Depression among medical students in Tunisia: Prevalence and associated factors.

BACKGROUND: Medical school is known for its lengthy process, which is both physically and emotionally draining. Students' mental balance would shrink as they progress in their medical training. A systematic review and meta-analysis reported that the prevalence of depressive symptoms among medical students remained relatively constant at 27.2%. AIM: To assess the prevalence of depressive symptoms among Tunisian medical students and evaluate its associated factors. METHODS: This is a descriptive cross-sectional study that was carried out in the second semester of the academic year 2017/2018, between April 2018 and July 2018 among 1138 medical students. Data were collected using a socio-demographic questionnaire and the Beck Depression Inventory-II (BDI-II). RESULTS: Sixty-four percent (n = 728) of the participants had depressive symptoms, of which 266 (23.4%) met the criteria for mild, 271 (23.8%) for moderate, and 191 (16.8%) for severe depressive symptoms. Female gender, low socio-economic level, smoking habits and history of mental disorder, performing leisure and physical activities, satisfaction toward a career choice, and happiness perception were the main prognostic factors for depression among medical students. Although academic grades may not be considered a prognostic factor, final-year students appeared to be less depressive than their colleagues. CONCLUSION: These findings give insight into mental health issues and comorbidities among Tunisian medical students. It is a hopeful request for decision-makers and academic authorities to set serious measures and draw effective interventions to minimize the currency of psychological distress among this subpopulation.

TLR4 Polymorphisms (T399I/D299G) Association with Schizophrenia and Bipolar Disorder in a Tunisian Population.

Immune dysregulation has been widely described in the pathophysiology of schizophrenia (SCZ) and bipolar disorder (BD). Particularly, TLR4-altered activation was proposed as one of the underlying processes of psychosis onset. Since TLR4 activation was altered by T399I and D299G polymorphisms, we hypothesized that those variants could present common genetic factors of SCZ and BD. A total of 293 healthy volunteers and 335 psychotic patients were genotyped using PCR-RFLP. Genotype, allele, and haplotype distribution between controls and patients were evaluated according to clinical parameters. Statistical analyses were adjusted by logistic regression. In dominant model, T399I CT + TT and allele frequency were significantly higher in controls compared to psychotic population (p = 0.004, p = 0.002, respectively), SCZ (p = 0.02, p = 0.01, respectively), and BD (p = 0.03, p = 0.02, respectively). Similarly, D299G AG + GG and allele frequency were significantly higher in controls compared to psychotic population (p = 0.04, p = 0.04, respectively) and SCZ (p = 0.04, p = 0.03, respectively). T399I CT + TT and T allele were overrepresented in controls compared to paranoid subgroup (Padjusted = 0.04, p = 0.04, respectively) and type I BD (p = 0.04). Moreover, T399I and D299G were less prevalent in SCZ late-onset age (p = 0.03, p = 0.02, respectively). TA haplotype was associated with protection from psychoses (p = 0.02) and particularly from schizophrenia (p = 0.04). In conclusion, TLR4 polymorphisms could present a preventive genetic background against psychoses onset in a Tunisian population. While T399I could be associated with protection against SCZ and BD, presenting an overlapping genetic factor between those psychoses, D299G was suggested to be associated with protection only from schizophrenia.

Association between polymorphisms of TLR2-1-6 and bipolar disorder in a tunisian population.

BACKGROUND: Bipolar disorder (BD) is a complex neuropsychiatric disease that has been strongly linked to immune dysregulation. In particular, an abnormal inflammatory response mediated by toll-like receptor 2 - 1/6 (TLR2-1/6) was described in BD. Nevertheless, genetic factors' contribution is still unknown. Thus, we suggested that functional polymorphisms of TLR2, 1 and 6 could be involved in BD predisposition. METHODS AND RESULTS: TLR2, 1 and 6 polymorphisms were genotyped by PCR-RFLP in 292 controls and 131 patients from a Tunisian population. Polymorphisms and haplotype associations were explored in BD and binary logistic regression analysis was performed for more powerful associations. In dominant model, we found a significantly higher genotype and minor allele frequencies in healthy females compared to patients for TLR2-196-174Ins/Del (p = 0.04; OR = 0.3, p = 0.04; OR = 0.3, respectively) and for TLR6-S249P only with minor allele (p = 0.03; OR = 0.2). In contrast, TLR2-R677W CT + TT and T allele frequencies were significantly higher in BD (padjusted<10- 4; ORadjusted =46.6, p < 10- 4; OR = 6.3, respectively), specifically in females (CT + TT: 100%). Similarly, TLR1-R80T showed significantly increased GC + CC and C allele frequencies in patients compared to controls (padjusted=0.04; ORadjusted=4, p = 0.009; OR = 4.3, respectively). Moreover, haplotype investigation demonstrated that InsGTCGT (p < 10- 4, OR = 275) and delGCCGT (p = 0.03, OR = 18.5) were significantly overrepresented in BD patients compared to controls. CONCLUSIONS: We suggest that TLR2-196-174Ins/Del and TLR6-S249P could be protective factors of females against BD. However, TLR2-R677W and TLR1-R80T could be strongly associated with higher risk of BD. Interestingly, TLR2-R677W could be a genetic marker for BD in females. However, further studies with larger groups are needed to confirm these findings.

Case control study: G-allele of rs4244165 in JAK1 gene correlated with high-level brief psychiatric rating scale in bipolar patients.

Bipolar disorder (BD) is a chronic and clinically complex disease, characterized by pathological disturbances in mood and energy. Cytokines can access the brain and their signaling pathways affect brain functions, such as neurotransmitter metabolism, neuroendocrine function, neural/synaptic plasticity, and mood neural circuitry. JAK 1 is the most common phosphorylation protein combined with the tyrosine kinase cytokine receptors; therefore, we investigated the association between the Janus family kinase 1 (JAK1) gene polymorphisms (rs2780895, rs4244165, and rs17127024) and susceptibility to BD. The case study population included 93 patients diagnosed with BD and 112 healthy controls, selected from the central coastal region of Tunisia. Polymerase chain reaction-restriction fragment length polymorphism was used to investigate these 3 JAK1 polymorphisms. We compared the sociodemographic and clinical parameters of 3 genotypes of this single nucleotide polymorphisms rs2780895, rs4244165, and rs17127024 of the JAK1 gene. The frequencies of the 3 genotypes were similar in the patient and control groups. One-way analysis of variance revealed a significant variation in rs4244165. After hospitalization, the average of the brief psychiatric rating scale score was significantly higher for the wild-type GG genotype than that for the double-mutation TT genotype (31.23% vs 22.85%, P = .043). The least significant difference post hoc test also showed a significant difference between the GG and TT genotypes at both hospital admission (P = .001) and after hospitalization (P = .012), with the GG genotype being associated with a higher brief psychiatric rating scale score. Haplotypic analysis revealed that the wild-type haplotype with the highest frequency (46.62%) was CTG. Our results showed no association between the 3 studied positions and bipolar disorder. However, the G-allele of rs4244165 in JAK1 is associated with the highest level of the brief psychiatric rating scale in patients with bipolar disorder. The JAK/signal transducer and activator of transcription pathway is an interesting therapeutic route that requires further investigations. Studying their regulatory regions can provide a clearer picture of all the interactions involved in the regulation of genetic expression in response to treatment.

Eating disorder and anxiety during Covid19 pandemic: the Maghrebian experience.

The coronavirus pandemic is considered the worst-hit that the world had witnessed in the current century. The impact of the pandemic, especially during the lockdown, was not only diverse but also worldwide. The African continent, including the Maghreb, was no exception. The aim of this study was to assess the levels of anxiety and eating behaviors and their correlations in three Maghrebian countries following the official outbreak of the COVID19 pandemic. It is a cross-sectional study of 754 participants from Tunisia, Algeria and Morocco. It took place between 30 April and 2 July 2020. The survey showed that eating disorders represented 45.9% of the sample while 26.8% (202 participants) matched the anxiety criteria. Statistical significant factors for eating disorders were gender (p = 0.002; OR = 1.760), underweight (p = 0.021; OR = 0.306), anxiety (p = 0.001; OR = 0.470), bulimia (p = 0.000; OR = 0.794) and body dissatisfaction (p = 0.000; OR = 0.920). This rise goes along with other surveys in different parts of the world. These results can be explained by multiple reasons such as the 'food insecurity' mechanism, the excessive feeling of boredom and loneliness resulting from social distancing and the overwhelming overthinking about the onset of a serious economic crisis.

Stress, anxiety, and depression among students at the Faculty of Medicine of Sousse (Tunisia).

OBJECTIVE: To evaluate the frequency of anxious and depressive symptoms and to determine their associated factors in a population of students enrolled at the Faculty of Medicine of Sousse (Tunisia). METHODS: this is a descriptive cross-sectional study that took place at the Faculty of Medicine of Sousse over the period from 09/15/2017 to 03/15/2018. An anonymous questionnaire was administered to the students in the guided teaching rooms. The assessment of anxiety and depressive symptoms was based on the Anxiety and Depression Scale (HADS) and the quality of sleep was assessed by the PSQI questionnaire. RESULTS: A total of 202 medical students participated in the study. The average PSQI score was 5.62±2.87 and 47% of students had poor sleep quality (PSQI ≥ 6). Symptoms of anxiety and depression were observed in 73 (36.1%) and 45 (22.3%) students respectively. The mean HADS-A score was 9.21±4.17 and that of the HADS-D score was 7.37±4.06. In univariate analysis, the factors found to predict a high level of perceived stress were the study cycle (p=0.022) and poor quality of sleep (p 11) were the use of sleeping pills (p=0.004), the quality of sleep (p<0.001), and a high level of perceived stress (p<0.001). The high level of perceived stress was found to predict depression (p=0.006).In the multivariate analysis of variables in the present study, poor sleep quality was a factor independently related to high perceived stress in medical students (ORa=9.062 [4.247-19.334]) while being a medical student of the 1st cycle proved to be a protective factor (ORa=0.101 [0.025-0.406]). Use of sleeping pills (ORa=4.481 [1.135-17.682]), poor sleep quality (ORa=2.131 [1.081-4.203]) and high level of perceived stress (ORa=5.790 [2.444-13.716]) were factors independently related to anxiety symptoms. Female sex was a protective factor for depressive symptoms (ORa=0.440 [0.205-0.945]) while a high level of perceived stress was a factor independently related to depressive symptoms (ORa=3.429 [1.469-8.005]). HAD-A and HAD-D scores were correlated (r=0.631 ; p<0.001). CONCLUSION: sleep disturbances, perceived stress, anxious and depressive symptoms are common among Tunisian medical students. Prevention strategies targeting the improvement of sleep quality and student stress management should be developed at the faculty and ministerial level.

A Preventive Role of RANTES Genetic Variation against Undifferentiated Schizophrenia.

AIM: Due to conflicting data from relevant studies, evidence for chemokine alterations in the pathophysiology of schizophrenia (Scz) remains inconclusive. Thus, we aimed to investigate the impact of rs2107538, rs2280788, and rs2280789 polymorphisms in CCL5 gene, as well as rs333 within CCR5 gene and the development of Scz in a Tunisian cohort. METHODS: We performed a case-control study composed of 200 patients and 200 controls using RFLP-PCR. RESULTS: Among the analyzed polymorphisms, only rs2107538 imparted protection against Scz and more specifically to male sex. This protective effect remained valid for the undifferentiated form. Moreover, this SNP had an impact on patients' symptomatology. When focusing on haplotypes, we noticed that the rs2107538-rs2280788-rs2280789 ACT genetic combination, with only one mutated allele rs2107538A, displayed reduced frequency in both Scz (as a whole group) and undifferentiated subtype. The haplotype distribution profile implies that the A allele at rs2107538 could induce a protective effect by increasing RANTES production. CONCLUSION: Additional independent analyses are required to corroborate these findings and elucidate the functional implications of the discovered preventing genotypes and haplotypes in Scz.

Association of VEGF-A and KDR polymorphisms with the development of schizophrenia.

AIM: Several approaches indicate different blood flow disturbances in schizophrenia. VEGF-A is widely recognized as one of the key molecules involved in the angiogenesis process through mainly its receptor KDR. The current work was designed to investigate the potential association between three polymorphisms (rs699947; rs833061 and rs3025039) in VEGF-A gene and two SNPs (rs2305948 and rs1870377) within KDR gene and predisposition to schizophrenia among the Tunisian cohort. METHODS: We carried-out a case-control study composed of 200 patients with schizophrenia and 200 healthy subjects using PCR-RFLP. RESULTS: Of all analyzed polymorphisms, only rs833061, rs3025039 and rs1870377) showed a significant risk for schizophrenia (PAdjusted = 0.04, PAdjusted=<0.001, PAdjusted = 0.005 respectively). Following the stratified analysis, rs3025039 was more prevalent among undifferentiated form (PAdjusted=<0.001) and more specifically with male sex (PAdjusted=<0.001). Yet, rs1870377 was correlated with paranoid subtype (PAdjusted = 0.002) and particularly with male sex (PAdjusted = 0.005). We found also that rs699947 is associated to negative symptoms before and after treatment (P = 0.004; P = 0.001 respectively) and rs3025039 had an impact on positive and negative symptoms only after treatment (P = 0.03; P = 0.008 respectively). Haplotype analysis revealed a strong LD between rs833061 and rs3025039 only for controls and undifferentiated patients (P = 0.005). Moreover, the rs699947*C âˆ¼ rs833061*T âˆ¼ rs3025039*T haplotype, with only one mutated allele rs3025039*T, conferred a high risk to schizophrenia (P = 0.016) and, in particular, to undifferentiated and paranoid forms (P = 0.03; P = 0.02 respectively). Among the last-mentioned subgroup, we noticed another overrepresented haplotype (rs699947*A âˆ¼ rs833061*T âˆ¼ rs3025039*T; P = 0.01). Furthermore, the rs2305948*G âˆ¼ rs1870377*T haplotype carrying the minor allele rs1870377*T displayed increased frequencies in the whole group of patients and particularly among paranoid subtype (P = 0.013; P=<0.001 respectively). CONCLUSION: Our results show that all SNPs associated with the development or the severity of schizophrenia, were subsequently correlated with a decrease in the VEGF-A levels or influence KDR binding affinity. These data need to be strengthened by further independent analyses.

Attitudes toward mental illness among medical students and impact of temperament.

BACKGROUND: Mental health-related stigma is a serious problem that has undesirable consequences for individuals with mental disorders including physical health disparities, increasing mortality, and social dysfunction. Besides, these individuals frequently report feeling 'devalued, dismissed, and dehumanized' when encountering health professionals who are also perpetrators of stigmatizing attitudes and discriminatory behaviors. AIMS: The present study concentrates on attitudes, and behavioral responses of medical students and junior doctors toward individuals with a mental illness and explores factors associated with stigma including temperament. METHODS: A cross-sectional study was conducted among medical students and junior doctors from medical schools of universities in Tunisia. All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform. Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians' Attitudes (MICA), Assessment of Affective Temperament, TEMPS-A scale. RESULTS: A total of 1,028 medical students and junior doctors were recruited. The completion of a psychiatry clerkship for medical students didn't improve significantly the level of stigma toward people with a mental illness. Students in the fourth year had significantly the lowest MICA scores comparing to other students. Psychiatrists had significantly lower scores of explicit stigma attitudes than the other groups (Mean score = 0.42). As for other specialties, surgical residents had more stigmatizing attitudes than those who had medical specialties. 70% of participants believed that people with a mental illness are more dangerous than the other patients. Hyperthymic temperament was significantly associated with decreased stigma attitudes toward patients with mental illness. CONCLUSION: A combination of medical school experiences of psychiatry's theoretical learning and clerkship and wider societal beliefs are important factors that shape students. Awareness of this will enable educators to develop locally relevant anti-stigma teaching resources throughout the psychiatry curriculum to improve students' attitudes toward mental illnesses.

Association between TLR2 polymorphisms (- 196-174 Ins/Del, R677W, R753Q, and P631H) and schizophrenia in a Tunisian population.

Since immune dysregulation has been well studied in schizophrenia pathophysiology, recent studies showed a potent role of TLR2 in neuroinflammation process underlying schizophrenia pathogenesis. However, the genetic predisposition is still unclear. Thus, we hypothesized that TLR2 polymorphisms - 196-174 Ins/Del (rs111200466), R753Q (rs5743708), R677W (rs121917864), and P631H (rs5743704) could be involved in schizophrenia predisposition. A case-control study was performed on a Tunisian population composed of 250 healthy controls and 250 patients genotyped by PCR-RFLP. Genotype and allele distribution were evaluated with sex, schizophrenia subtypes, and other clinical features. We also assessed a haplotype analysis for TLR2 polymorphisms with schizophrenia. Our results showed higher ins/del genotype frequency in healthy women compared to patients (p = 0.006; OR = 0.2). In the other hand, logistic regression showed higher ins/del genotype frequency in controls compared to paranoid patients (p = 0.05; OR = 0.48, adjusted). Frequencies of CT and T allele of R677W were significantly higher in patients compared to controls (p < 10-4, OR = 10.39; p < 10-4, OR = 4, adjusted, respectively). R753Q polymorphism was exclusively detected in patients (GA + AA = 2.5%) particularly in men with disorganized subtype. P631H did not show any association with schizophrenia. Finally, haplotype analysis showed that InsGTC and delGTC were associated with higher risk of schizophrenia (p = 0.0001, OR = 8.58; p = 0.04, OR = 5.01, respectively). In the Tunisian population, our results suggested that TLR2 R677W could be associated with susceptibility for schizophrenia, while - 196-174 Ins/Del suggested a trend of protection in women. Otherwise, R753Q could have an effect on schizophrenia especially for disorganized subgroup.

[Epidemioclinical and legal aspects of sexual abuse among minors in Monastir, Tunisia]. / Aspects épidémiocliniques et suites judiciaires des abus sexuels chez les mineurs à Monastir, Tunisie.

INTRODUCTION: Child sexual abuse is a disturbing reality and a major public health problem. Indeed, it is a subject that has long been treated as taboo, with dramatic consequences on physical and mental health as well as on social wellbeing of the victims. The purpose of this study was to highlight the epidemiological and clinical features as well as the legal aspects of child sexual abuse. METHODS: we conducted a retrospective descriptive study at the psychiatric outpatient service of the University Hospital of Monastir over a period of 12 years and 6 months. All children younger than 18 years diagnosed with suspected or confirmed sexual assault were included. RESULTS: a total of 93 children, victims of sexual abuse were enrolled. The average age of patients was 10 years, with a standard deviation of 3.9 years. Sex-ratio M/F was 0.9. The most common sexual contact was touching (47,3% of cases). The majority of abusers were male (93,5%). In more than half of the cases (53,8%) they were relatives of the child and in 28% of cases intra-familial abuse was reported. Initial psychiatric assessment showed mental disorders in 70% of cases. CONCLUSION: sexual abuse is a very broad field of violence which varies widely in nature and intensity. Although, in some types of sexual abuse occasionally there is a lack of physical traces, the emotional and psychological impact is ubiquitous and characterized by numerous clinical manifestations.

Clinical and genetic influencing factors on clozapine pharmacokinetics in Tunisian schizophrenic patients.

Clozapine (Clz) is an atypical antipsychotic, which its pharmacokinetics can be influenced by several factors. The CYP1A2 and CYP2C19, major enzymes implicated in Clz metabolism, present an interethnic variation on their activity caused by single nucleotide polymorphisms (SNPs). The present study investigated the influence of genetic and nongenetic factors on Clz pharmacokinetics in a southern Mediterranean population. We included adult Tunisian schizophrenic patients having received Clz and undergone a therapeutic drug monitoring (TDM) of Clz by morning C0 monitoring. The genomic DNA was extracted using a salting-out procedure. CYP1A2*1F (rs762551;-163C>A), CYP1A2*1C (rs2069514;-3860 G>A) and CYP 2C19*2 (rs4244285; 681G>A) was analyzed using PCR-RFLP. Fifty-one patients were enrolled in the study. The mutant allele (CYP1A2*1F) was the most frequently detected (58.8%). For CYP1A2*1F, Clz dose-normalized (C0/D ratio) was as high as 1.28 ± 0.37 in CC versus 0.67 ± 0.32 ng mL-1 per mg day-1 in AA group (p < 0.001). The influence of genetic (CYP1A2*1F, CYP1A2*1C and CYP2C19*2) and nongenetic parameters (age, weight, gender, tobacco, coffee, and alcohol consumption) on the variation of the Clz C0/D ratio was investigated. Only the CYP1A2*1 F polymorphism correlates significantly with the Clz C0/D variation and could explain 24% of its variability. Our data support a critical role of the CYP1A2 -163C>A on the variation of Clz exposure in Tunisian schizophrenic patients. Considering its narrow therapeutic range, CYP1A2 genotyping combined with TDM of Clz may improve efficacy and safety of this drug. Further studies are needed to investigate this issue.

Inteurleukin-8 gene variations and the susceptibility to schizophrenia.

The relevance of Interleukin-8 (IL-8) cytokine alteration in the peripheral and central system has been widely shown in psychosis while variation in the IL-8 gene remains largely unexplored and to the best of our knowledge, IL-8 polymorphisms have never been specifically targeted in Schizophrenia (Scz). Thus, we set out to search a potential correlation between rs4073, rs2227306 and rs1126647 polymorphisms in IL-8 gene and the development of Scz in a sample of the Tunisian population in a candidate gene approach. Targeted polymorphisms were analysed in 206 patients and 195 controls using PCR-RFLP method. Among all analysed polymorphisms, only rs1126647 showed a significant risk for Scz. After stratification analysis, we noted a significant association of TT genotype and T allele at rs1126647 with paranoid form, and more specifically with female sex. We find that the rare haplotypes at rs4073-rs2227306-rs1126647 of TTT, ACT and TCT, each containing the risk allele rs1126647T, were associated with increased risk for paranoid Scz while only the TCT combination constituted a risk factor for Scz more generally. Our findings support that IL-8 gene may be involved in susceptibility to Scz but this still preliminary and needs to be strengthened by further independent analyses.

Hashimoto's Encephalopathy Revealed by Hypochondriacal Delusion: A Case Report Involving a Male Patient.

Hashimoto's encephalopathy (HE) is a rare autoimmune disorder. It associates encephalopathy with autoimmune thyroiditis, presenting abnormal elevations of thyroid antibodies. It is more common in females. It can present with various symptoms, including seizures, myoclonus, psychosis, hallucinations, and mood disturbances. Hypochondriacal delusion is an unusual clinical presentation of this disorder. The authors report a case of HE in a male patient whose clinical presentation was dominated by hypochondriacal delusion. The absence of response to antipsychotics, high serum antithyroid peroxidase antibodiesof about 199 UI/ml, the normality of magnetic resonance imaging, and improvement with corticosteroids confirmed the diagnosis. This neuroendocrine disorder is often misdiagnosed and it represents a diagnostic challenge for clinicians. It should be considered in patients presenting a refractory or an atypical neuropsychiatric disorder and having a family history of autoimmune disease.

Protective Effect of the MCP-1 Gene Haplotype against Schizophrenia.

While cytokines and their genetic variants have been intensively studied in schizophrenia, little attention has been focused on chemokines in the last years. The monocyte chemoattractant protein 1 (MCP-1) is known to attract peripheral monocytes to the brain during an inflammatory reaction and to affect the T helper (Th) cell development by stimulating Th2 polarization. Owing to the neuroinflammation in schizophrenia and the variable level of MCP-1 in these patients' sera, we proposed to analyze the impact of functional genetic variants of the MCP-1 gene (MCP-1-2518A/G (rs1024611), MCP-1-362G/C (rs2857656), and MCP-1 int1del554-567 (rs3917887)) in schizophrenic patients. We conducted a case-control study on a Tunisian population composed of 200 patients and 200 controls using RFLP-PCR. Our results indicated that the minor alleles (-2518G and Del554-567) were significantly more prevalent in controls than in patients (P=0.001/adjusted OR = 0.42, P=0.04/adjusted OR = 0.64), whereas, for -362C minor allele, increased risk of schizophrenia was revealed (P=0.001, adjusted OR = 2.38). In conclusion, we have identified the haplotype combination -2581G/-362G/int1del554-567 that could mediate protection against schizophrenia (P=0.0038, OR = 0.19) and the effect could result more strongly from the MCP-1 -2582G with -362G variants, whereas the effect of int1del554-567 may in part be explained by its LD with -362.

Reduced peripheral availability of tryptophan and increased activation of the kynurenine pathway and cortisol correlate with major depression and suicide.

Objectives: Patients affected by major depression (MDD) are at high risk of suicide. The metabolism of tryptophan (Trp) along the serotonin (5-HT) and kynurenine (Kyn) pathways was found dysfunctional in MDD and in suicide. However, a clear biological framework linking dysfunctions in Trp metabolism via 5-HT and Kyn, cortisol, and the activities of tryptophan and indoleamino 2,3-dioxygenase (TDO, IDO) enzymes has not been yet clarified in MDD with or without suicidal behaviours.Methods: We analysed peripheral markers of Trp via 5-HT and Kyn pathways, Kyn/Trp ratio as a measure of TDO/IDO activities, cortisol, and psychopathology in 73 non-suicidal and 56 suicidal MDD patients, and in 40 healthy controls.Results: Plasma Trp levels were lower and the ratio Kyn/Trp higher in suicidal MDD than in non-suicidal MDD patients and controls. Trp levels and the ratio Kyn/Trp correlated with suicidal ideation, and cortisol with the Kyn/Trp ratio. Finally, Trp levels discriminated controls from non-suicidal and suicidal MDD patients, and also non-suicidal from suicidal MDD patients.Conclusions: Reduced availability of Trp for 5-HT synthesis and increased activation of the Kyn pathway and cortisol correlate with depression and suicide. Low plasma Trp levels may be a biomarker of MDD and suicide in MDD.

Suicidal ideation and suicide attempts among Tunisian adolescents: prevalence and associated factors.

INTRODUCTION: Studies directed on suicidal behavior in North African adolescents are rare. This study was conducted to estimate the prevalence of suicidal thoughts and attempts among high school students in Tunisia and to determine factors associated with this suicidal behavior. METHODS: This is an analytical cross-sectional study composed of a population containing 821 high school students obtained through cluster sampling. The participants completed a pre-established form related to socio-demographic characteristics and anxiety symptoms, the Suicide Behavior Questionnaire-Revised, the Beck depression scale, and the Rosenberg self-esteem scale. RESULTS: The mean age of the adolescents was 17.7±0.97 years. Prevalence of suicidal behavior was 26.9% for brief passing suicidal thoughts, 9.6% for serious suicidal thoughts, and 7.3% for suicide attempts. Six determining factors of suicidal behavior were found: female gender (OR=2.56 (1.32-4.95); p= 0.005), personal history of depression (OR=2.29 (1.38-3.80); p=0.001), tobacco smoking (OR=3.59 (1.61-8.01); p=0.002), current depression symptoms (OR=5.50 (2.14-14.11); p<0.001), history of non-suicidal self-injurious behavior (OR= 3.16 (2.05-4.86); p<0.001), and low self-esteem (OR=2.74 (1.71-4.38); p<0.001). CONCLUSION: Suicidal ideation and attempts are frequent among Tunisian adolescents and represent a serious public health problem. An urgent national prevention program is required.

Lipid profile in schizophrenia: case control study.

INTRODUCTION: Cardiovascular diseases are common co morbidities of schizophrenia and constitute the main factors of high mortality in this pathology. Cardiovascular damages are favored by some risk factors, of which one of the most important is dyslipidemia. In this context, a study of lipid profile in schizophrenia is interesting.  The aims of this study were to compare the lipid profile of patients with schizophrenia to healthy controls and to investigate the associations between lipid parameters and demographics, clinical and treatment characteristics of the patients. METHODS: We conducted a case-control study between April 2013 and March 2014 on 78 patients with schizophrenia and 68 healthy subjects who benefited from the dosage of four serum lipid parameters: total cholesterol (TC), triglycerides (TG), High-density lipoprotein Cholesterol (HDL-C) and Low-density lipoprotein cholesterol (LDL-C). For the socio-demographic and clinical assessments, we used an information sheet and the following psychometric scales: PANSS (Positive And Negative Syndrome Scale), CGI (Clinical Global Impressions), GAF (Global Assessment Functionning) and the Calgary scale for depression. RESULTS: The comparative study showed that serum concentrations of TC and LDL-C were significantly higher for patients compared to healthy controls respectively with (t=2,83 ; p=0,008) and             (t=9,35; p<0,001), the cholesterol ratio (TC / HDL-C) was also significantly higher for patients           (t=2,23; p=0,033). The patients had significantly higher prevalence of hypercholesterolemia              (OR = 2.96) and low density hyperlipoproteinemia (OR = 18.79). The analytical study in the population of patients showed that the age ≥35 year-old, male gender and alcohol consumption were associated with disturbances in lipid parameters. Cannabis consumption was associated with significantly lower concentrations in TG. Concerning clinical features, paranoid schizophrenia was associated with less dyslipidemia unlike the depressive dimension assessed by the Calgary scale. There was a negative correlation between plasmatic TG concentrations and doses of antipsychotics. CONCLUSION: The vast majority of the literature confirms that patients with schizophrenia are at greater risk of dyslipidemia. This high risk appears to be more important with the consumption of alcohol and tobacco. It seems also that age and masculine gender are dyslipidemia risk factors for schizophrenic patients. The paranoid type of schizophrenia and positive symptoms seem to be associated with less dyslipidemia while depressive symptoms worsen lipid parameters. It then follows that, clinical and regular monitoring of lipid profile, lifestyle recommendations (smoking cessation, exercise and balanced diet) and appropriate therapeutic choices could help reduce morbidity and mortality among patients with schizophrenia. A special focus should be accorded to patients with high negative and depression symptoms.

Unipolar Mania: A Particular Aspect of Bipolar Disorder in Tunisia.

OBJECTIVE: Unipolar mania is a clinical reality in our daily practice. Many authors suggested that bipolar patients can have only manic episodes without depressions. These findings lead us to explore more this particularity. METHODS: We conduct a retrospective, descriptive and comparative study including 173 patients, followed for bipolar disorder type I, according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria, during the period between January 2008 and December 2015. Two groups were identified. The first one was composed of 98 patients who had presented only manic episodes. The second group contained the rest of the sample. Unipolar mania was defined as the presence of three or more manic states without a depressive episode during the period of the study. RESULTS: One hundred seventy three patients were included in the study. The average age of the sample was 43 years old. The first episode was manic in 129 patients (74.6%). The dominant polarity was manic in 90.8% of the cases. Seasonal characteristic and psychotic symptoms were observed in respectively 11.0% and 53.2% of the sample. Rapid cycling evolution was observed among 2.3% of patients. The unipolar manic profile accounted for 56.6% of the population. This result is equivalent to an annual incidence of 8%. Comparing the two groups, we did not find a significant difference concerning the sociodemographic and clinical variables except for the number of suicide attempts (p=0.014). CONCLUSION: Our study shows that unipolar mania is clinical evidence. More studies should be conducted in order to understand its nosological and psychopathological foundations.

Pratique de l'électroconvulsivothérapie dans un hôpital universitaire Tunisien: The practice of electroconvulsivotherapy at a University Hospital in Tunisia.

This study aimed to describe the practice of electroconvulsivotherapy (ECT) at the University Hospital of Monastir (Tunisia). We conducted a retrospective study of all patients treated by ECT at the University Hospital of Monastir between 2002 and 2013. 80 patients were enrolled in the study (60 men and 20 women, with an average age of 42.1±15.7 years), accounting for 1.4% of all patients hospitalized in Psychiatry Department during the study period. The total number of ECT sessions was 784. In 50% of patients, the primary diagnosis was a major isolated or recurring depressive disorder. The majority of patients (78.8%) had undergone only one ECT session, with an average number of sessions of 8.1 ± 4.9. The most used anesthetic product was the propofol (97.4%). In 71% of cases the energy delivered was between 40 and 80 joules and it was positively correlated with patients' age. The average duration of the motor seizure was 22.3 ± 7.2 seconds and it was negatively correlated with patients' age. The highest response rate was found in depression scores (64.3%). Immediate adverse effects occurred in 51.2% of patients. Finally, 20% of patients continued to undergo maintenance ECT sessions on a weekly or a biweekly basis. The practice of ECT at the University Hospital of Monastir has been little developed in terms of number of patients and ECT sessions. Efforts should be made to promote the use of this method.