Differential predictors of expressed emotion toward individuals with schizophrenia between families and halfway houses.

Background: This study investigated patient- and caregiver-related predictors of expressed emotion (EE) toward individuals with schizophrenia in families and halfway houses and yet understudied differential effects across settings. Methods: We included 40 individuals with schizophrenia living with their families ("outpatients") and 40 "inpatients" in halfway houses and recorded the EE of 56 parents or 22 psychiatric nurses, respectively, through Five Minutes Speech Sample. Each outpatient was rated by one to two parents; each inpatient was rated by two to five nurses. As EE ratings had a multilevel structure, EE predictors were investigated in backward stepwise generalized linear mixed models using the "buildmer" R package. We first fitted models including either caregiver- or patient-related predictors in each setting and finally included both types of predictors. Setting-specific patient-related effects were investigated in interaction analyses. Adjustment for multiple tests identified the most robust associations. Results: In multivariate models including either caregiver- or patient-related predictors, nurses' higher age, shorter work experience and lower inpatients' negative symptoms robustly predicted higher emotional overinvolvement (EOI). In the final models including both types of predictors, nurses robustly displayed lower EOI (i.e., reduced concern and disengagement) toward inpatients with higher negative symptoms. Several other features were nominally associated with criticism and EOI in each setting. However, no feature robustly predicted criticism in inpatients and criticism/EOI in outpatients after adjustment for multiple tests. In interaction analyses, higher negative symptoms differentially predicted lower EOI in nurses only. Conclusion: Our findings suggest setting-specific pathogenetic pathways of EOI and might help customize psychoeducational interventions to staff in halfway houses.

Differential correlates of criticism versus emotional overinvolvement towards patients with schizophrenia living in halfway houses or with their families.

PURPOSE: This study systematically searched for differential correlates of criticism vs. emotional overinvolvement (EOI) towards patients with schizophrenia in families and halfway houses, which have only incidentally been reported in previous research. Identified patterns were compared across settings. METHODS: We included 40 inpatients with schizophrenia living in halfway houses and 40 outpatients living with their families and recorded the expressed emotion (EE) of 22 psychiatric nurses or 56 parents, respectively, through Five Minutes Speech Samples. Each nurse rated 1-12 inpatients and each inpatient was rated by 2-5 nurses. Each outpatient was rated by one or both parents. As EE ratings had a multilevel structure, weighted Spearman correlations of criticism and EOI with various patient- and caregiver-related characteristics were calculated and compared with Meng's z-test. RESULTS: Criticism was weakly negatively correlated with EOI in nurses but negligibly in parents. Distinct patterns of significant differential correlates arose across settings. Outpatients' aggressive behavior and parents' related burden were mainly associated with higher criticism. Inpatients' symptoms (agitation/aggression, negative and other psychotic symptoms) and nurses' burnout (Depersonalization) were mainly associated with lower EOI. Inpatients' perceived criticism and outpatients' previous suicide attempts were equally associated with higher criticism and lower EOI (mirror correlations). Finally, various inpatient attributes (older age, chronicity, unemployment and smoking) triggered higher EOI only. Inpatients' age, psychopathology (esp. agitation/aggression and negative symptoms) and perceived criticism survived adjustment for multiple comparisons. CONCLUSION: Our findings suggest setting-specific pathogenetic pathways of criticism and EOI and might help customize psychoeducational interventions to staff and families.

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review.

Introduction: Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods: A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results: We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion: Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration: [Prospero], identifier [CRD42021284959].

Mental health of unaccompanied refugee minors in Greece living "in limbo".

The closure of the Balkan migration route in 2016, had implications for unaccompanied refugee minors (URMs), given that the vast majority, who perceived Greece as "stopover" for their desired final destination, were forced to remain in the country for an indeterminate period of time. This created for URMs a challenging situation of living "in limbo" uncertain about their future awaiting for a long time the outcome of their asylum application. This cross-sectional study aimed to explore the mental health of URMs, who arrived in Greece in 2016. The sample comprised 90 URMs (76 boys), aged 13-17 years, consisting of 46 Syrians and 44 originating from other countries. Participants completed socio-demographic information and a range of clinical measures, including Children's Revised Impact of Events Scale (CRIES), Depression Self-Rating Scale (DSRS), Children's Post-Traumatic Cognitions Inventory (cPTCI), a measure of trauma exposure and perceived social support. Syrian URMs were significantly more likely than URMs originating from other countries to score within the probable clinical depression range (71.7% versus 47.7% respectively, p=0.020), to display probable posttraumatic stress disorder (PTSD), i.e., score within clinically significant range of posttraumatic stress symptoms and negative post-trauma cognitions (87% versus 65.9%, p=0.018), and meet the comorbidity PTSD/depression criterion (65.2% versus 40.9%, p=0.021). Multiple linear stepwise regression analyses showed that legal status (seeking asylum in Europe through family reunification procedure) significantly predicted higher levels of depressive symptoms (ß=0.29, p=0.004), posttraumatic stress symptoms (ß=0.21, p=0.034) and negative cognitions (ß=0.33, p=0.001). The total number of stressful/traumatic experiences and male gender were found to be significantly related only with posttraumatic symptoms severity score (ß=0.29, p=0.003), whereas lower levels of perceived social support were associated with increased levels of depressive symptoms (ß=0.24, p=0.018) and negative cognitions and appraisals of the world and the self (ß=0.26, p=0.008). These findings highlight the burden of living "in limbo" situation and add weight to the argument for amending restrictive EU asylum policies and accelerating the family reunification procedure under Dublin-III Regulation, as well as the pressing need for improved URMs access to mental health services and psychosocial support.

Effectiveness of a hybrid arts-based Cognitive Behavioral Therapy intervention for patients with non-malignant chronic pain.

Chronic Pain (CP) is defined as pain that persists or recurs for more than 3 to 6 months and may be conceived as a health condition in its own right. CP is a frequent condition, affecting an estimated 20% of people worldwide and requires special treatment and care. CP can contribute to depression, anxiety, sleep disturbances, poor quality of life and increased health care costs. Psychosocial approaches based on a cognitive conceptualization of pain can provide a solid foundation for research and clinical work. The development of a 10 week-session group treatment was based on key principles from the literature on Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) and Creative Arts Therapy, integrated with advances in research on CP management framework. The aim of this study is to evaluate a CBT-CP arts-based group intervention for patients with non-malignant CP addressing the biopsychosocial factors that influence pain perception. A total of 100 University Pain Management Unit outpatients participated, 50 in the intervention group and 50 in the control group (treatment as usual). In analyses of the pretest-posttest research design intervention including all participants, treatment gains were observed in almost all domains examined: severity of pain measured by the Brief Pain Inventory, conceptualization of mental pain measured by the Orbach and Mikulincer Mental Pain Scale, tolerance for psychological pain measured by the Tolerance for Mental Pain Scale, anxiety and depression levels measured by the Hospital Anxiety and Depression Scale, and quality of life measured by the WHO Quality of Life-BREF Questionnaire. The participants' mean age was 52.3 years and most were female (84%). Findings suggest that postprogram, there was significant reduction in pain intensity (p<0.001), depressive symptoms (p<0.001), confusion about pain (p=0.037), and improvement of emotional distress tolerance (p=0.012) and global health-related quality of life (p<0.001) in the intervention group. Beneficial effects can be expected from the implementation of an integrated CP intervention (including: creative and CBT techniques) reappraising some of the coping responses defined as adaptive within current psychosocial non-malignant CP regimens.

[Childhood trauma and suicidality in bipolar disorder: The mediatory role of impulsivity].

Childhood trauma (CT) is correlated with suicidality among patients with bipolar disorder (BD). However, it has not been adequately investigated if a third factor, for instance impulsivity, mediates the effect of CT on suicidality in BD. This study aimed to explore potential mediatory effects of impulsivity in the pathway from CT to suicidality in BD. CT was assessed with the Early Trauma Inventory Self Report-Short Form (ETI-SR-SF), impulsivity with the Barratt Impulsivity Scale-11 (BIS-11) while lifetime suicidality was investigated with the Suicidal Behaviors Questionnaire-Revised (SBQ-R). The effect of childhood trauma on suicidality and impulsivity as well as the effect of impulsivity on suicidality were examined with multiple linear regressions, including gender, age and diagnosis (BD-I, BD-II) as covariates. Structural equation models were built and path analyses were performed (with AMOS 25 software and using bootstrapping in 1000 samples) for the examination of the mediatory role of BIS-11 and its subtypes in the effect of childhood trauma and its subtypes on suicidality. We included 78 BD euthymic patients (60.3% female, 67.9% BD-I). ETI-SR-SF significantly predicted SBQ-R (p=0.004) and BIS-11 (p<0.001), while BIS-11 significantly predicted SBQ-R (p=0.001). In a model including ETI-SR-SF and BIS dimensions, only ETISR-SF physical abuse (p=0.012) and BIS attentional (p<0.001) subscales significantly predicted SBQ-R. In structural equation models, the indirect effect of childhood trauma on suicidality via impulsivity was significant (p=0.003) while the direct effect of childhood trauma on suicidality was non-significant (complete mediation of the effect of childhood trauma on suicidality via impulsivity). In specific, both the indirect effect of physical abuse on suicidality via attentional impulsivity (p=0.002) and the direct effect of physical abuse on suicidality (p=0.013) were statistically significant (partial mediation of the effect of physical abuse on suicidality via attentional impulsivity). Childhood trauma predicts suicidality and impulsivity, while impulsivity predicts suicidality. More specifically, physical abuse and attentional impulsivity predict suicidality. The mediatory role of impulsivity completely explained the effect of childhood trauma on suicidality. Moreover, attentional impulsivity partially mediated the effect of physical abuse on suicidality. Therefore, management of impulsivity and especially of attentional impulsivity is crucial for the prevention and management of suicidality among BD patients with a history of childhood trauma.

Investigating the phenomenon of overkill in Greece: A forensic psychiatric autopsy study between 2005 and 2020.

The purpose of this study was to investigate overkill in the Greek population from a criminological and victimological point of view and explore possible correlations of the phenomenon with socio-cultural or psychiatric factors. Overall, 158 autopsies of overkill victims were identified throughout the 15-year records of the national forensic laboratories throughout the northern Greek mainland. The pattern that has emerged from the statistical results of the present study on the victims of overkill within the Greek borders was generally in line with global statistics on homicide victims, but also presented differences. The phenomenon correlated more with homicides in the context of mental disorders (within schizophrenia spectrum), other crimes (such as burglary) as well as domestic violence. Overall, males outnumbered females both as victims (approximately threefold) and as perpetrators in overkill homicide cases, but regarding domestic violence, the sad majority of overkill victims stood for females murdered with excessive violence by male relatives. Close female relatives (especially mothers and grandmothers) were also victimized by psychiatrically ill offenders. Female perpetrators tended to attack male individuals with whom they shared a relationship (intimate partners). An important finding was the fact that less than half the offenders' population with major mental disorders were diagnosed at the time of the offense. Overkill victims were found, on average, to be older than average homicide victims, being probably associated with the entailed difference in the physical strength ratio between the victim and the perpetrator.

Characteristics of completed suicides after Greek financial crisis onset: A comparative time-series analysis study.

Severe financial crises could influence a country's suicide trends and characteristics. We aimed to highlight differences among suicide completers before and after the onset of Greece's serious debt crisis of 2010 based exclusively on forensic data. The sample's size permitted a further elaboration by means of a time series analysis too. Data were collected from the Piraeus Department of Forensic Medicine for the period 1992-2016. We extracted information on sociodemographic parameters, psychiatric medication and alcohol intake, suicide method, place and month of suicide. The "after crisis onset" group (2011-2016) was significantly older (p = 0.039)-primarily due to differences in the 55-64 age group-, had more frequently used psychiatric medications (p < 0.001), less often alcohol (p = 0.001) and died more frequently by immolation (p = 0.001). These differences were-almost exclusively-due to changes regarding male suicidal behavior. Time series analysis indicates that no strong increasing trend in total (male + female) suicide count can be observed, despite a local increase in 2009-2010. Antidepressant-positive suicides show an increase after 2010, whereas alcohol-positive suicides show a decrease. Future predicted forecasts for antidepressant-positive suicides indicate a decrease (from 5.6 per year in 2018 to 4.3 per year in 2025) whereas an increase is predicted in alcohol-positive suicides (7.7 per year in 2017, 9.36 per year in 2025). Middle-aged men, compared to middle-aged women, presumably found it harder to adjust to economic hardship after the crisis onset. Finally, comparatively more men than women who died by suicide appear to have started and/or complied with psychiatric treatment after 2010.

Adding stress to the stressed: Senior high school students' mental health amidst the COVID-19 nationwide lockdown in Greece.

The two-year preparation for the National university entrance exams in Greece is one of the most trying periods in a young person's life, physically and emotionally. The present study reports the results from 442 last year senior high school students who completed an online survey (16-30 April 2020) concerning the lockdown impact on their mental health. Overall, the rate of positive screen for depression (PHQ-9 score ≥ 11) significantly increased from 48.5% to 63.8% and of those scoring within severe depression range (PHQ-9 ≥20) from 10% to 27%; for anxiety (GAD-7 score ≥ 11) increased from 23.8% to 49.5% and of those scoring within severe anxiety range (GAD-7≥17) from 3.8% to 20.5%. After taking sex and baseline (one month prior to the lockdown) levels of depression and anxiety into account, the level of lockdown experienced distress was predictive of depression and anxiety levels in time of home confinement, accounting for about 30% of variance in symptoms severity scores. Although our results may be subject to sampling and recall bias, the unexpectedly high rates of anxiety and depression warrant an urgent call to action aiming at mitigating and managing mental health risks of senior high school students in future waves of pandemic.

Self-immolation Suicide in Greece: A Forensic Psychiatric Autopsy Study between 2011 and 2019.

Self-immolation is a rare suicide method in the developed countries of the western world (0.06-1%); however, it has relatively higher prevalence rates in the developing countries of Asia and Africa (6-57%). The present study aims to examine self-immolation suicides within the Greek mainland (Attiki, Thrace, and Peloponnese) over a period of 9 years (2011-2019) in order to investigate the phenomenon in the Greek population forensically, identify the characteristics and motivations of suicide victims, explore its associations to socio-cultural or psychiatric factors, and describe a fatal case of suicide by self-immolation that was partially recorded on camera. The medical files (autopsy reports) of cases performed at the Departments of Forensic Medicine of the National and Kapodistrian University of Athens, Democritus University of Thrace, and the Forensic Service of Messinia-Peloponnese were retrospectively examined yielding 19 cases of suicides by self-immolation. A 3.7% prevalence of suicide by self-immolation among suicide fatalities within the Greek population was estimated. A distinctive feature of the Greek population regarding self-immolation was disclosed that it is being practiced predominantly by the elderly (mean age 2-3.5 decades higher than other countries). The phenomenon correlated strongly with poorly controlled mental disorders (mostly affective and adjustment disorders). Unlike other countries, there was no significant association with domestic or sexual violence, social or political protest, or religious issues. Therefore, the suicide victims preferred secluded or private outdoor locations (not public). Findings deriving from the examined variables localize Greek population culturally between the Western European and Asian African countries, but with its own idiosyncrasies.

Psychiatric diagnosis, gender, aggression, and mode of attempt in patients with single versus repeated suicide attempts.

There is evidence that patients with multiple suicide attempts in their history are at greater risk to repeat attempt and eventually die by suicide compared to those with a single attempt. This cross-sectional study aimed to explore possible differences in clinical characteristics between patients with a single attempt and patients with repeated attempts. Two hundred thirty one patients hospitalised in psychiatric department after suicide attempt were studied. Comparisons were made in relation to age, gender, psychiatric diagnosis, aggression, depression severity, suicide intent and mode of attempt. Highest frequencies of patients with repeated attempts were found for bipolar disorder (69%) and lowest for adjustment/personality disorders (39%). In patients with repeated attempts, female gender was associated with non-violent attempt mode. Depressive symptomatology was higher in patients with repeated attempts among females. In patients with depression those with repeated attempts were younger than patients with single attempt. In patients with mood disorders, total aggression and hostility scores were higher in females with repeated attempts but not in males. Psychiatric diagnosis, gender and attempt mode are features that differentiate patients with single and repeated attempts and should be considered to identify patients at increased risk to repeat attempt and design effective prevention interventions.

Well-being in Patients with Affective Disorders Compared to Nonclinical Participants: A Multi-Model Evaluation of the Mental Health Continuum-Short Form.

OBJECTIVES: The Mental Health Continuum-Short Form (MHC-SF), measuring emotional, social, and psychological well-being, has scarcely been validated in clinical populations. We evaluated MHC-SF in 203 patients with affective disorders and 163 nonclinical participants. METHOD: Traditional confirmatory factor analysis (CFA), bifactor CFA, three-factor exploratory structural equation modeling (ESEM), and bifactor ESEM models were compared. Convergent/discriminant validity was tested against classic well-being validators and current mood state. RESULTS: All three subscales were significantly lower in patients. Test-retest reliability in patients was moderate. Bifactor ESEM fitted data best and displayed full scalar gender and partial scalar invariance across groups. Factor strength indices suggested that MHC-SF is primarily unidimensional, especially in patients. However, subscales differed considerably on size, internal consistency, distinctness, discriminant validity, and temporal stability. CONCLUSIONS: MHC-SF was valid and reliable for monitoring well-being in both clinical and nonclinical samples, but further research is needed before safely concluding on its dimensionality.

Self-esteem and aggression in women: differences between female prisoners and women without criminal records.

Contradictory findings have been reported regarding the association between self-esteem and aggression. Most studies have dealt with non-criminal populations. This study aimed to explore the relationship between self-esteem and aggression and investigate possible differences in self-esteem and aggression between female inmates and women without criminal records (non-criminals) in the prefecture of Attica, Greece. One hundred fifty-seven female inmates in the Attica's Korydallos Female Prison and 150 non-criminals from Attica's general population completed the Buss & Perry Aggression Questionnaire and Rosenberg's Self-esteem Scale between February 2012 and April 2014. Lower self-esteem was associated with higher aggression among women independent of criminality. Self-esteem was lower in inmates (Mean = 18.06, SD = 6.19) than in non-criminals (Mean = 21.65, SD = 4.90, p < .001). Female prisoners presented higher aggression than non-criminals (unadjusted Mean = 78.40, SD = 23.60 versus Mean = 68.82, SD = 14.95, p < .001). However, after adjusting for age, education and self-esteem, this difference was no longer statistically significant (p = .127). Further studies, especially in female offenders, should be conducted to broaden our understanding of female aggression with a view to developing and promoting focused therapeutic procedures.

Narcissism but Not Criminality Is Associated With Aggression in Women: A Study Among Female Prisoners and Women Without a Criminal Record.

Aggression has drawn research attention during the past decades. It remains unclear how self-esteem, self-perception, narcissism and certain socio-demographic factors impact the course of aggression. Female aggression is considered to differ in its origins and is understudied. Only few studies have attempted to examine the aforementioned variables among females, while none of them included a comparison between delinquent and non-delinquent individuals. The present study examines the effect of self-esteem, self-perception, narcissism, and socio-demographic factors on aggression among female inmates and women without criminal record (non-delinquents). One hundred fifty-seven female inmates in the Attica's Korydallos Female Prison and 150 women with no criminal record were assessed with Buss & Perry Aggression Questionnaire, Rosenberg's Self-esteem Scale, Narcissistic Personality Inventory-40 and the Self-Perception Profile for Adults. When inmates were compared to non-delinquent women, it emerged that higher aggression could be independently predicted by higher levels of narcissistic personality traits and sociability, as well as lower age, lower education, lower self-esteem, and lower levels of self-perception items including nurturance, job competence and athletic abilities. Aggression was not predicted by the participants' group (inmates vs. non-delinquents). Within female inmates, independently of the type of their offense (convicted for violent vs. non-violent crimes), it was found that lower job competence, higher narcissistic personality traits and a history of childhood maltreatment could predict higher aggression. Our results support the notion that female aggression differs from male and highlight the significant parameters that may predict aggression either among women (inmates and non-delinquent women) or among female inmates (violent or non-violent crimes). It is the presence of narcissistic traits which predict aggression rather than criminality in general, including violent and non-violent crimes.

Clinical and psychometric features of psychiatric patients after a suicide attempt in relation with menstrual cycle phases.

There is evidence that frequency of suicide attempts of fertile women is related to the menstrual cycle phases, while the influence of hormonal and psychiatric features has been hypothesized. This study aims to explore the distribution and possible differences in clinical characteristics of women who attempted suicide in relation to menstrual cycle. Seventy fertile female psychiatric patients, hospitalized in psychiatric department after a suicide attempt, were studied. Depression was assessed using Beck Depression Inventory, suicide intent with the Suicide Intent Scale, and aggression using the Buss-Perry Aggression Questionnaire. A profile of psychopathology was obtained by using Symptom Check List SCL-90-R. Attempts were more frequent during the last 4 days of luteal phase and during the 4 days of menses, with 59% of attempts to occur during these 8 days. Patterns of number of attempts and cycle phase were similar for subgroups regarding diagnosis, violent/non-violent mode of suicide attempt, and one or repeated attempts. Although attempts were unequally distributed during the cycle, none of the psychiatric features assessed in the present study were related to the higher frequency of attempts during premenstrual/menstrual days, indicating the need to include additional aspects of suicidal behavior in future studies.

The Relationship between Hopelessness and Clinical Characteristics of Hospitalized Patients with Recent Suicide Attempt.

This study aimed to assess hopelessness in 170 hospitalized individuals with recent suicide attempt and examine its association with patients' characteristics, with a view to improving awareness in health professionals and especially nurses, who are among the first to take care of these patients. Participants completed Beck Hopelessness Scale and Beck Depression Inventory. More than half (51.18%) experienced moderate-to-severe hopelessness. A multiple linear regression analysis showed that age, attempted suicide method, past suicide attempt, and psychiatric diagnosis contributed statistically significantly to hopelessness prediction. Hopelessness assessment could efficiently help health professionals to minimize both inpatient suicide and suicidal acts after discharge.

Comparative study of aggression - Dangerousness on patients with paranoid schizophrenia: Focus on demographic data, PANSS, drug use and aggressiveness.

This cross sectional study aimed to compare the differences in psychopathology of Greek homicide and homicide attempters, patients with schizophrenia, with non violent individuals, suffering from schizophrenia. The study compared three Groups of 220 men, diagnosed with schizophrenia: (a) Group Α (Schizophrenia - No violence, (b) Group Β (Schizophrenia - with violence or violent crime), (c) Group C (Schizophrenia - not guilty by reason of insanity - violent crime). Several psychometric tools were used, such as M.I.N·I (Mini-International Neuropsychiatric Interview), PANSS scale (Positive and Negative Symptoms Scale). Most subjects suffered from paranoid schizophrenia. On factors such as demographic characteristics (i.e. current occupational status, living status), statistically significant findings were shown for Groups B and C vs Group A. Predisposing psychosocial factors, such as family conflicts and aggressiveness against family, were found to be statistically significant in differentiating violent versus nonviolent individuals with psychosis. They differed significantly in factors like history of juvenile delinquency, but also in the type of aggressiveness in general. These differences were confirmed on PANSS scale. In conclusion, the longer the history of aggressiveness is presented, the greater the chances are of individuals falling into Group C and it is possible to spend several years from the onset of the disease until the moment of crime.

A comparative analysis of suicides in Greece's main port city area of Piraeus before (2006-2010) and during (2011-2015) the country's severe economic crisis.

We investigated all cases of completed suicide in the city area of Piraeus -the largest port in Greece- for the years 2006 up to 2015. We searched, among others, parameters regarding the victims' psychiatric medication intake and drug and alcohol use that -to the best of our knowledge- had never been investigated before by a study on suicides in Greece within the crisis' years. We documented variations before (2006-2010) and during (2011-2015) crisis. Information was provided by the victims' forensic records at the Piraeus Department of Forensic Medicine. During the period of the study 435 individuals died by suicide. "Before" crisis: 227 cases, 77,1% males, mean age 48.6 years (SD:19.8), 85% Greek. "During": 208 cases, 79,8% males, mean age 51.4 years (SD:17.7), 83.2% Greek. Psychiatric medication intake: "Before"-"During": 16.3%-29.8% (p=0.003), males: 16.1%-31.7%, females: 19.6%-27.5% (p=0.003). Drug use: opioids 2.7%(5.5%), cannabis 1.4%(5.5%), cocaine 0(1.5%), alcohol 14.5%(13.4%). Significant seasonality was observed only for suicides by jumping with a peak late in the month of July in the "Before" group. There were no significant differences regarding suicide method, place of suicide or place of death. The slight decrease in suicides within the crisis' years, together with the higher medication intake observed within the same period, could imply that more individuals were willing to accept their psychological difficulties and/or to commence treatment. Probably the stigma of psychiatric illness is somewhat lower after the beginning of the crisis and/or non-psychiatrists became more aware of the psychological origins of some of their patients' problems. Our findings tentatively suggest that, as the crisis persists, adaptive mechanisms have been set in motion.

Suicides by drowning in Greece: Findings from a 10-year sample (2006-2015).

We studied a sample of suicide victims from Greece's main port of Piraeus area (population: approx. 700,000 individuals) and investigated all suicides for the 10-year period 2006-2015, collecting data from the victims' forensic records at the Piraeus Department of Forensic Medicine. Sixty-nine (15.9%) out of 435 suicides were due to drowning, 51 (73.9%) males and 18 (26.1%) females. Drowning was the third most common suicide method with most in the sea (92.8%), fewer in wells (7.2%). Median age: males 52.2 years (standard deviation (SD): 20.3, range: 27-89) and females 58.8 years (SD: 15.2, range: 32-84). Psychiatric medications: antidepressants (6 cases, 8.9%), benzodiazepines (6 cases, 8.9%) and antipsychotics (1 case, 1.5%). Other substances: alcohol (14 cases, 20.9%), cocaine (1 case, 1.5%) and opioids (1 case, 1.5%). No seasonal effect was observed for suicides by drowning. Greece, being a country with an embracing coastline, could provide a field of study for suicide by drowning.

Validating a two-dimensional bipolar spectrum model integrating DSM-5's mixed features specifier for Major Depressive Disorder.

INTRODUCTION: The literature on DSM-5's 'Major Depressive Disorder with lifetime mixed features' (MDD-MF) is limited. This study investigated MDD-MF's potential inclusion into a bipolar spectrum. METHODS: We recruited 287 patients with Bipolar I disorder (BD-I), BD-II, MDD-MF or 'MDD without lifetime mixed features' (MDD-noMF); most (N=280) were stabilized for at least one year on medication. Sixteen validators (clinical features, psychiatric family history, temperament, stabilizing treatment) were compared across groups and subjected to trend analyses. Two discriminant function analyses (DFA; primary and secondary), excluding or including, respectively, treatment-related predictors, explored latent dimensions maximizing between-group discrimination; mahalanobis distances between group 'centroids' were calculated. RESULTS: Eleven validators differed significantly across groups; nine varied monotonically along a bipolar diathesis gradient with significant linear trends; two peaked at MDD-MF and displayed significant quadratic trends. In the primary DFA, apart from a classic bipolarity dimension, correlating with hospitalizations, early age at onset, lifetime psychosis and lower anxious temperament scores, on which groups ranked along a bipolar propensity gradient, a second dimension was also significant, peaking at BD-II and MDD-MF (challenging the classic bipolar ranking), which correlated with lifetime psychiatric comorbidities, suicidality, lower lifetime psychosis rates, female gender, higher cyclothymic and lower depressive temperament scores; MDD-MF was equipoised amidst BD-II and MDD-noMF. After including treatment-related predictors (secondary DFA), discrimination improved overall but BD-II and MDD-MF were closest than any other pair, suggesting similar treatment patterns for these two groups at this naturalistic setting. CONCLUSIONS: To our knowledge, this is the first time a two-dimensional bipolar spectrum based on classic external validators is proposed, fitting the data better than a unidimensional model. Additional predictors are warranted to improve BD-II/MDD-MF discrimination.