Residual cognitive and psychosocial functional impairment in outpatients in Greece who responded to conventional antidepressant monotherapy treatments for major depressive disorder (MDD).

BACKGROUND: Patients with MDD may experience diverse residual symptoms after clinical response to antidepressant treatment. Among these symptoms, cognitive problems in executive functioning are prominent and make functional recovery largely an unmet need for MDD patients. In this study we assessed cognitive symptoms and functional impairment in patients with MDD responding to antidepressant treatment. METHODS: This was a national, multi-site, non-interventional, cross-sectional study of depressive symptomatology, cognitive performance and psychosocial functioning in Greek outpatients with MDD who had clinically responded to antidepressant treatment. Both clinician- and patient- rated measures were employed. Symptom remission was assessed with the Montgomery Asberg Depression Rating Scale (MADRS) total score (≤12) and functional recovery was assessed with the Sheehan Disability Scale (SDS) score (<6). RESULTS: 335 MDD patients participated in the study. After antidepressant monotherapy approximately 60 % of responders and 40 % of remitted patients did not meet the functional recovery criterion. More than 60 % of responders had concentration difficulties as assessed by MADRS item. Patient reported cognitive symptoms were statistically significantly associated with functionality (ß coefficient = 0.126, p-value = 0.027). LIMITATIONS: Non-interventional study design and lack of a control group or active comparator/reference. CONCLUSIONS: This study highlights the persistence of decreased cognitive performance, particularly in executive functioning in patients with MDD who have shown response and/or remission to antidepressant treatment. This appears to contribute to psychosocial functional impairment. Patient-reported cognitive and psychosocial functioning impairment should be included in routine clinical monitoring of outcomes in MDD treatments.

Validation of the Greek ORTO-15 questionnaire for the assessment of orthorexia nervosa and its relation to eating disorders symptomatology.

PURPOSE: The aim of the study was the validation of the Greek version of the ORTO-15 questionnaire. An additional aim was to explore the relation between orthorexic and eating disorder behaviors in a sample of Greek students. METHODS: ORTO-15 was translated and adapted in the Greek language. After its final version was drafted, its test-retest reliability was checked. Then, the questionnaire was administered to 120 students of psychology along with EAT-26. Additionally, demographics, BMI and information related to eating disorders were collected. RESULTS: The Greek version of the ORTO-15 questionnaire showed acceptable internal consistency (Cronbach's a 0.7). Factor analysis produced a three-factor model similar to the original English version of the questionnaire. The correlation of ORTO-15 and EAT-26 revealed that higher measurements in the diet and bulimia EAT-26 scale were related to increased orthorexic symptomatology. Finally, there was no significant correlation between the 3 factors of the ORTO-15 (emotional, rational and behavioral) and age, education or Body Mass Index. CONCLUSIONS: This study is the first attempt to assess orthorexia nervosa in a Greek student population. ORTO-15 was found to be a reliable tool for the measurement of orthorexia in Greece. Finally, in accordance with other studies, orthorexic symptoms were partially related to eating disorder symptomatology, thus raising the question of possible similarities and overlap between the two clinical constructs. LEVEL OF EVIDENCE: Level V, Cross-sectional descriptive study.

The relationship between metacognitive beliefs and symptoms in eating disorders.

The present study aimed to explore the role of dysfunctional metacognitive beliefs in Eating Disorders (EDs) and their potential associations with core and comorbid symptoms. The Metacognition Questionnaire-30 (MCQ-30), the Eating Disorder Examination Questionnaire 6.0 (EDE-Q), the Hospital Anxiety and Depression Scale (HADS) and the Maudsley Obsessive- Compulsive Inventory (MOCI) were used to evaluate 44 Anorexia Nervosa (AN), 50 Bulimia Nervosa (BN) patients and 37 controls. Patients featured more dysfunctional metacognitive beliefs which positively correlated with ED and comorbid symptoms. Both AN and BN patients had higher scores than healthy controls on MCQ-30 total score, Positive Beliefs about Worry, Negative Beliefs about Thoughts Uncontrollability and Danger and Need to Control Thoughts. AN patients also featured higher scores than healthy controls on Cognitive Self-Consciousness. No statistically significant difference was found between the two clinical groups in MCQ-30 total and subscale scores. Among metacognitive beliefs, Negative Beliefs about thoughts Uncontrollability and Danger showed the stronger correlations with core EDs symptoms, (coefficients ranging from 0.24 to 0.40), followed by Need to Control Thoughts (coefficients ranging from 0.22 to 0.38). Dysfunctional metacognitive beliefs were also significantly positively correlated with HADS-Anxiety, HADS-Depression and MOCI Total, in a similar manner. Dysfunctional metacognitive beliefs also predicted 19%, 35%, 20%, and 21% of the variance in Global EDE-Q, HADS-Anxiety, HADS-Depression and MOCI Total scores respectively, in regression analyses. Nevertheless, mediation analysis indicated that the relationship between Negative Beliefs about thoughts Uncontrollability and Danger and core EDs symptomatology as measured by EDE-Q, was not mediated by comorbid anxiety, depression and obsessionality. As a result, dysfunctions in metacognitive beliefs may reflect a common, trans-diagnostic path in AN and BN patients, towards a wide range of symptoms, both core and comorbid.

Factor structure and psychometric properties of the Greek version of Saving Inventory-Revised (SI-R) in a non-clinical sample.

Hoarding disorder is a debilitating condition that results from difficulty or inability to discard possessions and the need to save items and leads to cluttered living space. It impedes normal everyday functioning and causes significant distress and dysfunction. The aim of the current study was to validate the Greek version of the Saving Inventory-Revised (SI-R) in a non-clinical sample of 554 Greek adults. Factor structure and psychometric properties were investigated. Common exploratory (EFA) and confirmatory factor analysis (CFA) were used to explore the factor structure of the data. A three-factor solution was emerged for the Greek SI-R Which appears to cover the clinical dimensions of the phenomenon and consists of clutter, difficulty discarding and acquisition dimensions. This finding is in accordance with the original English version as well as other adaptations of the instrument in other languages. Some items cross loaded but such findings of cross loading items are also reported in related literature. The Greek version of the SI-R exhibits satisfactory internal consistency and good test retest reliability (stability). The current study also aimed to gather evidence towards the convergent and discriminant validity of Greek SI-R. Findings showed no correlation with measurements of different constructs such as anxiety, depression and non-hoarding obsessive compulsive symptoms but also only partial correlation with measurements of relative clinical constructs, such as hoarding items in obsessive compulsive inventories. Current findings suggest that the Greek SI-R can be a useful tool in the detection and evaluation of hoarding symptoms in Greek population.

[Prisoners in Greek prisons: Correlation of demographic and psychosocial data with committed crimes].

Previous literature shows an association between several psychosocial factors or life events in general and delinquency. Factors such as gender, cannabis and drugs use are firmly connected to delinquency. Similarly, interpersonal violent behavior appears to be more frequent in people with lower socioeconomic status and people with lower education. The association of these factors with the violent or non-violent crimes, especially in Greek research literature, is very limited. The present study is an attempt to examine in a Greek prison population the correlation of demographic and psychosocial factors with violent and non-violent crime. The prison population sample comprised of 308 males from a total of 1300 prisoners, aged between 18 and 77 years old. The survey was conducted from January 2012 until August 2013 in Korydallos and Domokos prisons. In our prison population sample most of the crimes were non-violent. The prisoners were urban dwellers, of young age, were not married and were in short-term relationships on average. They had completed their military obligations, were not live alone, and have been working in the last six months before being imprisoned, in manual labor. They had low-grade education and poor school achievements, had been brawling with classmates and had history of antisocial behavior (liked to "put fire" and abuse animals). They report good relationships with their parents; however, they had experienced violence in parental relationships and some kind of violence, mainly by the father and secondarily by the mother. They have not been involved in gangs necessarily and have a history from a young age, of alcohol, cannabis and drugs use. Cannabis use history was reported by 208 prisoners (67.5%) and 133 (63.9%) of them started using at the age of 10-15 years old. A total of 179 prisoners (58.5%) reported a history of drug use, about half of them (50.3%) reported being addicted to a combination of drugs. For 40.8% (n=73) drug use was initiated in the age of 10-15 years old, while the largest percentage (46.4%) of prisoners mentioned as starting age 16-20 years old. Although the above features underline the great differences between prison population and the general population, there are no significant associations of these factors with violent or non-violent crime. However, the prisoners with drug use history were 65% less likely to have been sentenced for violent crime. Also, the prisoners exempted from their military duties, were 49% less likely to have committed violent crime.

Validation of the greek version of the Young Schema Questionnaire-Short Form 3: Internal consistency reliability and validity.

Schema therapy (ST) is an integrative therapy, which combines elements of cognitive behavior therapy, attachment theory, object relations theory and emotional-focused models. Schema therapy is an effective treatment for patients with personality disorders and other chronic psychological disorders. Early Maladaptive Schemas (EMSs) are a main concept in schema theory referring to self-defeating, core themes or patterns. They develop as a result of traumatic or toxic childhood experiences and the frustration of the core emotional needs in childhood. To date 18 EMSs have been identified and grouped into five higher order structures, known as domains. For the evaluation of the EMSs, Young developed a self-report inventory, the Young Schema Questionnaire (YSQ). There are two forms of the YSQ, the Young Schema Questionnaire - Long Form 3 (YSQ-L3) a 232-item inventory and the Young Schema Questionnaire - Short form 3 (YSQ-S3), a 90-item inventory, which is a subset of the Long form. The aim of this study was to validate the Greek Version of the YSQ-S3. A non-clinical sample of 1,236 undergraduate students completed the YSQ-S3 and 124 patients with Axis-I, Axis II or comorbid diagnosis, completed the YSQ-L3. Moreover, both samples completed the second part of the Adults Self Report (ASR). Internal consistency reliability, discriminative, convergent and predictive validity were examined. The internal consistency reliability of the schema factors was satisfactory with a Cronbach's alpha coefficient of 0.70 or above, for all factors in both student's and clinical sample. The effect sizes were high for most of the scales, regarding the differences between clinical and non-clinical sample. Emotional Deprivation, Vulnerability to harm or Illness, Subjugation, Social Isolation/Alienation and Defectiveness/Shame had the highest effect sizes in the clinical sample and in the non-clinical sample according to whether they had ever visited a mental health specialist. This may suggest that these EMSs are more sensitive and useful markers of psychological problems. In addition, patients with Axis II pathology scored significantly higher on Emotional Deprivation, Abandonment, Mistrust/Abuse, Social Isolation/Alienation compared to patients with only Axis I pathology. This finding is consistent with Schema theory, as these EMSs are associated with earlier in life traumatic experiences and insecure attachment and lie in the core of personality pathology. YSQ-S3 factors were significantly correlated with all ASR dimension and linear regression analysis showed that certain EMSs could predict Depressive and Anxiety problems. In total, the greek version of the YSQ-S3 showed good reliability and validity.

Hypothalamus-pituitary-adrenal (HPA) axis parameters and neurocognitive evaluation in patients with bipolar disorder.

Bipolar disorder is associated with neurocognitive impairment but the etiology of such impairment remains largely unknown. The present study aimed at investigating the performance of bipolar patients in various neuropsychological tasks within the framework of HPA axis hyperactivity model and also the impact of disease characteristics on neuropsychological functioning. Cognitive performance of 60 bipolar-I patients and 30 healthy controls was evaluated by using tasks from the CANTAB battery targeting visual memory, executive function and inhibitory control. Current symptoms were evaluated via administration of the Hamilton Depression Rating Scale (HAMD) and Young Mania Rating Scale (YMRS) whereas assessment of functioning was performed with the Global Assessment of Functioning (GAF). Basal cortisol levels were determined and all patients were administered the Dexamethasone Suppression Test (DST). Statistically significant differences between patients and controls were found in visuo-spatial associative learning and memory, planning, attentional set shifting and inhibitory control. Worse performance in visuospatial associative memory correlated with longer duration of illness and higher levels of basal cortisol. Poorer attentional set shifting was related to higher number of manic episodes. We found no relationship of neurocognitive measures with DST suppression status, current symptom severity or history of psychosis. The results of our study confirm the presence of cognitive deficits in bipolar disorder and provide evidence on the relation of cortisol with neuropsychological functioning, especially visuo-spatial associative memory. Moreover, we have found that number of previous manic episodes and duration of illness is associated with worse cognitive performance. It is known that neurocognitive deficits are evident in many patients with bipolar disorder. These deficits are often a cause of considerable distress and can lead to impairment of psychosocial and occupational functioning. The role of HPA axis needs to be further examined in bipolar disorder. Nevertheless, the identification of factors affecting neurocognitive functioning, like basal cortisol and number of manic episodes, may contribute to the implementation of more appropriate prevention strategies.

Body dysmorphic disorder: Latest neuroanatomical and neuropsychological findings.

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived defect or flaw in physical appearance that is not observable or appears slight to others. It leads to severe distress and functional impairment. Cognitive-behavioural and neurobiological similarities to obsessive compulsive disorder (OCD) have led to its newly conceived classification as an obsessive compulsive related disorder (OCRD). In the process of investigating the neurobiology of BDD, neuroimaging and neuropsychological studies have been conducted. This review presents the most recent research findings and their connection with BDD clinical features. Imaging studies have shown increased total white matter volume and caudate volume asymmetry in BDD patients. These findings are consistent with the striatal topography model of OCRDs. Other studies have showed perfusion deficits in bilateral anterior-medial temporal and occipital regions and asymmetric perfusion in parietal lobes. In addition, correlation between symptom severity and left inferior frontal gyrus volume reflects the degree of detailed, analytic encoding that occurs on day-to-day basis when viewing others and themselves, and that likely underlies their symptoms. Finally, positive correlation between right amygdala volume and symptom severity signifies pathological fear circuitry engagement, hypervigilance and heightened sensitivity to social situations. Neuropsychological studies of BDD reveal deficits in strategic organization, learning and free recall after short and long delays. Executive function deficits are related to spatial working memory and subsequent thinking speed as well as impaired higher level planning ability. BDD patients' organizational strategies tend to focus on detail rather than on larger, global clustering features. They are characterized by abnormal visual processing of both details and global elements, inaccurate processing of global elements and reduced flexibility in switching visual attention between global and local features. Moreover, BDD patients seem to have deficits in identifying facial emotional expressions and they tend to misinterpret expressions of disgust (and others) as anger. Poor insight and ideas of reference, common in BDD, might be related to emotion recognition biases for angry expressions. These findings have been supplemented by combined neuroimaging and neuropsychological studies. Left hemisphere hyperactivity for low and normal spatial frequency face tasks and abnormal activation of the amygdala for high and low spatial frequency face tasks suggests detail encoding and analysis in BDD. Patients may primarily perceive details but they are impaired in their ability to contextualize them holistically.

[Hoarding Disorder in DSM-5: Clinical description and cognitive approach].

Hoarding disorder is characterized by difficulty discarding or parting with possessions regardless their actual value as well as, in most cases, persistent acquisition of objects. Possessions are accumulated in large numbers that fill up and clutter active living space to the extent that its intended use is no longer possible resulting to significant functional impairment and/or distress. Saving and difficulty discarding appear to be associated to subjective beliefs about the instrumental, sentimental or intrinsic value of objects. Despite significant impact on the individual, the family and the community, until recently hoarding disorder had been a "neglected" clinical phenomenon. The recent research efforts to study and understand this phenomenon led to significant changes regarding the diagnostic status and therapeutic interventions. It was classified as a distinct diagnostic entity in the recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association-5th ed. (DSM-5). Hoarding is not considered a symptom of obsessive compulsive disorder or obsessive compulsive personality disorder anymore and it is now ranked among compulsive spectrum disorders. So far the cognitive model for hoarding disorder is the main, widely accepted, clinically and empirically supported theoretical framework for understanding its features. The cognitive model offers an explanation about the predisposing, onset and perpetuating factors of the disorder as well as the basis for the development of specific therapeutic interventions. The cognitive model conceptualizes hoarding disorder as a result of four factors: personal vulnerability (heredity, early experiences and life events, personality traits, interpersonal difficulties), difficulties in information processing (deficits in attention, memory, executive functions such as decision making and categorization), maladaptive cognitive content (meaning of possessions, emotional attachment to possessions, dysfunctional beliefs in relation to the mnemonic ability and memory importance) through which hoarding behaviors are reinforced and finally installed (positive and negative reinforcement, association with positive or negative emotions e.g. pleasure in relation to acquisition/saving and anxiety or discomfort in relation to discarding). The purpose of this article is to inform about this new disorder giving emphasis on recent data in regard to its phenomenology and provide a detailed description of the cognitive model. Finally, a brief mention on the psychotherapeutic and pharmacological interventions is presented. Hoarding Disorder is a difficult clinical problem to treat. Poor insight, ego-syntonic nature of symptoms and treatment resistance are often reported in patients. Further improvement of the therapeutic interventions in order to improve effectiveness and target the high rate of treatment drop out is needed.

[Psychiatrist-Psychotherapist: thoughts and suggestions].

A basic training in psychotherapy is a necessary requirement for the speciality of psychiatry. Nevertheless, any thorough training in psychotherapy in Greece lacks planning and a credible certification system. Τraining is carried out by different psychotherapeutic societies of varying prestige, through a number of programs. There have been very few attempts until now to map this field. The Section of Psychotherapy of the Hellenic Psychiatric Association (HPA) has tried to document the characteristics of the psychiatrists practicing psychotherapy. The study aimed at all of the trainee and trained psychiatrists, members of HPA. 210 questionnaires were filled in by members of HPA in 2000 and 2009-2011. Most of them were returned by post to the Section of Psychotherapy, while some were filled in during the 21rst HPA congress. With regard to psychotherapeutic training 151 (72%) reported some kind of psychoanalytic training, 90 (42.8%) cognitive, 85 (40.5%) systemic and 38 (18%) other (interpersonal, drama therapy, existentialist, cognitive-analytic, hypnosis, group therapy of another kind, orgonotherapy, vegetotherapy, Eye Movement Desensitization Reprocessing). The average duration of the training in years was 5.26 (±3.7) for the psychoanalytic one, 2.73 (±1.6) for the cognitive, 3.83 (±2.1) for the systemic and 3.08 (±2.5) for the psychiatrists with a different type of training. Interestingly, many of the participants reported more than one types of psychotherapeutic training. Another important finding is the fact that the range of training varies from a single seminar to many years, something which underlines the considerable divergence with regard to what is considered psychotherapeutic training. Several questions arise from the above findings: A first one is if a psychiatrist should, during his/her training, also be trained in psychotherapy and what kind of training this should be. A second question is if being a trained psychiatrist entails the capacity to practice psychotherapy and to be called a psychotherapist. Should the title of psychotherapist be a general one or should a specific theoretical-clinical approach be mentioned in the title (psychoanalyst, cognitive-behavioral, systemic, etc.). One more question is which institution is appropriate for the certification of a psychotherapist: a state authority or another, possibly private, institution such as scientific societies or Non-Governmental Organizations? A final question is where professionals from different fields certified as psychotherapists could converge and how their differences could be specified. The mapping and study of the field of psychotherapy within HPA can create the basis for a fruitful discussion on the issue of the psychiatrists' training and certification in psychotherapy, thus outlining a number of questions and dilemmas.

Contrasting patterns of deficits in visuospatial memory and executive function in patients with major depression with and without ECT referral.

BACKGROUND: The pretreatment neuropsychological profile of drug-resistant patients with major depressive disorder (MDD) referred for electroconvulsive therapy (ECT) may differ from that of their drug-respondent MDD counterparts. Such differences could help in identifying distinct MDD subtypes, thus offering insights into the neuropathology underlying differential treatment responses. METHOD: Depressed patients with ECT referral (ECTs), depressed patients with no ECT referral (NECTs) and non-psychiatric Controls (matched groups, n=15) were assessed with memory and executive function tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). RESULTS: ECTs scored significantly lower than NECTs in the Mini-Mental State Examination (MMSE; p=0.01). NECTs performed worse than Controls in the Paired Associates Learning (PAL) task (p<0.03; Control/NECT p<0.01) and the Spatial Recognition Memory (SRM) task (p<0.05; Controls/NECTs p<0.05); ECTs performed between Controls and NECTs, not differing from either. In the Intra/Extradimensional (IED) set-shifting task, ECTs performed worse that Controls and NECTS (IED: p<0.01; Controls/ECTs p<0.01), particularly in the shift phases, which suggests reduced attentional flexibility. In Stockings of Cambridge (SOC), ECTs abandoned the test early more often than Controls and NECTs (H=11, p<0.01) but ECTs who completed SOC performed comparably to the other two groups. CONCLUSIONS: A double dissociation emerged from the comparison of cognitive profiles of ECT and NECT patients. ECTs showed executive deficits, particularly in attentional flexibility, but mild deficits in tests of visuospatial memory. NECTs presented the opposite pattern. This suggests predominantly frontostriatal involvement in ECT versus temporal involvement in NECT depressives.

[Psychotherapeutic approaches of depression].

All schools of psychotherapy have developed specific therapeutic approaches for depression. Common elements exist but still there are differences as well. In this we will review the following approaches, mostly cited in the depression therapy literature: Psychoanalytic, Behavioral, Cognitive and Interpersonal. Recent studies show that psychotherapy is ef fective in depression, even in the elderly and in hospitalized patients. Psychotherapy results are very good in mild to moderate depression. In combination with pharmacotherapy, psychotherapy shows good results in severe depression. It has an important role in preventing new episodes. Recent functional imaging studies show how psychotherapy can affect biological brain structure and function. However, there are still methodological issues that have to be dealt with in psychotherapy research.

Quetiapine monotherapy in bipolar disorder: Two years maintenance treatment in an elderly woman.

Queatiapine has been used in bipolar mania and most recently in bipolar depression with good results. However its use in maintenance treatment has not been established yet. A case of an elderly woman suffering from bipolar disorder and diabetes mellitus (type II) is presented. The use of quetiapine as a monotherapy (300 mg/day) was efficient and safe and proved to be a good treatment in mood stabilization for two years.

Sublingual use of olanzapine in combination with alprazolam to treat agitation in a terminally ill patient receiving parenteral nutrition.

This paper reports the case of a 64-year-old man who was receiving parenteral nutrition after repeated operations due to stomach cancer. Olanzapine (orally disintegrating tablets) in combination with alprazolam was used successfully to relieve this terminally ill patient's anxiety and tension improving his relationship with his physicians and his daily life.

[Hospital anxiety and depression scale (HADS): Validation in a Greek general hospital sample].

UNLABELLED: The Hospital Anxiety and Depression Scale (HADS) has been translated and widely used in several countries to assess anxiety and depression in general hospital patients with good results. Material-Method The HADS was administered to 521 participants (275 controls and 246 inpatients and outpatients of Internal Medicine and Surgical Departments). The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were used as "gold standards" for depression and anxiety respectively. Results The HADS presented high internal consistency; Cronbach's α=0.884 (0.829 for anxiety and 0.840 for depression) and stability (test-retest Intraclass Correlation Coefficient 0.944). Factor analysis showed a two-factor structure. The HADS showed high concurrent validity; the correlations of the scale and its subscales with the BDI and the STAI were high (0.722-0.749). CONCLUSIONS: The Greek version of HADS showed good psychometric properties and could prove as a good tool for clinicians to assess anxiety and depression in general hospital patients.

Set shifting deficits in melancholic vs. non-melancholic depression: preliminary findings.

Twenty-two patients with major depressive disorder, 11 of them with melancholic features, and 11 controls were investigated with CANTAB subtests focusing in visual memory/learning and executive functions. Melancholic patients performed worse than the other groups in all tasks and manifested a significant impairment in set shifting. The results are discussed in association with prefrontal dysfunction.