The role of income inequality as an ecological determinant of mental health: A nation-wide multilevel analysis on an Italian sample.

INTRODUCTION: Income inequality, a pivotal determinant of general and mental health, operates through intricate mechanisms at various geographical scales. While established at country or region levels, the impact of lower-level (municipal or neighborhood) inequality remains inconsistent. This study explores the influence of regional- and municipal-level income inequality on individual psychological distress during the COVID-19 pandemic in Italy, employing a multilevel data analysis. MATERIALS AND METHODS: In a post hoc analysis of data from the first wave of the pandemic (March to April 2020), three hierarchical levels were considered: individual participants, municipalities, and regions. Depressive and anxiety symptoms were measured using the PHQ-9 and GAD-7 scales, while the Gini coefficient gauged income inequality at municipal and regional levels. The analysis incorporated demographic variables as potential confounders. RESULTS: The study encompassed 21 regions, 3,900 municipalities, and 21,477 subjects. Income inequality at both regional and municipal levels exhibited associations with distress scores, suggesting independent effects. Notably, higher distress scores were identified in southern regions with elevated inequality, despite a more substantial COVID-19 impact in the north. DISCUSSION: Findings contribute to existing literature by emphasizing the independent impact of lower-level (municipal) and higher-level (regional) income inequality on population psychopathology. The study supports theories suggesting diverse pathways through which inequality at different levels influences health, such as potential associations with healthcare system dysfunction at the regional level and welfare dysfunction at the municipal level. The observed north-south gradient in distress scores highlights the need for psychosocial interventions to alleviate income inequality, especially in historically disadvantaged southern regions. Future research should explore the nuanced interplay between income inequality and various ecological variables to provide a comprehensive understanding of its health impact.

Insight in cognitive impairment assessed with the Cognitive Assessment Interview in a large sample of patients with schizophrenia.

The Cognitive Assessment Interview (CAI) is an interview-based scale measuring cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). The present study aimed at assessing, in a large sample of SCZ (n = 601), the agreement between patients and their informants on CAI ratings, to explore patients' insight in their cognitive deficits and its relationships with clinical and functional indices. Agreement between patient- and informant-based ratings was assessed by the Gwet's agreement coefficient. Predictors of insight in cognitive deficits were explored by stepwise multiple regression analyses. Patients reported lower severity of cognitive impairment vs. informants. A substantial to almost perfect agreement was observed between patients' and informants' ratings. Lower insight in cognitive deficits was associated to greater severity of neurocognitive impairment and positive symptoms, lower severity of depressive symptoms, and older age. Worse real-life functioning was associated to lower insight in cognitive deficit, worse neurocognitive performance, and worse functional capacity. Our findings indicate that the CAI is a valid co-primary measure with the interview to patients providing a reliable assessment of their cognitive deficits. In the absence of informants with good knowledge of the subject, the interview to the patient may represent a valid alternative.

Correction to: The Rising of the Shield Hero. Development of the Post-traumatic Symptom Questionnaire (PTSQ) and Assessment of the Protective Effect of Self-esteem from Trauma-related Anxiety and Depression.

[This corrects the article DOI: 10.1007/s40653-022-00503-z.].

The Rising of the Shield hero. Development of the Post-Traumatic Symptom Questionnaire (PTSQ) and Assessment of the Protective Effect of self-esteem from trauma-related Anxiety and Depression.

Background: Adverse life events such as life-threatening accidents, domestic and/or sexual violence, organic diseases (i.e., cancer), or COVID-19 can have a strong traumatic impact - generating reactions as intrusive thoughts, hyperarousal, and avoidance. Indeed, the traumatic impact of COVID-19 seems to lead individuals to experience anxiety and depression. However, the Anxiety-Buffer Hypothesis suggests that self-esteem could be considered a shield (buffer) against traumatic experiences and their outcomes (i.e., anxiety and depression). The present study has two objectives. First, to develop a measure of the impact of the traumatic event considering the aforementioned reactions. Second, to test the process - triggered by COVID19-related traumatic experience - in which self-esteem buffers the path that leads to anxiety and depression. Method: In Study 1 (N = 353), the Post-Traumatic Symptom Questionnaire (PTSQ) was developed and a deep investigation of its psychometric properties was conducted. In Study 2 (N = 445), a structural equation model with latent variables was performed to assess the buffering effect of self-esteem. Results: The PTSQ has excellent fit indices and psychometric properties. According to the ABH, results confirm the buffering effect of self-esteem in the relationships between traumatic symptoms and both anxiety and depression. Conclusion: On the one hand, the PTSQ is a solid and reliable instrument. On the other hand, that self-esteem is a protective factor against anxiety and depression related to a traumatic experience - such as COVID-19. Targeted psychological interventions should be implemented to minimize the psychological burden of the illness while promoting adaptation and positive aspects of oneself. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-022-00503-z.

The Cognitive Assessment Interview (CAI): Association with neuropsychological scores and real-life functioning in a large sample of Italian subjects with schizophrenia.

INTRODUCTION: The Cognitive Assessment Interview (CAI) is an interview-based scale developed to measure cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). Previous studies demonstrated good psychometric properties of the CAI. However, only relatively small samples of SCZ were investigated. This study aimed to determine in a large sample of SCZ (N = 580) the relationships of the Italian Version of the CAI with measures of cognitive performance and functional capacity and real-life functioning, using state-of-the-art instruments. METHODS: Intraclass correlation coefficients (ICCs) and Cronbach's alpha were calculated to examine the CAI's inter-rater reliability and internal consistency. Pearson's correlation coefficients were used to evaluate relationships between CAI global and domain composite scores with neurocognition, social cognition, functional capacity, and functioning. RESULTS: The inter-rater reliability and internal consistency were good to excellent. The CAI global composite score showed a strong correlation with the MATRICS Consensus Cognitive Battery (MCCB) composite score (r = -0.50) and moderate/strong associations with measures of functional capacity (-0.46 < r < -0.52) and real-life functioning (-0.30 < r < -0.51). Finally, CAI composite social cognition score correlated moderately with the Facial Emotion Identification Test (r = -0.31) and two subscales of the Awareness of Social Inference Test (-0.32 < r < -0.34). CONCLUSIONS: The study suggests that CAI is a valid co-primary measure for clinical trials and a suitable instrument to screen impairment in neurocognitive and social cognitive domains and its impact on functioning in SCZ in everyday clinical practice.

On the Implementation of Computerized Adaptive Observations for Psychological Assessment.

The use of observational tools in psychological assessment has decreased in recent years, mainly due to its personnel and time costs, and researchers have not explored methodological innovations like adaptive algorithms in observational assessment. In the present study, we introduce the behavior-driven observation procedure to develop, test, and implement observational adaptive instruments. In Study 1, we use a preexisting observational checklist to evaluate nonverbal behaviors related to psychotic symptoms and to specify the adaptive algorithm's model. We fit the model to observational data collected from 114 participants. The results support the model's goodness of fit. In Study 2, we use the estimated model parameters to calibrate the adaptive procedure and test the algorithm for accuracy and efficiency in adaptively reconstructing 58 nonadaptively collected response patterns. The results show the algorithm's good accuracy and efficiency, with a 40% average reduction in the number of administered items. In Study 3, we used real raters to test the adaptive checklist built with behavior-driven observation. The results indicate adequate intrarater agreement and good consistency of the observed response patterns. In conclusion, the results support the possibility of using behavior-driven observation to create accurate and affordable (in terms of resources) observational assessment tools.

Glycogen Storage Disease Type Ia: Current Management Options, Burden and Unmet Needs.

Glycogen storage disease type Ia (GSDIa) is caused by defective glucose-6-phosphatase, a key enzyme in carbohydrate metabolism. Affected individuals cannot release glucose during fasting and accumulate excess glycogen and fat in the liver and kidney, putting them at risk of severe hypoglycaemia and secondary metabolic perturbations. Good glycaemic/metabolic control through strict dietary treatment and regular doses of uncooked cornstarch (UCCS) is essential for preventing hypoglycaemia and long-term complications. Dietary treatment has improved the prognosis for patients with GSDIa; however, the disease itself, its management and monitoring have significant physical, psychological and psychosocial burden on individuals and parents/caregivers. Hypoglycaemia risk persists if a single dose of UCCS is delayed/missed or in cases of gastrointestinal intolerance. UCCS therapy is imprecise, does not treat the cause of disease, may trigger secondary metabolic manifestations and may not prevent long-term complications. We review the importance of and challenges associated with achieving good glycaemic/metabolic control in individuals with GSDIa and how this should be balanced with age-specific psychosocial development towards independence, management of anxiety and preservation of quality of life (QoL). The unmet need for treatment strategies that address the cause of disease, restore glucose homeostasis, reduce the risk of hypoglycaemia/secondary metabolic perturbations and improve QoL is also discussed.

Accuracy of self-assessment of real-life functioning in schizophrenia.

A consensus has not yet been reached regarding the accuracy of people with schizophrenia in self-reporting their real-life functioning. In a large (n = 618) cohort of stable, community-dwelling schizophrenia patients we sought to: (1) examine the concordance of patients' reports of their real-life functioning with the reports of their key caregiver; (2) identify which patient characteristics are associated to the differences between patients and informants. Patient-caregiver concordance of the ratings in three Specific Level of Functioning Scale (SLOF) domains (interpersonal relationships, everyday life skills, work skills) was evaluated with matched-pair t tests, the Lin's concordance correlation, Somers' D, and Bland-Altman plots with limits of agreement (LOA). Predictors of the patient-caregiver differences in SLOF ratings were assessed with a linear regression with multivariable fractional polynomials. Patients' self-evaluation of functioning was higher than caregivers' in all the evaluated domains of the SLOF and 17.6% of the patients exceeded the LOA, thus providing a self-evaluation discordant from their key caregivers. The strongest predictors of patient-caregiver discrepancies were caregivers' ratings in each SLOF domain. In clinically stable outpatients with a moderate degree of functional impairment, self-evaluation with the SLOF scale can become a useful, informative and reliable clinical tool to design a tailored rehabilitation program.

Development and factorial validity of the Psychological Skills Inventory for Sports, Youth Version - Short Form: Assessment of the psychometric properties.

Researchers in sport often try to investigate relations between athletes' psychological skills and their sports results to predict top athletic achievements or unexpectedly poor performances. The Psychology Skills Inventory for Sports (Youth version), PSIS-Y, was developed to measure psychological characteristics of young athletes-differentiating well more talented and less talented young athletes. Nevertheless, previous studies revealed its inadequate, factorial validity. Thus, the aim of this study was to develop and investigate the psychometric proprieties of a brief version of the PSIS-Y (PSIS-Y-SF) in a sample of young Croatian athletes. Participants (n = 304; 188 females and 116 male) were recruited in clubs/teams all over Croatia and all of them competed in the Croatian Championship in youth (n = 157) and junior category (n = 147). The PSIS-Y-SF was derived by ten expert psychologists with five of them who had past experiences of agonistic sport practice. Psychometric analysis included Confirmatory Factor Analysis (CFA), internal consistency analysis (Raykov's Maximal Reliability), and correlation between subscales. Moreover, Multivariate Analyses of Variance (MANOVA) was run to test statistical differences between the players' categories (male youth vs. male junior vs. female youth vs. female junior) in all of the subscales. Results of the CFA suggested the adequateness of the supposed six first-order factor solution for the PSIS-Y-SF. The Maximal Reliability statistics suggest a good internal consistency for all of the subscales and the MANOVA suggested differences between the player's categories. The PSIS-Y-SF resulted to be a valid and reliable tool for the assessment of sports psychological skills. Findings from the psychometric evaluation of PSIS-Y-SF suggest that this is a useful tool, which may further assist in the measurement and conceptualization of sport psychological skills.

Italian Atlas of mortality inequalities by education level. / Atlante italiano delle disuguaglianze di mortalità per livello di istruzione.

OBJECTIVES: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators. DESIGN: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration. SETTING AND PARTICIPANTS: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census. MAIN OUTCOME MEASURES: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs). RESULTS: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men. CONCLUSIONS: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

Assessment of de novo copy-number variations in Italian patients with schizophrenia: Detection of putative mutations involving regulatory enhancer elements.

OBJECTIVES: Variants appearing de novo in genes regulating key neurodevelopmental processes and/or in non-coding cis-regulatory elements (CREs), as enhancers, may increase the risk for schizophrenia. However, CREs involvement in schizophrenia needs to be explored more deeply. METHODS: We investigated de novo copy-number variations (CNVs) in the whole-genomic DNA obtained from 46 family trios of schizophrenia probands by using the Enhancer Chip, a customised array CGH able to investigate the whole genome with a 300-kb resolution, specific disease loci at a ten-fold higher resolution, and which was highly enriched in probes in more than 1,250 enhancer elements selected from Vista Enhancer Browser. RESULTS: In seven patients, we found de novo CNVs, two of which overlapped VISTA enhancer elements. De novo CNVs encompass genes (CNTNAP2, MAGI1, TSPAN7 and MET) involved in brain development, while that involving the enhancer element hs1043, also includes ZIC1, which plays a role in neural development and is responsible of behavioural abnormalities in Zic mutant mice. CONCLUSIONS: These findings provide further evidence for the involvement of de novo CNVs in the pathogenesis of schizophrenia and suggest that CNVs affecting regulatory enhancer elements could contribute to the genetic vulnerability to the disorder.

Interplay Among Psychopathologic Variables, Personal Resources, Context-Related Factors, and Real-life Functioning in Individuals With Schizophrenia: A Network Analysis.

Importance: Enhanced understanding of factors associated with symptomatic and functional recovery is instrumental to designing personalized treatment plans for people with schizophrenia. To date, this is the first study using network analysis to investigate the associations among cognitive, psychopathologic, and psychosocial variables in a large sample of community-dwelling individuals with schizophrenia. Objective: To assess the interplay among psychopathologic variables, cognitive dysfunctions, functional capacity, personal resources, perceived stigma, and real-life functioning in individuals with schizophrenia, using a data-driven approach. Design, Setting, and Participants: This multicenter, cross-sectional study involved 26 university psychiatric clinics and/or mental health departments. A total of 921 community-dwelling individuals with a DSM-IV diagnosis of schizophrenia who were stabilized on antipsychotic treatment were recruited from those consecutively presenting to the outpatient units of the sites between March 1, 2012, and September 30, 2013. Statistical analysis was conducted between July 1 and September 30, 2017. Main Outcomes and Measures: Measures covered psychopathologic variables, neurocognition, social cognition, functional capacity, real-life functioning, resilience, perceived stigma, incentives, and service engagement. Results: Of 740 patients (221 women and 519 men; mean [SD] age, 40.0 [10.9] years) with complete data on the 27 study measures, 163 (22.0%) were remitted (with a score of mild or better on 8 core symptoms). The network analysis showed that functional capacity and everyday life skills were the most central and highly interconnected nodes in the network. Psychopathologic variables split in 2 domains, with positive symptoms being one of the most peripheral and least connected nodes. Functional capacity bridged cognition with everyday life skills; the everyday life skills node was connected to disorganization and expressive deficits. Interpersonal relationships and work skills were connected to avolition; the interpersonal relationships node was also linked to social competence, and the work skills node was linked to social incentives and engagement with mental health services. A case-dropping bootstrap procedure showed centrality indices correlations of 0.75 or greater between the original and randomly defined samples up to 481 of 740 case-dropping (65.0%). No difference in the network structure was found between men and women. Conclusions and Relevance: The high centrality of functional capacity and everyday life skills in the network suggests that improving the ability to perform tasks relevant to everyday life is critical for any therapeutic intervention in schizophrenia. The pattern of network node connections supports the implementation of personalized interventions.

Stages of change in obesity and weight management: factorial structure of the Italian version of the University of Rhode Island Change Assessment Scale.

PURPOSE: To examine the factorial structure of the University of Rhode Island Change Assessment Scale (IT-URICA) for weight management in a sample of Italian overweight and obese patients enrolled in a nutritional rehabilitation program. METHODS: 334 inpatients completed the translated and adjusted version of the IT-URICA at admission to the hospital. Psychometric testing included confirmatory factor analysis and internal consistency (Cronbach's α). RESULTS: The IT-URICA for weight management was successfully translated into Italian, and the factorial analysis confirmed the four-factor solution of the commonly accepted version of the measure. CONCLUSION: High levels of RTC are considered critical to the long-term success of weight management, and the IT-URICA may be an appropriate measure of motivational readiness for use among Italian overweight and obese patients. Its use is, therefore, recommended for clinical and research purposes.

Preventing and managing herpes zoster: key actions to foster healthy aging.

Population aging is the demographic phenomenon characterizing all countries in the world, and it is challenging the national infrastructures, in particular health systems. However, aging itself is not associated with increased medical spending, but disability and comorbidity that affect older individuals are the actual drivers for health expenditures. Therefore, if people age in better health, medical spending may be significantly reduced. Preventative interventions proved to be effective in reducing/preventing disease and disability and often found to be cost effective, include diet and exercise interventions, medications, routine disease screenings, and immunizations. Vaccination can protect older citizens against life-threatening diseases, such as influenza, pneumococcal infections, tetanus, and against diseases which adversely impact their quality of life, such as herpes zoster (HZ). Including HZ vaccination in its citizens' lifetime immunization calendar can reinforce Europe's commitment toward active, healthy aging. This paper outlines the consensus statement of a group of Italian experts on HZ.

Assessment and comparison of left ventricular shear in normal and situs inversus totalis hearts by means of magnetic resonance tagging.

Situs inversus totalis (SIT) is characterized by complete mirroring of gross cardiac anatomy and position combined with an incompletely mirrored myofiber arrangement, being normal at the apex but inverted at the base of the left ventricle (LV). This study relates myocardial structure to mechanical function by analyzing and comparing myocardial deformation patterns of normal and SIT subjects, focusing especially on circumferential-radial shear. In nine control and nine SIT normotensive human subjects, myocardial deformation was assessed from magnetic resonance tagging (MRT) image sequences of five LV short-axis slices. During ejection, no significant difference in either circumferential shortening (εcc) or its axial gradient (Δεcc) is found between corresponding LV levels in control and SIT hearts. Circumferential-radial shear (εcr) has a clear linear trend from apex-to-base in controls, while in SIT it hovers close to zero at all levels. Torsion as well as axial change in εcr (Δεcr) is as in controls in apical sections of SIT hearts but deviates significantly towards the base, changing sign close to the LV equator. Interindividual variability in torsion and Δεcr values is higher in SIT than in controls. Apex-to-base trends of torsion and Δεcr in SIT, changing sign near the LV equator, further substantiate a structural transition in myofiber arrangement close to the LV equator itself. Invariance of εcc and Δεcc patterns between controls and SIT subjects shows that normal LV pump function is achieved in SIT despite partial mirroring of myocardial structure leading to torsional and shear patterns that are far from normality.

Reducing the burden of Herpes Zoster in Italy.

Herpes Zoster (HZ) is a viral disease with painful neuro-dermatologic manifestations. Incidence increases with age. In Italy, the estimated incidence is 6.3 cases/1000 person/year; hospital admissions are less than 2%, 69% in patients aged over 65 years. The most frequent complication of HZ is Post-Herpetic Neuralgia (PHN) characterized by metameric pain, allodynia, and hyperalgesia. In Italy 20.6% and 9.2% of HZ patients experience PHN after 3 and 6 months, respectively. Available antiviral and analgesic treatments are relatively unsatisfactory in reducing pain and length of the disease. Prevention has recently become possible with the live attenuated vaccine Oka/Merck. Clinical studies show a reduction of 51% in the incidence of the disease, 61% of its burden and 67% of PHN in vaccinees. Protection seems to be long lasting and vaccine safety matches registration requirements. Available evidence suggests that the costs for QALY (less than € 20 000) and avoided cases is favorable. Due to the heavy burden of disease, it is time to offer this vaccination to elderly population.

Psychiatrists' perceptions of the clinical importance, assessment and management of patient functioning in schizophrenia in Europe, the Middle East and Africa.

BACKGROUND: It has been estimated that as many as two thirds of patients with schizophrenia are unable to perform basic personal and social roles or activities. Occupational functioning and social functioning, as well as independent living, are considered as core domains of patient functioning. Improvement in patient functioning has also been recognized as an important treatment goal in guidelines and an important outcome by regulatory agencies. Nevertheless, information is lacking on how these aspects are being considered by psychiatrists across the world and how they are being assessed and managed. METHODS: The 'Europe, the Middle East and Africa functioning survey' was designed to canvas opinions of psychiatrists across these regions to ascertain their perceptions of the clinical importance, assessment and management of functioning amongst their patients with schizophrenia. The survey comprised 17 questions and was conducted from March to April 2011 in 42 countries. Data collected included the demographics of respondents and their opinions regarding personal and social functioning in patients with schizophrenia. RESULTS: Results were obtained from 4,163 clinicians. Psychiatrists estimated that more than two thirds (70%) of their patients with schizophrenia showed impaired or very poor levels of functioning. The majority of psychiatrists (92%) believed that personal and social functioning was an important treatment goal for patients with schizophrenia, and 91% believed it was an important goal for patients' families. The majority of psychiatrists (55%) assess the personal and social functioning of their patient at each visit; however, 81% reported that they determine the level of functioning through clinical interview and not by using a specific assessment scale. To manage personal and social functioning in their patients, 26% of psychiatrists prefer pharmacological interventions, whereas 46% prefer psychosocial interventions. CONCLUSION: Psychiatrists recognize that functioning is impaired/very poor in patients with schizophrenia, and there is still an important need to address functioning as a main treatment goal for patients with schizophrenia.

Prevalence, chronicity, burden and borders of bipolar disorder.

Bipolar disorder (BD) has traditionally been thought of as an episodic condition, characterized by periods of hypomania/mania and depression. However, evidence is accumulating to suggest that this condition is associated with significant chronicity. For a large proportion of patients with BD, residual, sub-syndromal symptoms persist between major syndromal episodes, and studies have shown that many patients with bipolar disorder are symptomatic for approximately 50% of the time over follow-up periods of greater than 10 years. Moreover, while the prevalence of BD has been estimated to be around 1-2%, there is growing evidence that this may be a substantial underestimation. There are a number of reasons for this potential underestimation, including difficulties in diagnosis. Adding to the burden of BD is the issue of comorbidity, with an increased prevalence of many chronic conditions in those with a primary diagnosis of BD. Conversely, for many patients with chronic conditions, both medical and psychiatric, BD frequently exists as a comorbid secondary diagnosis. This issue of comorbidity complicates estimates of use of pharmaceutical agents for BD, such as mood stabilizers, which are known to be used off-label in conditions such as borderline personality or substance use disorder. We speculate that such off-label prescribing may not be truly off-label but may be instead fully justified by an overlooked secondary diagnosis of BD. Finally, we discuss the association of bipolar disorder with a significant economic burden, to the individual and to society, both due to the direct costs of medical expenditure and indirect costs such as loss of productivity and increased mortality.

How much stress is needed to increase vulnerability to psychosis? A community assessment of psychic experiences (CAPE) evaluation 10 months after an earthquake in L'Aquila (Italy).

Since severe stress can induce mental disorder symptoms that interact with vulnerability factors, the Community Assessment of Psychic Experiences (CAPE) was evaluated in a population of 419 young adults who survived an earthquake; results were compared to a database of 1,057 'non-exposed' subjects. Unexpectedly, earthquake survivors showed lower CAPE scores for 'small' to 'medium' effect size. Post-trauma positive changes or re-appraisal for successful adaptation may explain these findings.