric Hospital "Sveti Ivan" Zagreb, Croatia. We selected a consecutive sample of 86 veterans with combat-related chronic PTSD admitted to the group psychotherapy during 2009-2012. The primary outcome was ≥5% improvement in PTSD symptoms severity measured by Mississippi Scale for Combat-Related PTSD and adjusted for the baseline Mississippi scale score. Predictors were participants' 17 baseline sociodemographic and clinical characteristics and psychological features like personality traits, stress-coping mechanisms, and depression. RESULTS: We identified two patients' segments with significantly higher likelihood for the favorable treatment outcome. The first one were patients with the low score (≤8) on the phobia scale and high score (≥7) on the hysterical personality scale. In this segment 100% of patients experienced a favorable treatment outcome. The second one were the patiens with a higher score (>8) on the phobia scale, the low score (≤12) on the free-floating anxiety scale and the high score ≥8) on the obsession scale. In this segment, 64% experienced the favorable treatment outcome. CONCLUSION: The favorable outcome of the group psychotherapy of PTSD symptoms severity in patients with combat-related chronic PTSD can be predicted before the start of the treatment. The favorable outcome should be expected in patients with the low phobia and pronounced hysteria personality traits, or in patients with higher phobia, but with low free-floating anxiety and low obsession.

Association of Childhood Trauma and Personality Dimensions with the Duration of Untreated Psychosis.

BACKGROUND: Understanding causes and consequences of untreated psychosis is important since the duration of psychosis prior to the treatment initiation is a potentially modifiable prognostic factor, and comprehending its impact on outcome may enhance therapeutic strategies. SUBJECTS AND METHODS: This cross-sectional study was performed on a consecutive sample of 105 participants, 47 first episode participants and 58 with multiple episodes. Primary outcome was the duration of untreated psychosis (DUP). We observed three independent variables: childhood trauma measured by Childhood Trauma Questionnaire, psychotic symptoms measured by Positive and Negative Syndrome Scale (PANSS) and personality dimensions measured by the Inventory of Personality Organization (IPO) (primitive defences, identity diffusion and reality testing). All outcomes were observed among total sample and subgroups of first and multiple episode participants. RESULTS: Median DUP in total sample was 60.0 (IQR 14.5-285) days. In the subgroup of multiple episode participants, an association between multiple childhood trauma and shorter DUP was found, while no association between DUP and the existence of any specific trauma was found in neither subgroup, or in total sample. With regards to personality dimensions, in the first episode subgroup, significant positive correlations between DUP and primitive defences and reality testing subscales were found, while no correlations in total sample, nor in multiple episode subgroup were observed. Positive symptoms and general psychopathology correlated positively with DUP in total sample, and in first episode subgroup, while in multiple episodes subgroup only a positive correlation with positive symptoms was found. Total PANSS score positively correlated with the DUP only in the first episode subgroup. CONCLUSIONS: DUP was not associated with specific type of childhood trauma. First episode participants with longer DUP had predominant primitive defences and severely decreased ability to test reality, while there were no correlations between personality dimensions and DUP in multiple episode subgroup.

Current Status of Repetitive Transcranial Magnetic Stimulation (rTMS) in Croatia and in University Psychiatric Hospital Sveti Ivan.

This article reviews the history, evolution, and current status of repetitive transcranial magnetic stimulation (rTMS) in Croatia. University Psychiatric Hospital Sveti Ivan experts performed the first rTMS in 2015 as a first treatment and research group in Croatia. In addition to being a leading center for rTMS in clinical trials and in treating depression, University Psychiatric Clinic Sveti Ivan TMS center continues to research rTMS for depression and other neuropsychiatric disorders and conditions, exploring novel stimulation parameters and individualized treatment protocols. Since 2017 rTMS treatment for MDD in Croatia has been reimbursed by the National Insurance Fund and has been available to hospital and ambulatory patients by indication, and now is widely used in other health centers in Croatia, to treat depression and other neuropsychiatric disorders and conditions, especially when drugs are ineffective or produce harmful side effects.

Overview of Studies on the Efficacy of Repetitive Transcranial Magnetic Stimulation on the Severity of Symptoms of Major Depressive Disorder, Conducted in University Psychiatric Hospital Sveti Ivan 2016-2022.

This brief report presents the studies on HF rTMS efficacy on major depressive disorder (MDD) symptoms conducted in University Psychiatric Hospital Sveti Ivan from 2016 to 2022. We assessed the clinically relevant effects of rTMS delivered by H1-coil and the figure-8-coil on MDD symptoms severity in the pooled sample of patients. During the last seven years, we enrolled in the studies on MDD 336 patients with a median (interquartile range; IQR) age of 53 (45-61) years, 181 (54%) of them women. We performed interventions with two different coils (8-coil and H1-coil) at 120% of the motor threshold, approximately half with 10 and half with 18 Hz frequency, and > 90% with one daily session during 20 workdays. We offer considerations on how the bulk of our research informed the future direction of our laboratory's studies and clinical work.

A pilot investigation of accelerated deep transcranial magnetic stimulation protocols in treatment-resistant depression.

Accelerated repetitive transcranial magnetic stimulation (rTMS) protocols are being increasingly studied because of their potential to provide quicker and enhanced treatment efficacy. However, there is a lack of accelerated deep TMS with H1-coil (adTMS) treatment research. This randomized pilot study investigated the efficacy and safety of adTMS protocols. Twenty-eight TRD patients received 20-min sessions twice daily for 10 or 15 days. Primary outcomes were changes in Hamilton Depression Rating Scale (HDRS) scores and discontinuation because of adverse events (AE). Secondary outcomes were response, remission, daily changes in Beck Depression Inventory-II (BDI-II) scores, and AE incidence. HDRS scores decreased by 13 (95% CI 11-17; 59%, 95% CI 45-73%) and 13 (95% CI 11-14; 62%, 95% CI 54-69%) points in the 10- and 15-day protocols, respectively. The adjusted difference between the two protocols was not significant or clinically relevant. Remission was achieved by 38% and 42% after 10-day and 15-day protocols, respectively. The intervention was discontinued because of AEs in 3/33 (9%) patients. The BDI-II decreases were significant and clinically relevant during the first 8 days. Twice-daily adTMS for 10 days seems to be safe and effective, with rapid clinical benefits during the first week of treatment. These promising results warrant further investigation in larger randomized clinical trials comparing adTMS with the standard dTMS protocol.

Integration of mental health comorbidity in medical specialty programs in 20 countries.

METHODS: A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented. RESULTS: Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content. DISCUSSION: The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Comparison of the Schein and Osdi Questionnaire as Indicator of Tear Film Stability in Patients with Schizophrenia.

BACKGROUND: The aim of this research was to determine which of two chosen questionnaires for subjective symptoms of dry eye (Ocular Surface Disease Index and Schein questionnaire) is more reliable in the assessment of dry eye in patients with schizophrenia. SUBJECTS AND METHODS: Our research included 80 patients (160 eyes) of both sexes with schizophrenia ranging between the age of 25 and 55 who have been taking one of three antipsychotic drugs namely clozapin, olanzapin, quetiapin for five or more years and were in a stable phase of the disease or remission. All participants were required to satisfy all included and excluded criteria. They all filled out the Schein and OSDI questionnaires for assessment of subjective symptoms. Tear break-up time test (TBUT) for objective evaluation of tear film stability was also performed. In order to determine the correlation between two subjective and objective tests we calculated Spearmans correlation coefficients. RESULTS: Obtained results of the correlation between OSDI questionnaire and TBUT test for the right eye was r=-0.73; p<0.01 and for the left eye was r=-0.72; p<0.01. Results of the correlation between Schein questionnaire and TBUT test for the right eye was r=-0.62; p<0.01 and for the left eye was r=-0.60; p<0.01. A detailed analysis shows that there are no statistically significant differences between the correlations. Both subjective questionnaires are statistically significantly and negatively related to the TBUT test, showing that an increase in the results on the OSDI and Schein's questionnaires led to the decreases in the results on the TBUT test. CONCLUSION: In patients with schizophrenia the OSDI and Schein questionnaires are equally reliable in the assessment of subjective symptoms of Dry eye disease. Considering that, OSDI is more common in clinical practice and includes questions regarding quality of life, it would have certain advantages and it is recommended for use in patients with schizophrenia.

How to Square a Circle?

Psychodynamic group psychotherapy in Daily Hospital for non-psychotic disorders was held through Hangouts program during CoViD-19 pandemic lockdown. In our pilot study we compared patients' impressions and their satisfaction with online program vs. usual, in-person setting program. We analyzed the impressions of group therapists as well. Our conclusion is that according to our patients' impressions and satisfaction, online psychodynamic group psychotherapy is good enough option in extreme situations such as infectious disease pandemic, although it cannot completely replace all the aspects of usual "live" setting.

Time from the Admission as the Predictor of Aggressive Behavior of Inpatients with Schizophrenia Spectrum Disorder.

The aim was to assess the incidence of aggressive events (AE) committed by patients diagnosed with schizophrenia spectrum disorethder (SSD) after the first 7 days of hospitalization in psychiatric institution, in comparison to other psychiatric patients. This retrospective cohort study was performed at Psychiatric Hospital "Sveti Ivan", Zagreb, Croatia, using hospital safety records of all patients admitted between 2015 and 2017. Primary outcome was the proportion of patients who committed AE more than a week after the admission to the hospital. Secondary outcome was the time in days from admission to the first incident of AE. The primary analysis was performed using a multivariable binary logistic regression. SSD patients committed AE more often than other patients (incidence rate ratio 3.97 (95% CI 2.35-6.69; p < 0.001; FDR q = 0.002), but these occurred earlier in the course of hospitalization: median (IQR) 2 (1-10) days from admission compared to 11 (2-32) days in other patients. SSD patients had significantly and clinically relevantly lower odds for AE after the first week of hospitalization adjusted for the large number of pre-planned possible confounders (OR = 0.10; 95% CI 0.02-0.45; p = 0.003; FDR q = 0.002). SSD patients seem to express more aggression earlier in the course of hospitalization. Findings of this study indicate that hospitalization-inherent AE risk factors may play an important role in the etiology of AE and inpatients aggressive behavior. Their possible moderating effect should be included in risk-assessment instruments.

Telepsychiatry in the Time of the COVID-19 and Earthquake in Zagreb as Odysseus between Scylla and Charybdis.

In this paper we would like to reveal some of the many challenges during the time of the twofold simultaneous trauma; the COVID-19 pandemic and the devastating earthquake in Zagreb. We described the functioning mode of two Day Hospitals for Early Intervention and Psychotic Disorders at Psychiatric Hospital "Sveti Ivan" during the outbreak of the COVID-19 pandemic. We tried to find ways to ensure the necessary continuation of treatment and to provide continuity in times of uncertainty. The vulnerable group of people treated for mental illnesses faced exceptional psychological demands and was in need for care in these moments. Telemedicine, more specifically telepsychiatry, through online therapy and telephone communication made it possible for people treated for psychotic disorders not to feel isolated and rejected. Health care professionals, in a state of distress themselves, should understand, support, be able to reduce anxiety, and provide stability and constancy. The psychotherapeutic approach and the capacity for mentalization allowed us to turn challenges into opportunities. Rapid changes without delay extended our scope of practice in these extraordinarily difficult times.

The Role of Ambulatory Cardiac Rehabilitation in Improvement of Quality of Life, Anxiety and Depression.

BACKGROUND: Psychological reactions may adversely affect recovery after major cardiac events. This study investigates the role and frequently negligible importance of ambulatory cardiac rehabilitation (ACR) in improvement of quality of life (QoL), anxiety and depression at patients with various cardiac pathology. SUBJECTS AND METHODS: This prospective study included subjects treated for acute coronary syndrome (ACS), those with performed elective revascularization, and OTHERS (after valve replacement, implanted pacemaker or other device, with stable heart failure and coronary artery disease). Their anxiety (State Trait Anxiety Inventory (STAI) questionnaire), depression (Beck Depression Inventory (BDI-II) questionnaire) and QoL data (Short Form Health Survey-36 (SF-36) questionnaire, for physical and mental QoL components) were collected initially and after 3-month of ACR. RESULTS: ACR underwent 170 patients, aged 59 (53-66 years), predominately males (74.7%). At both genders, median duration of ACR was 12 weeks, with reduction of anxiety and depression scores and improvement in almost all components of QoL (P<0.05), except in mental health and bodily pain in males and females, respectively. After ACS (63.5%), ACR lasted 12 weeks, with reduction of anxiety and depression scores and improvement in all components of QoL (P<0.05). After elective revascularization (14.1%), ACR lasted 12 weeks, with reduction of anxiety score and improvement in almost all components of QoL (P<0.05), except mental health. At OTHERS (22.4%), ACR lasted 4 weeks, with improvement in almost all components of QoL (P<0.05), except mental health; ACR duration negatively correlated with anxiety and depressive scores (P<0.05). CONCLUSION: ACR during 3-month results with improvement of anxiety, depression and QoL at patients with various cardiac pathology.

Utilization of somatic healthcare in Croatian patients with schizophrenia spectrum disorder, major depression, PTSD and the general population.

BACKGROUND: Utilization of somatic healthcare services is highly predictive of the development of chronic physical illnesses and increased mortality risks. The objective of this study was to assess the differences in healthcare utilization among patients with schizophrenia spectrum disorders (SSD), major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and the general population in Croatia. METHODS: We enrolled 566 Croatian participants from the general population, 282 with SSD, 178 with MDD, and 86 with PTSD. The primary outcome was a self-reported specialist consultation for non-psychiatric (e.g., somatic) causes within the previous 12 months. RESULTS: Although SSD patients with chronic physical illnesses were significantly more often hospitalized for physical illness than the general population, the proportion of patients who had a specialist consultation were equal in SSD and the general population. MDD and PTSD patients had significantly higher adjusted odds for specialist consultation than the general population and SSD patients (MDD compared to SSD: OR = 2.14; 95% CI 1.27-3.59; PTSD compared to SSD: OR = 2.03; 95% CI 1.00-4.10). CONCLUSIONS: SSD patients' utilization of somatic healthcare is equal to the general population, despite their increased healthcare needs. However, their utilization is lower than in MDD and PTSD patients and, therefore, probably not adequate. TRIAL REGISTRATION: The study protocol was registered at ClinicalTrials.gov ( NCT02773108 ) on May 16, 2016.

Clustering of Mental and Physical Comorbidity and the Risk of Frailty in Patients Aged 60 Years or More in Primary Care.

BACKGROUND This study aimed to identify the clustering of comorbidities, cognitive, and mental factors associated with increased risk of pre-frailty and frailty in patients ≥60 years in a primary healthcare setting in eastern Croatia. MATERIAL AND METHODS There were 159 patients included in the cluster analysis who were ≥60 years and who underwent four-month follow-up. The first cluster contained 50 patients, the second cluster contained 74 patients, and the third cluster contained 35 patients. Clinical parameters were identified from electronic health records and patient questionnaires. Laboratory tests, anthropometric measurements, the number of chronic diseases, the number of prescribed medications were recorded. Frailty was determined using the five criteria of Fried's phenotype -model. Levels of anxiety and depression were recorded using the Geriatric Anxiety Scale (GAS) and the Geriatric Depression Scale (GDS), and the Mini-Mental State Examination (MMSE) score assessed cognitive impairment. Logistic regression models were used to identify predictors of frailty and pre-frailty. RESULTS Three overlapping clusters of phenotypes predicted frailty, and included obesity (n=50), multimorbidity with mental impairment (n=74), and decline in renal function with cognitive impairment (n=35). The predictors of outcome included increasing age, number of chronic diseases, inflammation, anemia, anxiety, and cognitive impairment, and reduced muscle mass. CONCLUSIONS In patients ≥60 years in a primary healthcare setting, multimorbidity predictors of pre-frailty and frailty included a decline in cognitive function and renal function.

Hyperprolactinemia - side effect or part of the illness.

BACKGROUND: Hyperprolactinemia is associated with side effect of antipsychotics in people suffering from psychotic disorders. However, increased prolactin levels (mlU/L) were found in patients suffering from the first psychotic episode who were not receiving antipsychotic therapy. The assumption of this study is that the abnormality in the level of prolactin is associated with the effect and influence of the disease, not the therapy that is carried out. SUBJECTS AND METHODS: Study involved 54 female patients hospitalized in Psychiatric hospital "Sveti Ivan", whose average age was 33.9 years. All patients had been diagnosed with a psychotic disorder (according to MKB-10, F20-F29). 18 patients had their first psychotic episode, while 36 patients had relapses of psychotic disorder. The methods used were: PANSS scale and measurement of prolactin concentration (Immunoanalyzer ACCESS 2, CLIA method). Arithmetic mean, standard deviations, correlation coefficient, Mann Whitney U test and the chi-squared test were used. RESULTS: 75.5% of patients had prolactin values above the reference values (min 121, max 4192 ml/L). In a sample of patients with first psychotic episode, 77.8% had elevated prolactin levels, while among re-hospitalized patients, elevated levels had 74.2%. Statistically significant results were obtained: patients with higher pronounced symptoms had higher prolactin values, especially particles on PANSS: P1 (delusions), N4 (Apathy), G15 (preoccupation) and G16 (active avoidance). CONCLUSION: Elevated prolactin in patients has been demonstrated regardless of antipsychotic therapy, therefore the question of etiology of hyperprolactinemia in psychotic disorders is questionable. The association of hyperprolactinemia with the severity of the clinical picture has also been demonstrated, higher prolactin values indicating a stronger clinical picture, which calls into question the protective role of prolactin in psychotic disorders.

Improving the quality of life during treatment in the Day hospital for early intervention in Psychiatric Hospital "Sveti Ivan".

BACKGROUND: The Day hospital for early intervention is a time-limited structured therapeutic program based on different psychotherapy and socio-therapy techniques. The aim of this study was to examine the outcomes of the Day hospital treatment for early intervention on self-esteem, and quality of life, and to determine which patients benefit the most from the program. SUBJECTS AND METHODS: The study was conducted on 124 patients with an early phase of psychosis who were treated at the Day hospital. They filled out Rosenberg Self-Esteem Scale, and WHOQOL-BREF upon the admission and again after three months of the treatment. Interaction effects were examined between their sociodemographic characteristics (gender, age, employment status), clinical features (first episode of psychosis or longer duration of illness), and results on applied questionnaires. RESULTS: After three months of the treatment, patients evaluated their self-esteem, overall quality of life and satisfaction with different QoL domains (physical and psychological health, environment) as significantly improved. Younger patients had greater increase in estimated self-esteem compared to older patients. No other significant interactions were found. CONCLUSION: Notwithstanding the limitations of this study, we may conclude that the findings are encouraging and may assist with development of more effective therapeutic approaches.

Clinical Challenges in Patients with First Episode Psychosis and Cannabis Use: Mini-Review and a Case Study.

The influence of cannabis use on the occurrence, clinical course and the treatment of the first psychotic episode (FEP) is well documented. However, the exact link is still not clearly established. The aim of this article is to review and report the noticed increase in the number of hospitalizations of young people with a clinical appearance of severe psychotic decompensation following cannabis consumption and to show the clinical challenges in treatment of the FEP. The case study describes the clinical course of a five selected patients with a diagnosis of the FEP and positive tetrahydrocannabinol (THC) urine test who were hospitalized in a similar pattern of events. They all have a history of cannabis consumption for at least 6 years in continuity and were presented with severe psychomotor agitation, disorganisation, confusion and aggression at admission. Although the chosen drug to treat all patients was atypical antipsychotic and benzodiazepines, the course of the disorder and the clinical response to therapy were noticeably different in each patient. The clinical presentation of FEP in cannabis users can be atypical and highly unpredictable from mild psychotic symptoms to severe substance intoxication delirium. In clinical practice clinicians treating new onset psychosis need to be watchful for cannabis and synthetic cannabinoids induced psychosis. Pharmacotherapeutic interventions include prompt and adequate use of the benzodiazepine, second-generation antipsychotic, and mood-stabilizers. Further research in the pharmacotherapy of cannabis-induced psychosis is required.

Efficacy of Center for Integrative Psychiatry Multimodal Early Intervention Services in Early-Phase Psychosis on Hospital Readmission.

BACKGROUND: Growing body of evidence has opened new opportunities to enhance treatment outcomes during early-phase psychosis (EPP). The objective of this study was to evaluate the effect of the Centre for integrative psychiatry (CIP) multimodal Early Intervention Services (EIS) on time to relapse in the patients with early-phase psychosis (EPP) during 12 and 24 month period. SUBJECTS AND METHODS: We performed a retrospective cohort study on the sample of 454 EPP patients (duration of the diagnosed disorder ≤5 years) admitted to Psychiatric Hospital "Sveti Ivan", Zagreb Croatia, from January 2, 2015, to December 5, 2018, for the acute treatment of EPP. The end of follow up was March 5, 2019. The primary outcome was the time to rehospitalization because of relapse during the 12 months from the hospital discharge. Independent variable was the EIS. RESULTS: We analyzed 454 EPP patients, 260 in EIS group and 194 in no EIS group. After the adjustment for twenty possible confounding factors using the Cox proportional hazard regression, patients who received EIS had significantly and clinically relevantly lower hazard for rehospitalization because of relapse during the first 12 months (HR=0.39; CI95% 0.21-0.61; p<0.001), and during the first 24 months from the hospital discharge (HR=0.56; CI95% 0.39-0.80; p=0.003; sequential Holm-Bonferroni corrected pcorr=0.004). CONCLUSIONS: Our study indicated efficacy of the CIP multimodal EIS in patients with EPP demonstrated through the time to the hospital readmission because of relapse during the 12 and 24 months from the hospital discharge. These results strongly support the need for implementation of multimodal EIS in all patients with EPP.

Integration of complementary biomarkers in patients with first episode psychosis: research protocol of a prospective follow up study.

In this project, we recruited a sample of 150 patients with first episode of psychosis with schizophrenia features (FEP) and 100 healthy controls. We assessed the differences between these two groups, as well as the changes between the acute phase of illness and subsequent remission among patients over 18-month longitudinal follow-up. The assessments were divided into four work packages (WP): WP1- psychopathological status, neurocognitive functioning and emotional recognition; WP2- stress response measured by saliva cortisol during a stress paradigm; cerebral blood perfusion in the resting state (with single photon emission computed tomography (SPECT) and during activation paradigm (with Transcranial Ultrasonography Doppler (TCD); WP3-post mortem analysis in histologically prepared human cortical tissue of post mortem samples of subjects with schizophrenia in the region that synaptic alteration was suggested by WP1 and WP2; WP4- pharmacogenetic analysis (single gene polymorphisms and genome wide association study (GWAS). We expect that the analysis of these data will identify a set of markers that differentiate healthy controls from patients with FEP, and serve as an additional diagnostic tool in the first episode of psychosis, and prediction tool which can be then used to help tailoring individualized treatment options. In this paper, we describe the project protocol including aims and methods and provide a brief description of planned post mortem studies and pharmacogenetic analysis.

Schizophrenia and Physical Comorbidity.

Schizophrenia is a severe psychiatric disorder increasingly recognized as a systemic disorder. In addition to the burden and suffering caused by the mental illness itself, individuals with schizophrenia have a high risk for physical illnesses. The life expectancy gap remains 13 to 30 years wider in people with schizophrenia compared to the general population. This premature mortality is caused largely by deaths due to cardiovascular disease, cancer, diabetes mellitus, and other natural causes, poor diagnosis and treatment, and insufficient prevention of modifiable risk factors. Although the links between schizophrenia and physical illnesses are well established, in clinical practice, physical illnesses in patients with schizophrenia are often overlooked, and the mortality gap between general population and people with schizophrenia continues to widen. The physical health of people with schizophrenia is commonly self-neglected but also ignored by people around them and by health systems, resulting in significant physical health disparities and limited access to health services. The root of the problem of insufficient healthcare appear to lie in interrelated contributory factors from illness, patients, and medical and mental healthcare system. Furthermore, a growing body of literature has been indicating the effect of the chronic physical illness on the treatment outcome of psychosis. Premature mortality and disability could be reduced if there was a greater focus on the implementation of strategies that effectively prevent modifiable risk factors from the first psychotic episode and enhance early recognition of physical illnesses, reduce the burden of physical comorbidity and lead to improved health outcomes. Ultimately, to improve treatment outcome and to reduce the suffering of people with schizophrenia, it is crucial to treat physical comorbidity promptly and assertively from the appearance of the first symptoms of the psychotic disorder. The integrative approach and collaborative care within all levels of healthcare providers should be the imperative in clinical practice.

Prevalence of Pathological Gambling among Alcohol Addicts in Outpatient Treatment in the City of Zagreb: a Cross-Sectional Study.

BACKGROUND: Various types of addictions often co-occur, particularly substance and behavioral ones, which affects the clinical course of mental health disorders as well as the efficacy of therapy and rehabilitation efforts. The present study aims to explore gambling activities and possible gambling addiction among alcoholics in an outpatient treatment in the city of Zagreb. SUBJECTS AND METHODS: Gambling activities were assessed in 140 members of alcohol addiction clubs in the City of Zagreb (Croatia). Participants were undergoing treatment after being diagnosed by their psychiatrist with alcohol dependence syndrome based on ICD-10 criteria. Intensity of gambling-related problems was measured using the South Oaks Gambling Screen (SOGS), while intensity of alcohol addiction was assessed using DSM-5 diagnostic criteria for alcohol use disorder. All instruments were self-report forms and were completed using pen and paper in a group context during outpatient treatment. RESULTS: Pathological gambling was more prevalent in this clinical subsample than in general populations analysed in other studies. Alcohol addicts showing problematic or pathological gambling behaviors tended to play more highly addictive games (sports betting, slot machines, roulette). However, intensity of gambling-related problems did not correlate significantly with the intensity of alcohol addiction. CONCLUSION: These results confirm studies from other countries showing higher prevalence of problematic and pathological gambling among alcohol addicts than in the general population. Gambling behavior in our sample more often involved games with greater addictive potential. These findings suggest that alcohol addicts should be systematically screened for problematic and pathological gambling, which may improve therapeutic efficacy and rehabilitation, as well as reduce relapse in addictive behavior in general.