Gender, age at onset, and duration of being ill as predictors for the long-term course and outcome of schizophrenia: an international multicenter study.

BACKGROUND: The aim of the current study was to explore the effect of gender, age at onset, and duration on the long-term course of schizophrenia. METHODS: Twenty-nine centers from 25 countries representing all continents participated in the study that included 2358 patients aged 37.21 ± 11.87 years with a DSM-IV or DSM-5 diagnosis of schizophrenia; the Positive and Negative Syndrome Scale as well as relevant clinicodemographic data were gathered. Analysis of variance and analysis of covariance were used, and the methodology corrected for the presence of potentially confounding effects. RESULTS: There was a 3-year later age at onset for females (P < .001) and lower rates of negative symptoms (P < .01) and higher depression/anxiety measures (P < .05) at some stages. The age at onset manifested a distribution with a single peak for both genders with a tendency of patients with younger onset having slower advancement through illness stages (P = .001). No significant effects were found concerning duration of illness. DISCUSSION: Our results confirmed a later onset and a possibly more benign course and outcome in females. Age at onset manifested a single peak in both genders, and surprisingly, earlier onset was related to a slower progression of the illness. No effect of duration has been detected. These results are partially in accord with the literature, but they also differ as a consequence of the different starting point of our methodology (a novel staging model), which in our opinion precluded the impact of confounding effects. Future research should focus on the therapeutic policy and implications of these results in more representative samples.

Outcome of Voluntary vs Involuntary Admissions in Greece over 2 years after Discharge: A Cohort Study in the Psychiatric Hospital of Attica "Dafni".

The increasing rates of involuntary hospitalization constitute a major ethical issue in psychiatric practice. The present cohort study endeavours to investigate the relationship between patients' legal status (involuntary vs voluntary) and the outcome of their hospitalization, over 2 years after discharge. All individuals admitted in the 3rd Psychiatric Department of the Psychiatric Hospital of Attica during February 2015-February 2017 took part in the study. 64.7% of patients were compulsory admitted. Findings indicate a statistically significant improvement in global functioning and symptomatology levels from admission to discharge for all treated patients, independently of their legal status. However, readmission rates over 2 years after discharge were high (34.8% vs. 21.9% in voluntary and involuntary patients, respectively). In conclusion, psychiatric admission, irrespectively of legal status leads to clinical improvement.

Cortisol to Dehydroepiandrosterone Sulphate Ratio and Executive Function in Bipolar Disorder.

INTRODUCTION: Bipolar disorder (BD) is associated with impairment in cognitive domains such as verbal memory and executive functions. Very few studies have assessed dehydroepiandrosterone sulphate (DHEA-S) in BD and its relation to cognitive functioning despite evidence showing its regulatory effects on glucocorticoid action. The aim of our study was to explore the association of cortisol, DHEA-S, and cortisol to DHEA-S ratio with visuospatial memory and executive functioning in BD. METHODS: Cognitive performance of 60 bipolar I patients and 30 healthy subjects was evaluated by using Cambridge Neuropsychological Test Automated Battery tasks targeting visuospatial memory (spatial recognition memory) and executive functions (planning [Stockings of Cambridge; SOC] and attentional set shifting [ID/ED]). Morning serum cortisol and DHEA-S levels were measured in patients. Main effects of cortisol, DHEA-S, and cortisol/DHEA-S ratio for each neurocognitive task were explored in multiple regression analyses correcting for demographic and clinical parameters as well as treatment-related factors (current use of antipsychotic and mood stabilizer medication). RESULTS: Bipolar patients showed poorer performance than healthy subjects in planning and attentional set shifting but not in visuospatial memory. Cortisol to DHEA-S ratio predicted worse performance in planning (SOC). CONCLUSIONS: This is the first study to assess memory and executive function in BD in relation to DHEA-S and cortisol to DHEA-S ratio. We report an association of cortisol to DHEA-S ratio with worse performance in planning in bipolar I patients, which warrants further investigation.

Modeling psychological function in patients with schizophrenia with the PANSS: an international multi-center study.

BACKGROUND: The aim of the current study was to explore the changing interrelationships among clinical variables through the stages of schizophrenia in order to assemble a comprehensive and meaningful disease model. METHODS: Twenty-nine centers from 25 countries participated and included 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Multiple linear regression analysis and visual inspection of plots were performed. RESULTS: The results suggest that with progression stages, there are changing correlations among Positive and Negative Syndrome Scale factors at each stage and each factor correlates with all the others in that particular stage, in which this factor is dominant. This internal structure further supports the validity of an already proposed four stages model, with positive symptoms dominating the first stage, excitement/hostility the second, depression the third, and neurocognitive decline the last stage. CONCLUSIONS: The current study investigated the mental organization and functioning in patients with schizophrenia in relation to different stages of illness progression. It revealed two distinct "cores" of schizophrenia, the "Positive" and the "Negative," while neurocognitive decline escalates during the later stages. Future research should focus on the therapeutic implications of such a model. Stopping the progress of the illness could demand to stop the succession of stages. This could be achieved not only by both halting the triggering effect of positive and negative symptoms, but also by stopping the sensitization effect on the neural pathways responsible for the development of hostility, excitement, anxiety, and depression as well as the deleterious effect on neural networks responsible for neurocognition.

Personality dimensions could explain resilience in patients with eating disorders.

PURPOSE: Resilience can be defined as the ability to maintain health in the face of adversity. Resilience has been associated with personality traits. Personality traits in the context of Eating Disorders (ED) have also been examined. However, the relationship between resilience and personality profile in patients with ED has not been studied. The aim of this study is to investigate whether personality dimensions impact on resilience, in patients with ED, compared to healthy participants. METHODS: Connor and Davidson resilience scale, as a measure of resilience and temperament-character inventory, as a measure of personality dimensions, were completed by 100 participants: 50 (50%) healthy University students (controls subgroup) and 50 (50%) patients with ED, matched on age and gender. RESULTS: Patients with ED showed lower resilience than healthy participants and scored higher on harm avoidance, and lower on reward dependence, self-directedness and cooperativeness than controls. Lower harm avoidance, higher persistence and higher self-directedness were associated with resilience in both subgroups. Self-directedness and persistence predicted resilience in both subgroups. Only Harm Avoidance predicted resilience in patients' subgroup. CONCLUSION: To our knowledge, there are no existing data examining the effect of personality dimensions in resilience, in the context of ED. We found that only the effect of Harm Avoidance in resilience was different among the participants' subgroups. In conclusion, Harm Avoidance could explain differences in resilience between healthy participants and patients with ED. LEVEL OF EVIDENCE: Level III: case-control analytic study.

Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study.

INTRODUCTION: A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method. METHODS: Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed. RESULTS: Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients. DISCUSSION: This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.

Guilt Delusional Beliefs Increase the Risk of Suicidal Attempt in Elderly Unipolar Psychotic Depressives.

The aim of this study was to investigate the differential effect of various delusion categories, namely, guilt, paranoid, impending disaster, and somatic on suicidal attempts in elderly patients experiencing unipolar psychotic major depression (PMD), because the evidence on this is scarce. The sample consisted of 65 consecutively admitted patients 60 years or older, experiencing PMD, and assessed by means of Structured Clinical Interview for DSM-4 (Patient Edition), Hamilton Depression Rating Scale, Mini-Mental Status Examination (MMSE), and by a physical impairment rating scale. Patients with guilt delusional beliefs had 5.31 times higher odds (95% confidence interval, 1.37-25.40) of a suicidal attempt than the patients without guilt delusional beliefs, controlling for sex, age, prior history of suicide attempt, MMSE, and hallucinations. In addition, 17 PMD patients with lifetime suicidal attempt compared with 48 PMD patients without lifetime suicidal attempt presented only higher age of disorder onset (p = 0.008). Of the four categories of delusions assessed, only guilt delusions were associated with an increased risk for suicidal attempt.

Testamentary Capacity Assessment: Legal, Medical, and Neuropsychological Issues.

INTRODUCTION: The increase in the aging population and the number of patients with dementia led to the research in older adults' capacity assessment over the last 3 decades. Many cases of contested wills occur due to lack of testamentary capacity (TC), especially in cases of dementia. AIM: Purpose of the present study was to overview the legal, medical, and neuropsychological aspects of TC as well as the instruments used for TC assessment. FINDINGS: The testator/testatrix with intact TC has realistic perception of his or her property value, lack of psychopathology affecting contact with reality, and intact intention of how and to whom he or she will dispose his or her assets. It is frequent for the health practitioners to serve as "gold standards assessors" by examining an individual's ability to make a valid will and giving evidence to the court to support or not a will contest. The TC assessment is a complex process of clinical and legal practice requiring usually a variety of methods, that is, interviews, evaluation of clinical records, and administration of neuropsychological instruments. CONCLUSION: The evaluation of TC is a multidimensional process that integrates both the legal and medical field, requiring a collaborative approach to its definition and assessment.

Psychotic (delusional) depression and completed suicide: a systematic review and meta-analysis.

BACKGROUND: It remains unclear whether psychotic features increase the risk of completed suicides in unipolar depression. The present systematic review coupled with a meta-analysis attempts to elucidate whether unipolar psychotic major depression (PMD) compared to non-PMD presents higher rates of suicides. METHODS: A systematic search was conducted in Scopus, PubMed, and "gray literature" for all studies providing data on completed suicides in PMD compared to non-PMD, and the findings were then subjected to meta-analysis. All articles were independently extracted by two authors using predefined data fields. RESULTS: Nine studies with 33,873 patients, among them 828 suicides, met our inclusion criteria. PMD compared to non-PMD presented a higher lifetime risk of completed suicides with fixed-effect pooled OR 1.21 (95% CI 1.04-1.40). In a sub-analysis excluding a very large study (weight = 86.62%), and comparing 681 PMD to 2106 non-PMD patients, an even higher pooled OR was found [fixed-effect OR 1.69 (95% CI 1.16-2.45)]. Our meta-analysis may provide evidence that the presence of psychosis increases the risk of suicide in patients suffering from severe depression. The data are inconclusive on the contribution of age, mood congruence, comorbidity, and suicide method on PMD's suicide risk. The lack of accurate diagnosis at the time of suicide, PMD's diagnostic instability, and the use of ICD-10 criteria constitute the main study limitations. CONCLUSIONS: The presence of psychosis in major depression should alert clinicians for the increased risk of completed suicide. Thus, the implementation of an effective treatment both for psychotic depression and patients' suicidality constitutes a supreme priority.

Association of Schizoid and Schizotypal Personality disorder with violent crimes and homicides in Greek prisons.

BACKGROUND: Personality disorders (PDs) have been associated with both violent crimes and homicides in many studies. The proportion of PDs among prisoners reaches up to 80%. For male prisoners, the most common PD in the literature is antisocial PD. The aim of this study was to investigate the association between PDs and violent crimes/homicides of male prisoners in Greece. METHODS: A sample of 308 subjects was randomly selected from a population of 1300 male prisoners incarcerated in two Greek prisons, one urban and one rural. The presence of PDs was assessed using the Mini International Neuropsychiatric Interview (MINI) and the Personality Diagnostic Questionnaire-4 (PDQ-4). Using logistic regression models PD types and PD "Clusters" (independent variables) were associated with "violent/non-violent crimes" and "homicides/non homicides" (dependent variables). RESULTS: "Cluster A" PDs (Paranoid, Schizoid, and Schizotypal) were diagnosed in 16.2%, "Cluster B" (Antisocial, Borderline, Histrionic, Narcissistic) in 66.9% and "Cluster C" (Obsessive-Compulsive, Dependent, Avoidant) in 2.9% of the studied population. Violent crimes and homicides were found significantly associated with "Cluster A" PDs (p = 0.022, p = 0.020). The odds ratio of committing violent crimes was 2.86 times higher for patients with "Cluster A" PDs than the ones without PDs. In addition, the odds ratio of committing homicides was 4.25 times higher for patients with "Cluster A" PDs. In separate analyses, the commitment of violent crimes as well as homicides, was significantly associated with Schizoid (p = 0.043, p = 0.020) and Schizotypal PD (p = 0.017, p = 0.030). CONCLUSIONS: The majority of prisoners was found to suffer from a PD, mainly the Antisocial "Cluster B", but the commitment of violent crimes and homicides was significantly associated only with "Cluster A" PDs and specifically with Schizoid and Schizotypal PD.

The distinguished Austrian ophthalmologist Ernst Fuchs (1851-1930) and the "sarcom des uvealtractus".

Born in Vienna, in mid 19th century, Ernst Fuchs became an innovative ophthalmologist and is currently considered as the father of modern ophthalmology. Conditions like heterochromic uveitis and endothelial dystrophy were discovered by Fuchs and a series of ocular diseases are named after him. His work dealing with eye pathology, entitled: "Textbook of Ophthalmology", became known as the masterpiece of the 19th century ophthalmology. In ocular oncology, Fuchs introduced first the "sarcom des uvealtractus" (uveal sarcoma), known today as uveal melanoma. His treatment approach by enucleation was in vogue for more than 100 years, while his theory for hepatic metastasis of ocular cancer remains valid.

Association of Plasma Cortisol Levels with Clinical Characteristics of Suicide Attempters.

OBJECTIVE: There is evidence that suicidal behavior, among others, is an abnormal response to stress caused by a dysfunction in the activity of hypothalamus-pituitary-adrenal axis, and that cortisol levels are low in a considerable number of people attempting suicide. In this study, we aimed to search for associations of plasma cortisol levels with the clinical characteristics of a group of psychiatric suicide attempters. METHOD: The cortisol was measured in the morning in 200 psychiatric patients hospitalized after a suicide attempt, with diagnoses of major depressive disorder, bipolar disorder, psychosis, and personality/adjustment disorder, and compared to the levels of 138 healthy controls. Comparisons were also made for diagnostic subgroups and across diagnoses, with regard to depressive symptomatology, mode of attempt, suicide intent, number of attempts, and age. RESULTS: Cortisol levels were significantly lower for the whole group of attempters compared to controls. Furthermore, low cortisol levels characterized attempters with personality/adjustment disorder, higher depressive symptomatology, low suicide intent, non-violent attempt mode, repeated attempts, and of younger age. CONCLUSIONS: Certain clinical characteristics were identified in attempters with low cortisol levels. In previous studies, low cortisol levels have been associated with impairments in cognitive control, decision-making, and emotional processing that may lead, in the presence of stressors, to suicidal behavior, frequently with non-fatal outcome. Adding plasma cortisol levels to demographic and psychopathological data may help in identifying a subpopulation of attempters with neurocognitive deficits linked to dysfunction of Hypothalamic-Pituitary-Adrenal-axis activity, with implications for treatment.

Clinical and treatment-related predictors of cognition in bipolar disorder: focus on visual paired associative learning.

Bipolar disorder (BD) is associated with impairment in cognitive domains such as verbal memory and executive functions. However, visual paired associative learning (PAL) has been far less researched. Neurocognitive dysfunction in BD patients has been related to several clinical factors, but data on the effect of medication are relatively scarce and inconsistent. The aim of our study was to explore the effect of clinical and treatment-related parameters on executive functions and visual memory/learning, including PAL, in BD. Cognitive performance of 60 bipolar I patients and 30 healthy subjects was evaluated by using CANTAB battery tasks targeting spatial recognition memory, PAL and executive functions (set shifting, planning, inhibitory control). Bipolar patients showed poorer performance in PAL, set shifting, planning and inhibitory control than healthy subjects; however, only differences in PAL and planning survived correction for multiple comparisons. Number of previous manic episodes and illness duration predicted worse performance in set shifting and PAL, respectively, whereas current treatment with valproate predicted better performance in PAL. This is one of the first studies to assess clinical and treatment-related predictors of PAL in BD. We report a possibly beneficial effect of valproate on PAL, which warrants further investigation.

Islam, mental health and law: a general overview.

Islam is the dominant religion in about 56 countries around the globe, and has more than 1.2 billion followers. Islam represents a holistic way of life, and according to a large proportion of its followers, the Islamic law or Shari'ah should prevail over secular law and should be implemented as state law. The etymological root of the word Shari'ah can be traced back to the harsh life in the desert and it means "pathway to be followed" or "path to the water hole," since the water was the basic element and preserver of life. At the dawn of its historical course and at its moral and ethical core, Islam introduced many interesting and innovative beliefs concerning the mentally ill. Islam underlines the moral necessity for the protection and care of the vulnerable individuals, as dictated by God himself. On the other hand, beliefs about "possession" and stigmatization influence the peoples' attitude against and apprehension of mental disorders. This strange admixture is reflected upon the status of the mental health services and corresponding legislation found in the different countries of the Islamic world.

Body mass index and plasma leptin in psychiatric suicide attempters.

OBJECTIVES: To evaluate body mass index (BMI) and its correlate plasma leptin levels that have been associated with psychiatric morbidity and suicidal behaviour, in relation to clinical features in psychiatric patients after a suicide attempt. METHODS: BMI and plasma leptin were assessed in 198 patients (66 males, age range of 21 to 80 years) who were admitted to the hospital after a suicide attempt, 98 with major depressive disorder, 28 with bipolar disorder, 30 with psychosis, and 42 with personality or adjustment disorder, compared to data of 134 healthy subjects, and evaluated in relation to gender, diagnosis, mode of attempt, and pharmacological treatment before attempt. The ratio leptin/BMI was used as a measure of adipocyte leptin secreting activity. RESULTS: Drugs taken for treatment before attempt, among them atypical neuroleptics, were not associated either to BMI or to plasma leptin. The positive correlation between BMI and leptin was significant in all groups. Compared to same gender controls, significant differences were found only for female patients, namely higher BMI for patients with psychosis and patients with bipolar disorder, while leptin/BMI ratio was higher only in females with bipolar disorder. CONCLUSION: BMI and plasma leptin in psychiatric suicide attempters are elevated in certain diagnostic groups in females, not related to previous pharmacologic treatment. The lack of a control group without a history of suicide attempts does not allow the attribution of enhanced leptin secreting activity found in female bipolar attempters specifically to suicidal behavior or to the disorder as a diagnostic entity.

Smoking reduction in psychiatric inpatients is feasible: results from a 12-month prospective study.

BACKGROUND: Despite the fact that smoking is a crucial morbidity factor among psychiatric patients, little progress has been made in order to reduce smoking during psychiatric hospitalization. METHODS: We studied the smoking behaviour of patients admitted to a non-smoking psychiatric ward, after monitoring them for smoking habits and helping them cope in order to modify their smoking behaviour. For a period of 12 months, we conducted a prospective study of simple smoking avoidance measures in the 2nd Department of Psychiatry of Attikon University Hospital in Athens. RESULTS: From 330 admitted patients, 170 (51.5%) were smokers; they were monitored for their smoking habits and encouraged by the nursing staff to reduce smoking. The mean number of cigarettes per day (CPD) at admission was 32.2 (sd 22.1) and upon discharge 14.1 (sd 14.8) (t = 11.7, p < 0.001). Most of the smokers, 142 (83.5%), managed to reduce their cigarette consumption per day. Diagnosis did not affect the reduction or increase in CPD. The only factor that predicted reduction in CPD was the female sex. CONCLUSIONS: Our findings indicate that seriously mentally ill psychiatric inpatients despite negative preconceptions and stereotypes respond well to simple measures aiming to reduce their smoking and modify their behaviour.

Neurotoxic syndrome induced by clomipramine plus risperidone in a patient with autistic spectrum disorder: serotonin or neuroleptic malignant syndrome?

To the best of our knowledge, there are no case studies of serotonin syndrome (SS) in patients with autism spectrum disorder. We report the case of a 33-year-old male who presented SS under the combined use of clomipramine and risperidone. More specifically, within 2 days after clomipramine (10 mg/BID-two times a day) was added to risperidone (4 mg/OD-once a day), mirtazapine 45 mg/OD and alprazolam (0,5 mg/TID-three times a day) he began to present mental, neurological and autonomic symptoms. All his psychopathological manifestations and laboratory findings normalized after the above-mentioned drugs' discontinuation, and the administration of supportive medical care and lorazepam 2,5 mg/TID. The diagnosis of serotonin syndrome was challenging due to the relatively low dose of clomipramine, an increase of risperidone which had taken place before clomipramine administration and clinical symptoms which could be attributed to both serotonin and neuroleptic malignant syndrome.

Sacred psychiatry in ancient Greece.

From the ancient times, there are three basic approaches for the interpretation of the different psychic phenomena: the organic, the psychological, and the sacred approach. The sacred approach forms the primordial foundation for any psychopathological development, innate to the prelogical human mind. Until the second millennium B.C., the Great Mother ruled the Universe and shamans cured the different mental disorders. But, around 1500 B.C., the predominance of the Hellenic civilization over the Pelasgic brought great changes in the theological and psychopathological fields. The Hellenes eliminated the cult of the Great Mother and worshiped Dias, a male deity, the father of gods and humans. With the Father's help and divinatory powers, the warrior-hero made diagnoses and found the right therapies for mental illness; in this way, sacerdotal psychiatry was born.

Alexithymia, anxiety and depression in patients with psoriasis: a case-control study.

BACKGROUND: Alexithymia, the difficulty in describing or recognizing emotions, has been associated with various psychosomatic pathologies including psoriasis. The aim of this study was to examine the prevalence of alexithymia and its association with anxiety and depression in patients with psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables. METHODS: One hundred and eight psoriatic patients and 100 healthy participants from the general population completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS). The severity of patients' psoriasis was clinically assessed using the Psoriasis Area and Severity Index (PASI). RESULTS: Psoriatic patients had higher levels of alexithymia compared with healthy participants. While a rather high rate of psoriatic patients presented anxiety and depression as defined by the HADS, the differences that were found in comparison with the control group were not significant. Neither alexithymia nor its dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT), were associated with gender or psoriasis severity. Age was associated only with EOT, which was independent of depression and anxiety. Higher anxiety and depression were connected with higher alexithymia and DIF, while higher anxiety with higher DDF as well. CONCLUSIONS: The alexithymia prevalence was higher in psoriatic patients than that in healthy participants, while it was positively correlated with anxiety and depression. Difficulty in identifying feelings was connected with both anxiety and depression, whereas difficulty in describing them was only with anxiety. Finally, externally oriented thinking was predicted only from age.

Family in Crisis: Do Halfway Houses Perform Better Than Families with Expressed Emotion toward Patients with Schizophrenia? A Direct Adjusted Comparison.

Expressed emotion (EE) toward patients with schizophrenia is typically reported to be lower in psychiatric halfway houses than in families. This is the first study directly comparing EE between these settings and investigating the pathways mediating EE differences. We included 40 inpatients in halfway houses and 40 outpatients living with their families and recorded 22 psychiatric nurses' and 56 parents' EE, respectively, through Five Minutes Speech Samples. Each inpatient was rated by 2-5 nurses and each outpatient by 1-2 parents. As EE ratings had a multilevel structure, generalized linear mixed models were fitted, adjusting for patient-related confounders and caregiver demographics. Mediatory effects were investigated in multilevel structural equation models. Outpatients were younger, less chronic, and better educated, with higher negative symptoms and perceived criticism than inpatients. Nurses were younger and better educated than parents. Before adjustment, EE rates were equally high across settings. After adjusting for patient-related confounders, emotional overinvolvement was significantly higher in parents. However, after also adjusting for caregiver demographics, only criticism was significantly higher in nurses. Patients' age, negative symptoms, and perceived criticism and caregivers' age and sex significantly mediated EE group differences. Our findings highlight pathways underlying EE differences between halfway houses and families and underscore the importance of staff and family psychoeducation.