Covid-19-related stressors, mental disorders, depressive and anxiety symptoms: a cross-sectional, nationally-representative, face-to-face survey in Serbia.

AIM: The Covid-19 pandemic may be associated with an increase in mental disorders and mental distress. However, there are no representative studies testing the impact of stressors directly related to Covid-19. We aimed to determine whether Covid-19-related stressors were associated with mental disorders, depressive and anxiety symptoms in the second year of the pandemic. METHOD: This cross-sectional observational epidemiological survey was conducted from June to October 2021. We interviewed a representative sample of the adult population in Serbia (18-65 years) in the second year of the pandemic, at a time when large parts of the population had been affected by the pandemic in different ways. A multistage probabilistic household sampling of the adult population in 60 municipalities was used. Mental disorders were assessed by in-person interviews using the Mini International Neuropsychiatric Interview. Depressive and anxiety symptoms were measured by PHQ-9 and GAD-7 scales. Covid-19-related stressors (Sars-CoV-2 infection, the infection of a close relative, self-isolation and lack of protective equipment at work), as well as other stressors during the pandemic (not directly related to the risk of the infection), were measured. The associations with mental disorders, depressive and anxiety symptoms were explored through univariable and multivariable regression analyses. RESULTS: In total, 1203 individuals (mean age 43.7 ± 13.6 years, 48.7% male) were interviewed. Most respondents (67.8%) of the sample had already experienced Covid-19-related stressors (20.1% had Sars-CoV-2 infection; 43.2% had a close relative member who had Covid-19; 28.2% reported lack of appropriate protection; 27.5% had been quarantined) and about 50% had already been vaccinated. The prevalence of any mental disorder was 15.2% (95% CI 13.2-17.2): mood disorders 4.6%, anxiety disorders 4.3% and substance use disorders 8.0%. Mean PHQ-9 was 3.2 ± 3.8 and GAD-7 was 2.1 ± 3.1. In this study, one Covid-19 stressor, i.e. lack of protective equipment, was weakly associated with a greater frequency of anxiety disorders (p = 0.023), while the other stressors had significant associations with several groups of mental disorders and symptom levels. CONCLUSIONS: Our study did not provide any evidence that the prevalence of mental disorders exceeds the range of pre-pandemic data reported in the literature. Covid-related stressors, although frequently reported, did not dramatically influence the prevalence of mental disorders. The provision of the appropriate equipment at workplaces might lead to the reduction of anxiety disorders.

Child and adolescent psychiatry training and mental health care in Southeast Europe.

There is very limited information available on child and adolescent psychiatry (CAP) training in the Southeast European (SEE) region. The objective of this study was to fill in this gap by presenting descriptive data on CAP training and national mental health services for children and adolescent in 11 SEE countries. On the initiative of World Psychiatric Association-CAP section, national CAP association boards from each SEE country allocated one member to the Consortium on Academic Child and Adolescent Psychiatry in SEE (CACAP SEE) in 2018. Using an internally distributed questionnaire, CACAP SEE members provided information on the CAP training structure and mental health care. Ten out of eleven SEE countries recognized CAP as a separate specialty. Duration of training did not differ much between the SEE countries. Other components were more variable (availability of rotations, overseas electives, and inclusion of psychotherapy). Ten countries were familiar with the CAP requirements of the European Union of Medical Specialists (UEMS-CAP) and five provided the training in accordance with it. Nine countries had less than 36 board-certified child and adolescent psychiatrists practicing in the country. The number of general psychiatrists treating children and adolescents with mental disorders was higher than the number of CAP specialists in five of the countries. Although CAP was recognized as a separate specialty in the vast majority of SEE countries, there was a substantial variation among them in available CAP training. In most of the countries, there is a considerable lack of CAP specialists for several reasons, including loss of trained specialists to other countries.

Evaluating Sex and Age Differences in ADI-R and ADOS Scores in a Large European Multi-site Sample of Individuals with Autism Spectrum Disorder.

Research on sex-related differences in Autism Spectrum Disorder (ASD) has been impeded by small samples. We pooled 28 datasets from 18 sites across nine European countries to examine sex differences in the ASD phenotype on the ADI-R (376 females, 1763 males) and ADOS (233 females, 1187 males). On the ADI-R, early childhood restricted and repetitive behaviours were lower in females than males, alongside comparable levels of social interaction and communication difficulties in females and males. Current ADI-R and ADOS scores showed no sex differences for ASD severity. There were lower socio-communicative symptoms in older compared to younger individuals. This large European ASD sample adds to the literature on sex and age variations of ASD symptomatology.

Child is father of the man: child abuse and development of future psychopathology.

Available epidemiological data indicate that the abuse of children within families is a very common phenomenon, and is still on the rise. Among others, abuse includes direct physical and emotional violence to the child, as well as the indirect emotional trauma of witnessing interparental violence. These early trauma experienced within the context of the family can influence the development of the child's personality as well as predispose towards the development of mental disorders in adulthood. There are some important factors influencing the occurrence of abuse, or the conditions predisposing it: certain parental personality traits appear to be instrumental, and the presence of individual psychopathology of parents is also connected with different forms of family dysfunction as a system, representing a variable which is interpolated in the quality of parenthood as the most important factor that determines long-term consequences on children and possible future psychopathology. The complex but tangible effects of parents' personality traits on the psychological development of children may contribute to the transgenerational transmission of abuse and violence. The phenomenon of domestic violence and abuse can be described from the perspective of the psychological and systemic theoretical postulates. According to systemic theory and practice, dysfunctional communication in the family is a significant predictor for domestic violence. Characteristics of dysfunctional communication include low levels of verbal expressiveness and emotional responsiveness, low tolerance to criticism and its interpretation as a threat or intimidation, and consequently increased anxiety and subsequent escalation of an argument into violence. Overall it seems that there may be a complex connection between parental personality and family interaction patterns, leading to dysfunctional communication which further amplifies the detrimental characteristics of family dynamics, and eventually escalates to violence. According to one theory, there may be a degree of transgenerational transmission of these communication patterns in children who have been victims of violence, thus propagating the conditions for violence, this time perpetrated by the victims themselves. Therefore there is a pressing need for prevention, perhaps through psychoeducation for parents or through early detection and treatment of traumatized children and adolescents, in the hope that the transgenerational vicious cycle of violence may be broken.

Management in child and adolescent psychiatry: how does it look in the Balkans?

This paper examines the situation of child and adolescent psychiatry in the following Balkan countries: Greece, Serbia, Bulgaria, Romania, Bosnia and Herzegovina, FYROM, and Montenegro. With the exception of Greece, these countries are new democracies, with their mental health services in a transitional stage of organization. Overall, they have initiated programmes to move psychiatric care towards deinstitutionalization, developing outpatient infrastructures to handle psychiatric disorders. Child psychiatry as a specialization is still less developed than adult psychiatry at a significant, albeit different degree among these countries. The number of mental health services offered to children and adolescents is deemed insufficient, and the type of services limited and lacking. This situation is also reflected in the small number of child psychiatrists and other mental health specialists for children and adolescents, as well as in the complete lack (Montenegro) or deficiency of special programmes and actions for children and adolescents. The same also applies to mental health legislation. Greece is the exception in the development of the entire spectrum of services, the number of specialists, and the establishment of an adequate legislation framework reinforced by the incorporation of all international treaties on children's rights; although the recent economic crisis has affected the country negatively, threatening with regression to pre-reformational practices. Children and adolescents in need of mental health care have been increasing in all countries. The effect of violent and sudden changes taking place in most countries is a major factor for the emergence of increased and stress-related psychopathology and psychosocial problems in children and families. In all countries, there is a significant development of nongovernmental organizations undertaking a large part of reformation work. There is also the disconcerting phenomenon of professional exhaustion and the migration of experts from their countries. Finally, there is the common need to develop educational programmes and related clinical practices in all degrees of prevention, promoting interdisciplinary cooperation, the biopsychosocial approach to understanding and dealing with mental health issues, as well as the development of cooperation among all institutions concerning children (education, health, etc.). All this should be reflected in a national plan to promote child mental health as the foundation upon which the necessary cooperation among Balkan countries would be established in order to promote research, the exchange of experiences, common practices, mutual understanding, and common interests.

Psychotropic medication use in children and adolescents in an inpatient setting.

Medication can be an effective part of treatment for several psychiatric disorders of childhood and adolescence but its use should be based on a comprehensive psychiatric evaluation and treatment plan. The aim of this study was to evaluate psychotropic medication use for children and adolescents treated as inpatients and to compare it with principles of rational pharmacotherapy, thus identifying possible downsides of current practices and pointing a way towards safer and more efficient practices. This is a descriptive study of prescribing trends at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade, during the period from September 2009 to September 2010. Analyzed demographic data (age, gender) and the number of hospitalizations were obtained from medical histories, while diagnoses were obtained from discharge notes. Prescribed therapy was copied from medication charts. Drug dosages were analyzed as average daily doses prescribed during the hospitalization. Psychiatric diagnoses were classified according to The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). During the examined time period, 264 patients were hospitalized (61.4% males), with an average age of 11.4±5.1 years. We have found that 66.3% of admitted patients were treated with pharmacotherapy in addition to other treatment modalities. There was a highly significant correlation between the age of patients and the prescribed dosage (Spearman's rho=0.360, p<0.001) as well as the number of prescribed drugs (Spearman's rho=0.405, p<0.001). The most commonly diagnosed psychiatric disorders were: autism spectrum disorders (20.8%), conduct disorders(19.7%), mixed developmental disorder (14.8%), adjustment disorder (7.2%), mental retardation (7.2%),acute psychosis (4.5%), and ADHD (2.3%). The most commonly prescribed medications were antipsychotics(45.9%), followed by antidepressants (17.2%), mood stabilizers (16.1%), benzodiazepines (14.4%), and other psychotropic drugs (6.4%). The most commonly prescribed antipsychotic was risperidone, used for more than 50% of the patients treated with antipsychotics. Taken together risperidone and chlorpromazine were more than 75% of all prescribed antipsychotics. 98.4% of prescribed antidepressants belonged to the SSRIs,with sertraline and fluoxetine accounting for almost 90% of them. All prescribed dosages were in accordance with the official guidelines. This is the first survey in Serbia to document the practice of prescribing psychotropic medication in the field of child and adolescent psychiatry. Current drug-prescribing practices at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade are in accordance with current practices in the United States and Europe. Not every child with symptoms of mental health problems needs pharmacological treatment; when they do, the general rule of thumb should be "start low, go slow, and taper slowly". Follow-up studies are necessary to assess the change of trends, as well as studies in different patient populations and health centers, in order to globally evaluate psychotropic medication use in children and adolescents in Serbia.