Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries.

BACKGROUND: Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care. METHODS: The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions. RESULTS: We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures. CONCLUSIONS: We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Lithium and suicide prevention in mood disorders and in the general population: A systematic review.

Suicide contributes to 1-4 % of deaths worldwide every year. We conducted a systematic review aimed at summarizing evidence on the use of lithium for the prevention of suicide risk both in mood disorders and in the general population. We followed the PRISMA methodology (keywords: "lithium", "suicide" AND "suicidal" on Pubmed, Cochrane CENTRAL, Clinicaltrial.gov, other databases). Inclusion criteria: lithium therapy in mood disorder or found in drinking water or scalp in the general population. Exclusion criteria: no lithium administration. From 918 screened references, 18 prospective (number of participants: 153786), 10 retrospective (number of participants: 61088) and 16 ecological studies (total sample: 2062) were included. Most of the observational studies reported a reduction in suicide in patients with mood disorders. All studies about lithium treatment's duration reported that long-term lithium give more benefits than short-term lithium in suicide risk The evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its proven efficacy as a mood stabilizer.

Real-world effectiveness of long acting aripiprazole: Treatment persistence and its correlates in the Italian clinical practice.

OBJECTIVES: To identify the variables that are associated with persistence to Aripiprazole-Long Acting (A-LAI), in adult patients with schizophrenia. METHODS: Observational, retrospective, non-interventional study involving 261 patients with schizophrenia. RESULTS: Eighty-six percent of study subjects were persistent for at least 6 months. All subjects with baseline CGI-S of 1 or 2, 95% of subjects with CGI-S of 3, 86% with CGI-S of 4, 82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7 were persistent. A-LAI treatment continuation rate was higher in patients with: 1) baseline CGI score ≤ 4; 2) schizophrenia dimension (LDPS) mania score ≤ 5; 3) psychotic spectrum schizoid score ≤ 11. CONCLUSIONS: A relatively high number of patients (n = 225, 86%) were persistent to A-LAI for at least 6 months. Not surprisingly, very severe patients were more unlikely to be persistent. However, it is noteworthy that a large number of subjects with high CGI score at the time when A-LAI was started (82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7) were persistent. Larger, controlled, prospective and longer studies are warranted.

Disorganization and real-world functioning in schizophrenia: Results from the multicenter study of the Italian Network for Research on Psychoses.

BACKGROUND: A general consensus has not yet been reached regarding the role of disorganization symptoms in real-world functioning in schizophrenia. METHODS: We used structural equations modeling (SEM) to analyze the direct and indirect associations between disorganization and real-world functioning assessed through the Specific Levels of Functioning Scale (SLOF) in 880 subjects with schizophrenia. RESULTS: We found that: 1) conceptual disorganization was directly and strongly connected with SLOF daily activities; difficulty in abstract thinking was associated with moderate strength to all SLOF domains, and poor attention was connected with SLOF work skills; 2) grandiosity was only related with poor work skills, and delusions were associated with poor functioning in all SLOF domains; interpersonal relationships were weakly indirectly influenced by hallucinatory behavior, delusions and unusual thought contents through the mediation of social cognition (SC); 3) among the negative symptoms, avolition had only direct links with SLOF work skills and SLOF activities; anhedonia had direct links with SLOF work skills and SLOF interpersonal and indirect link with SLOF work skills through functional capacity (FC); asociality with SLOF interpersonal; blunted affect had direct links with SLOF activities and indirect links with SLOF interpersonal relationships mediated by SC. Lastly, alogia had only indirect links mediated by SC, FC, and neurocognition (NC). CONCLUSIONS: Overall conceptual disorganization is the symptom that contributed more (both directly and indirectly) to the activities of community living in real-world. Thus, it should be considered as a treatment target in intervention programs for patients with schizophrenia.

Familial aggregation of MATRICS Consensus Cognitive Battery scores in a large sample of outpatients with schizophrenia and their unaffected relatives.

BACKGROUND: The increased use of the MATRICS Consensus Cognitive Battery (MCCB) to investigate cognitive dysfunctions in schizophrenia fostered interest in its sensitivity in the context of family studies. As various measures of the same cognitive domains may have different power to distinguish between unaffected relatives of patients and controls, the relative sensitivity of MCCB tests for relative-control differences has to be established. We compared MCCB scores of 852 outpatients with schizophrenia (SCZ) with those of 342 unaffected relatives (REL) and a normative Italian sample of 774 healthy subjects (HCS). We examined familial aggregation of cognitive impairment by investigating within-family prediction of MCCB scores based on probands' scores. METHODS: Multivariate analysis of variance was used to analyze group differences in adjusted MCCB scores. Weighted least-squares analysis was used to investigate whether probands' MCCB scores predicted REL neurocognitive performance. RESULTS: SCZ were significantly impaired on all MCCB domains. REL had intermediate scores between SCZ and HCS, showing a similar pattern of impairment, except for social cognition. Proband's scores significantly predicted REL MCCB scores on all domains except for visual learning. CONCLUSIONS: In a large sample of stable patients with schizophrenia, living in the community, and in their unaffected relatives, MCCB demonstrated sensitivity to cognitive deficits in both groups. Our findings of significant within-family prediction of MCCB scores might reflect disease-related genetic or environmental factors.

Estimating the Impact of Workplace Bullying: Humanistic and Economic Burden among Workers with Chronic Medical Conditions.

BACKGROUND: Although the prevalence of work-limiting diseases is increasing, the interplay between occupational exposures and chronic medical conditions remains largely uncharacterized. Research has shown the detrimental effects of workplace bullying but very little is known about the humanistic and productivity cost in victims with chronic illnesses. We sought to assess work productivity losses and health disutility associated with bullying among subjects with chronic medical conditions. METHODS: Participants (N = 1717) with chronic diseases answered a self-administered survey including sociodemographic and clinical data, workplace bullying experience, the SF-12 questionnaire, and the Work Productivity Activity Impairment questionnaire. RESULTS: The prevalence of significant impairment was higher among victims of workplace bullying as compared to nonvictims (SF-12 PCS: 55.5% versus 67.9%, p < 0.01; SF-12 MCS: 59.4% versus 74.3%, p < 0.01). The adjusted marginal overall productivity cost of workplace bullying ranged from 13.9% to 17.4%, corresponding to Italian Purchase Power Parity (PPP) 2010 US$ 4182-5236 yearly. Association estimates were independent and not moderated by concurrent medical conditions. CONCLUSIONS: Our findings demonstrate that the burden on workers' quality of life and productivity associated with workplace bullying is substantial. This study provides key data to inform policy-making and prioritize occupational health interventions.

The role of comorbidities in duration of untreated illness for bipolar spectrum disorders.

BACKGROUND: Growing interest has been given to the construct of Duration of untreated illness (DUI) on the outcome of bipolar disorder (BD), due to its potentially modifiable nature. The aim of this study was to identify possible clinical correlates of DUI in a sample of BD patients. METHOD: 119 BD spectrum patients included. DUI rate was calculated and dichotomized into short DUI and long DUI subgroups, cut-off 24 months. These subgroups were compared for socio-demographic and clinical variables. Significant results were included into direct logistic regressions to assess their impact on the likelihood of presenting with long DUI. RESULTS: Mean DUI±SD was 75.6±98.3 months. Short DUI subgroup comprised 56 (47.1%), long DUI 60 (52.9%) patients. Age at onset of BD was lower in the long DUI subgroup (p=0.021), illness duration longer (p=0.011). Long DUI subgroup showed significantly more comorbidity with Axis I (p=0.002) and personality disorders (p=0.017), less interepisodic recovery (p<0.001) and less Manic Predominant Polarity (p=0.009). Direct logistic regression as a full model was significant, correctly classifying 76.7% of cases. A unique statistically significant contribution was made by: Manic Predominant Polarity, Personality Disorder Comorbidity, and Total Changes in Medications. LIMITATIONS: Partial retrospective data, cross sectional study. CONCLUSIONS: DUI was longer than 24 months in half of the sample. Psychotic /Manic onset contributed to a quick diagnostic classification. Personality disorders in depressed patients could delay a correct diagnosis of BD, factors associated with an increased likelihood of BD must be considered. More research on personality disorder comorbidities is needed.

[Duration of untreated psychosis and cognitive deficits in a cohort of chronic psychotic patients]. / Durata di psicosi non trattata e deterioramento cognitivo in una coorte di pazienti psicotici cronici.

AIMS: Outcome of psychotic disorders, particularly schizophrenia and related disorders, seems to be associated, among a number of other factors, to the latency of treatment of irst episode (duration of untreated psychosis, DUP); indeed, outcome seems to be worse in subjects with a longer DUP. However, few studies addressed the topic of long term outcome and DUP as regard to cognitive functioning, though the latter plays a crucial role in explaining a significant proportion of disability both in non-affective and affective psychoses. The study aims to analyze relationships between DUP and cognitive functioning in a sample of chronic psychotic patients. MATERIALS AND METHODS: We considered a unselected sample constituted by 82 chronic outpatients, 49 males (59,8%) e 33 females (40,2%), age range 20-74 yrs (mean age 46,59; s.d. 10,68 yrs); these patients were affected by schizofrenia (n=41, 50%), Bipolar Disorder type I, with psychotic mood congruent or uncongruent features (n=18, 22%,) and Schizoaffettive Disorder (n=23, 28%) according to DSMIVTR, with diagnosis confirmed by means of SCID-I. Patients underwent WAIS-R in order to evaluate cognitive functioning. RESULTS: A longer DUP (more than 3 months between onset of first clinically evident psychotic symptoms and first antipsychotic treatment) was associated with significantly lower scores in 9 out of 11 subtests of WAIS, weighted total score, IQ-verbal score, IQ-performance score and IQ-total score. A significant relationship between a longer DUP and lower cognitive performances was confirmed among schizophrenic and schizoaffective patients, although limited to some subtests. CONCLUSIONS: The study provides new evidence for a positive association between longer DUP and worse neurocognitive functioning, even in the long term.

Mental disorders in patients with metabolic syndrome. The key role of central obesity.

BACKGROUND: The Authors sought to evaluate current prevalence of mental disorders in patients affected by metabolic syndrome compared with patients affected by central obesity alone. METHODS: 186 (63.5%) patients affected by central obesity and 107 (36.5%) affected by metabolic syndrome according to ICF criteria were interviewed by means of SCID I. RESULTS: Axis I current prevalence was respectively 45.7% and 44.9% among patients with central obesity and patients with metabolic syndrome, differences which were not significant. No statistically significant differences were found between groups as far as each single axis I diagnostic category was concerned. Moreover, current prevalence of any axis I, anxiety and mood disorders were independent of the number of components of metabolic syndrome. CONCLUSION: metabolic syndrome is associated to an higher risk for current mental disorders, which seems to be mainly due to the strong association of central obesity to psychopathology.

[Effectiveness of antipsychotics in schizophrenia and related disorders. Results of a naturalistic study]. / L' "Effectiveness" degli antipsicotici nella schizofrenia e disturbi correlati. Risultati di uno studio naturalistico.

INTRODUCTION: The present study aims to evaluate effectiveness of antipsychotics in a cohort of chronic outpatients affected by schizophrenia and related disorders. MATERIALS AND METHODS: Three hundred chronic patients affected by schizophrenia (n=173), schizoaffective (n=117) and delusional (n=60) disorder who were in treament with antipsychotics on 1.3.2008 were considered in the study; effectiveness of antipsychotic treatment was evaluated by means of rates of all cause discontinuation in a 12 months period (31.3.2008-31.3.2009) and of "overall duration of treatment" (DT) (duration of treatment retrospectively evaluated on the basis of clinical records+duration of treatment prospectively evaluated during the 12-months follow up). RESULTS: Discontinuation of treatment was registered in 25% of patients (29% due to side effects, 14% due to scarce adherence, 11% due to lack of efficacy, 22% due to more causes). Clozapine (7%), Risperidon Long-acting (10%), Typical Antipsychotics depot (11%) and Olanzapine were associated to lower rates of all causes discontinuation. Overall mean duration of antipsychotic treatment was 18± 32 months, with statistically significant differences between drugs (F=4.65, p=0.000). Clozapine (65 mo), Olanzapine (50 mo), butyrophenones (49 mo), typical antipsychotics depot (48 mo), and risperidone (47.5 mo) were the antipsychotics with a longer duration of treatment. Only Clozapine showed a significantly longer DT than any other antipsychotic medication excluding buthyrrohenones. CONCLUSIONS: Rates of all cause discontinuation of antipsychotics appear to be somewhat lower than expected on the basis of pragmatic studied published in the last years; similarly overall duration of treatment seems to be longer. Clozapine is associated to a higher overall effectiveness respect to any other atypical antipsychotic.

Obesity, alexithymia and psychopathology: a case-control study.

OBJECTIVE: The relationship between psychopathology and alexithymia in obese patients is uncertain. The present study was performed to evaluate this relationship in a clinical sample of patients attending a centre for the diagnosis and treatment of obesity compared to a matched sample of non-obese subjects. METHODS: 293 consecutive obese patients (48 males, 245 females, mean age 45, 41±13.55 yrs; mean BMI 35.60±6.20) were compared with a control group made of 293 non-obese subjects (48 males, 245 females, mean age 45, 66±13.86 yrs; mean BMI 21.8±2.06); all subjects were interviewed by means of SCID I and SCID II together with several self-evaluation instruments including the TAS-20 (Toronto Alexithymia Scale) and SCL-90 (Symptom Check List, Revised). RESULTS: Alexithymia was significantly more frequent among obese patients compared to "normal" controls (12.9% vs 6.9%, p=0.010); moreover obese patients achieved significantly higher mean scores on subscales 1 and 2 and on overall scale of the Toronto Alexithymia Scale; comorbidity with axis I/II disorders, in particular Binge Eating Disorder, was associated with a significantly higher frequency of alexithymic traits and higher scores at TAS. CONCLUSIONS: Alexithymia and psychopathology are strongly correlated among obese patients seeking treatment. Routine evaluation of personality traits and comorbid psychopathology may be relevant in treatment of obesity.

Mental disorders in obese patients with and without metabolic syndrome.

OBJECTIVE: The authors sought to evaluate lifetime prevalence of mental disorders in patients affected by metabolic syndrome compared with patients affected by central obesity alone. METHODS: One hundred eighty-six (63.5%) patients affected by central obesity and 107 (36.5%) affected by metabolic syndrome according to ICF criteria were interviewed by means of SCID I and SCID II. RESULTS: Axis I and axis II lifetime prevalence were respectively 53.8% and 30.1% among patients with central obesity, 50.5% and 28% among patients with metabolic syndrome, differences which were not significant. No statistically significant differences were found between groups as far as each single axis I and II diagnostic category was considered. CONCLUSION: Metabolic syndrome is not associated with a higher risk of mental disorders compared to central obesity alone.

[Schizophrenia, obesity and pharmacotherapy-associated weight gain]. / Schizofrenia, obesità e incremento ponderale associato alla farmacoterapia.

BACKGROUND: Obesity seems to be very frequent among schizophrenics, partly due to psychotropic medications. To examine this possibility the authors compared the distribution of Body Mass Index and of Abdominal Obesity among an outpatient sample of schizophrenics, comparing their data with those of the Italian population as a whole. MATERIALS AND METHODS: Weight, height, BMI and waist circumference were evaluated in 126 schizophrenic spectrum outpatients (51 F; 75 M, mean age 43.7 +/- 13.3 yrs) receiving treatment in a university community mental health centre. RESULTS: Mean BMI of the sample was 26.8 +/- 4.9,without any significant difference between genders (females = 25.9 +/- 4.9; males = 27.4 +/- 4.9). The prevalence of obesity (BMI>or=30) in the sample was 26.2%, 2.8 times higher that of Italian average (9.8%). 46.8% out of the patients was affected by abdominal obesity measuring waist circumference, a prevalence 1.7 times higher that of the Italian average (31%). Abdominal obesity was significantly more frequent among females (F = 60.5%; M= 37.3%, p 0.05). 53% out of those patients who were under treatment with atypical antipsychotics respect to 25% of those who were not under treatment (p>0.05) and 71% of those who were submitted to an association of typical and atypical antipsychotics respect to those patients who were not treated with this association (p 0.05) were affected by abdominal obesity. CONCLUSIONS: Also in Italy schizophrenic were found more frequently obese than the corresponding general population. Female schizophrenics and patients who undergone treatment with atypical antipsychotics or with the combination of typical and atypical antipsychotics were significantly more at risk for abdominal obesity.

[Sexual dysfunctions and bipolar disorder: a study of patients submitted to a long- term lithium treatment]. / Disfunzioni sessuali e disturbo bipolare dell'umore: risultati di uno studio su pazienti in trattamento a lungo termine con sali di litio.

AIM: A wide range of psychotropic drugs has been reported to affect human sexual functioning. Most of the literature regarding the relationship between sexual function and psychotropic drugs deals with antidepressants-induced sexual side effects, mainly due to SSRIs. Lithium is a first-line long-term treatment for mood disorders, primarily bipolar disorder; unfortunately, there are a limited number of studies specifically concerning sexual side effects in patients on long-term lithium treatment. MATERIALS AND METHODS: The present study concerns fifty-one clinically stable outpatients of both sexes (M=24, 47.1%; F=27, 52.9%), mean age 33.1+/-11.5 yrs, affected by bipolar I/II disorder according to DSM IV-TR criteria, submitted to long-term lithium treatment alone, compared to 176 healthy subjects (M=96, 54.5%; F=80,45.5%), mean age 30.2+/-8.7 yrs, as control group. Patients and controls were submitted to a questionnaire purposely developed for the study. RESULTS: A significantly higher percent of patients with respect to controls reported to have "never" or "rarely" sexual intercourses (45% vs 20%), sexual fantasies (25.4% vs 13.6%), and desire (37.3% vs 9.5%); moreover, a significantly lower amount of patients with respect to controls reported pleasure (73% vs. 91%) and satisfaction (57% vs. 83%) during intercourses. 18% of patients reported a worsening in sexual life after the onset of bipolar disorder; 30% of patients related their sexual problems to the introduction of lithium treatment. CONCLUSIONS: Notwithstanding the interpretative limits given by the use of questionnaires, our data seem to confirm even in patients under monotherapy, the negative influence of lithium on sexual excitation and desire, already depicted in patients with bipolar disorder under polytherapy.

[Tardive dyskinesia: review of the literature]. / La terapia della discinesia tardiva, una revisione sistematica della letteratura.

PURPOSE: Tardive Dyskinesia (TD) is an adverse effect of several psychotropic drugs for long-term therapy for schizophrenia and other psychoses. TD is considered an important issue for public health for its invalidating characteristics. An extensive review of the literature on studies concerning efficacious treatments for TD has been carried out. MATERIALS AND METHODS: A computer-generated search of the biomedical literature up to and including December 2002 was undertaken to identify studies. RESULTS: Some evidence supports the switch from typical neuroleptics to atypical antipsychotics in patients with TD (particularly clozapine and olanzapine) and supports the use of atypical antipsychotics as first choice treatments. Other than the new antipsychotics, the gabaergic compounds, the new anticolinergics and some antioxidants as melatonin seem to be clinically useful. However, their tolerability and efficacy have to be confirmed by randomized clinical trials. CONCLUSIONS: The recent introduction of atypical antipsychotics seems to reduce the risk of TD in patients with long-term and maintenance therapies. Available literature data show that TD is less frequent with the new antipsychotics but still remains a well-known complication. The future research sould be directed to confirm the efficacy of these new drugs and to offer other treatment opportunities for patients that cannot change typical with atypical antipsychotics or for patients where the onset of the TD appears during therapy with atypical compounds.

Could health care costs for depression be decreased if the disorder were correctly diagnosed and treated?

BACKGROUND: The aim of the present study was to assess the general population from two Sardinian areas to ascertain the direct health care costs involved in a diagnosis of major depression, and to verify the hypothesis of an increased expenditure for untreated depressed subjects. DESIGN: A case-control study was carried out using the database of an epidemiological community survey. Cases were subjects with a diagnosis of Major Depressive Episode (ICD-10, WHO 1992) in the last year, and controls comprised two groups matched to cases for sex and age, made up of healthy subjects and subjects affected by chronic somatic disorders, respectively. RESULTS: Depressed subjects use more health care resources than those affected by chronic somatic disorders or healthy subjects. An increase in health care costs is observed for drugs and hospitalisations in depressed subjects for whom no adequate antidepressive treatment has been prescribed. CONCLUSIONS: In spite of the limitations of the small sample size, the results seem to confirm an increase of direct health care costs in untreated depressed subjects. In view of the availability of efficient forms of treatment for depression, the findings obtained indicate that depression should be considered a priority question for public health and assigning of resources. Further confirmation should be sought in larger population-based studies representing the entire national context.

Case control study on health-related quality of life in adult coeliac disease.

AIMS: To evaluate whether health-related quality of life in adult coeliac disease is related to: 1) adhesion to gluten-free diet; 2) manifestation of clinical features; and 3) associated diseases. PATIENTS AND METHODS: A total of 68 coeliac patients (54 female and 14 male) aged between 18 and 74 years, on gluten-free diet for at least two years were studied. The subjective health status was measured by means of the Short Form 36 Health Survey. A series of 136 subjects, matched according to sex, age and ethnic group, were evaluated as control group. RESULTS: Patients obtained worse scores with respect to healthy controls at all domains of Short Form 36 Health Survey (p<0.05); compliers showed better results than non-compliers. The lowest scores were obtained in patients with more than six symptoms, mostly in non-compliers, the highest in compliers with less than six symptoms. Patients with two or more associated diseases presented significantly worse scores than patients with only one associated disease. CONCLUSIONS: The importance of gluten-free diet in clinical management of coeliac disease is confirmed by results of the present study; moreover, the results seem to indicate that a complex interplay of factors should be taken into account in evaluating health-related quality of life in adult coeliac disease. Accordingly, our data show that health-related quality of life of coeliac patients is impaired not only by poor compliance but also by different negative factors such as severity of illness (in terms of number of symptoms) at diagnosis and comorbidity.

[Survey of five years psychiatric consultations in a university general hospital]. / La consulenza psichiatrica in un ospedale generale universitario. Uno studio su cinque anni di attività.

A survey of 5 year period activity (1995-99) of a university consultation-liaison service is reported, concerning 1556 psychiatric consultations. The majority of referrals (68%) came from internal medicine units; the reason of referral was prevalently due (approx. 50%) to the presence of psychiatric symptoms; moreover, the majority of patients (approx. 51%) for which the consultation has been requested were already under psychiatric treatment and 32% of them took psychoactive drugs. In 75% of cases a psychiatric diagnosis according to ICD-10 was formulated after consultation: "Affective syndromes" were diagnosed in 25% of cases and "Neurotic, somatoformand stress-related syndromes" in 36.6% of cases. Approx. 60% of patients were prescribed psychoactive drugs; 50% received psychological support.

Psychiatric disorders in Sardinian immigrants to Paris: a comparison with Parisians and Sardinians resident in Sardinia.

BACKGROUND: The aim of the present study was to compare the prevalence of ICD-10 psychiatric disorders in a community sample of subjects of Sardinian origin resident in Paris (here "immigrants"), of the general Parisian population ("Parisians") and of Sardinians resident in Sardinia ("Sardinians"). METHODS: The sample of immigrants was obtained by contacting a fifth of all households with a Sardinian surname in Paris telephone directories. The other samples have already been partially described in previous studies. All subjects were interviewed using the CIDIS, a shortened version of the structured WHO interview CIDI. RESULTS: High or very high response rates were achieved in all studies. The final sample sizes were: 153 immigrants, 2,260 Parisians and 1,040 Sardinians. Immigrants showed high rates of depressive disorders, as did Parisians, and high rates of anxiety disorders, as did Sardinians. The immigrants' offspring (second-generation immigrants) seemed to be particularly at risk for depression, drug-abuse and bulimia. Elderly Sardinians who had returned to Sardinia after a long period of emigration showed an increased risk of dysthymia. The presence of a confidential relationship had a protective effect. CONCLUSIONS: The results are consistent with previous findings which suggest a greater risk of anxiety disorders in Southern Europe and of depression in Northern European countries. Immigrants in this study seem to present a particularly unfavourable pattern of mental disorders compared to both origin and host populations. The role of social support, use of mental health services and social conditions of second-generation immigrants should be analysed in greater depth.