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issn:1744-859
1.  Intestinal obstruction in a mentally retarded patient due to pica 
A 40-year-old mentally retarded Japanese man was admitted at rehabilitation facility for handicapped persons and found dead in his bed. His neonatal period was complicated by seizures, and he had a medical history of schizophrenia. A postmortem computed tomography scan suggested an intestinal obstruction, but the cause was unknown. To clarify the cause of death, a medicolegal autopsy was carried out. The gastrointestinal tract was found to contain copious amounts of cloth pieces. A diagnosis of intestinal obstruction secondary to pica of clothes was made. Despite still being an essentially neglect condition; mental retardation is cause to significant burden to the patient, his relatives and caregivers and the whole society. Moreover, people with mental retardation may be at increased risk for potentially self-injury due to ingestion of non-eating substance or incongruent intake of eating substances, which may on turn lead to severe or even life-threatening medical and surgical complications as herein reported. Specific attention also to pica in mentally-retarded patients with sudden, severe, gastrointestinal events, should therefore be placed in order to prevent potential death or otherwise severe chronic consequences, ideally aiming at enhancing the early recognition and multi-disciplinary management of those psychological stressors or triggers potentially responsible for pica too.
doi:10.1186/s12991-015-0060-4
PMCID: PMC4521501
Intestinal obstruction; Mental retardation; Pica; Autopsy imaging; Postmortem computed tomography
2.  Food insecurity in adults with mood disorders: prevalence estimates and associations with nutritional and psychological health 
Background
Because little is known about food insecurity in people with mental health conditions, we investigated relationships among food insecurity, nutrient intakes, and psychological functioning in adults with mood disorders.
Methods
Data from a study of adults randomly selected from the membership list of the Mood Disorder Association of British Columbia (n = 97), Canada, were analyzed. Food insecurity status was based on validated screening questions asking if in the past 12 months did the participant, due to a lack of money, worry about or not have enough food to eat. Nutrient intakes were derived from 3-day food records and compared to the Dietary Reference Intakes (DRIs). Psychological functioning measures included Global Assessment of Functioning, Hamilton Depression scale, and Young Mania Rating Scale. Using binomial tests of two proportions, Mann–Whitney U tests, and Poisson regression we examined: (1) food insecurity prevalence between the study respondents and a general population sample from the British Columbia Nutrition Survey (BCNS; n = 1,823); (2) differences in nutrient intakes based on food insecurity status; and (3) associations of food insecurity and psychological functioning using bivariate and Poisson regression statistics.
Results
In comparison to the general population (BCNS), food insecurity was significantly more prevalent in the adults with mood disorders (7.3% in BCNS vs 36.1%; p < 0.001). Respondents who were food-insecure had lower median intakes of carbohydrates and vitamin C (p < 0.05). In addition, a higher proportion of those reporting food insecurity had protein, folate, and zinc intakes below the DRI benchmark of potential inadequacy (p < 0.05). There was significant association between food insecurity and mania symptoms (adjusted prevalence ratio = 2.37, 95% CI 1.49–3.75, p < 0.05).
Conclusions
Food insecurity is associated with both nutritional and psychological health in adults with mood disorders. Investigation of interventions aimed at food security and income can help establish its role in enhancing mental health.
doi:10.1186/s12991-015-0059-x
PMCID: PMC4504128  PMID: 26185523
Food insecurity; Nutrient intakes; Mood disorders
3.  Automatic processing of facial affects in patients with borderline personality disorder: associations with symptomatology and comorbid disorders 
Background
Instability of affects and interpersonal relations are important features of borderline personality disorder (BPD). Interpersonal problems of individuals suffering from BPD might develop based on abnormalities in the processing of facial affects and high sensitivity to negative affective expressions. The aims of the present study were to examine automatic evaluative shifts and latencies as a function of masked facial affects in patients with BPD compared to healthy individuals. As BPD comorbidity rates for mental and personality disorders are high, we investigated also the relationships of affective processing characteristics with specific borderline symptoms and comorbidity.
Methods
Twenty-nine women with BPD and 38 healthy women participated in the study. The majority of patients suffered from additional Axis I disorders and/or additional personality disorders. In the priming experiment, angry, happy, neutral, or no facial expression was briefly presented (for 33 ms) and masked by neutral faces that had to be evaluated. Evaluative decisions and response latencies were registered. Borderline-typical symptomatology was assessed with the Borderline Symptom List.
Results
In the total sample, valence-congruent evaluative shifts and delays of evaluative decision due to facial affect were observed. No between-group differences were obtained for evaluative decisions and latencies. The presence of comorbid anxiety disorders was found to be positively correlated with evaluative shifting owing to masked happy primes, regardless of baseline—neutral or no facial expression condition. The presence of comorbid depressive disorder, paranoid personality disorder, and symptoms of social isolation and self-aggression were significantly correlated with response delay due to masked angry faces, regardless of baseline.
Conclusions
In the present affective priming study, no abnormalities in the automatic recognition and processing of facial affects were observed in BPD patients compared to healthy individuals. The presence of comorbid anxiety disorders could make patients more susceptible to the influence of a happy expression on judgment processes at an automatic processing level. Comorbid depressive disorder, paranoid personality disorder, and symptoms of social isolation and self-aggression may enhance automatic attention allocation to threatening facial expressions in BPD. Increased automatic vigilance for social threat stimuli might contribute to affective instability and interpersonal problems in specific patients with BPD.
doi:10.1186/s12991-015-0058-y
PMCID: PMC4499878  PMID: 26170894
Borderline personality disorder; Affective priming; Automatic processing; Perception; Facial expression; Anger; Evaluative judgment; Attention allocation
4.  Psychosocial treatment and interventions for bipolar disorder: a systematic review 
Background
Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Several psychotherapeutic techniques have tried to fill this gap, but which intervention is suitable for each patient remains unknown and it depends on the phase of the illness.
Methods
The papers were located with searches in PubMed/MEDLINE through May 1st 2015 with a combination of key words. The review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.
Results
The search returned 7,332 papers; after the deletion of duplicates, 6,124 remained and eventually 78 were included for the analysis. The literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and only in a selected subgroup of patients at an early stage of the disease who have very good, if not complete remission, of the acute episode. Cognitive-behavioural therapy and interpersonal and social rhythms therapy could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes.
Conclusion
The current review suggests that the literature supports the usefulness only of specific psychosocial interventions targeting specific aspects of BD in selected subgroups of patients.
doi:10.1186/s12991-015-0057-z
PMCID: PMC4493813  PMID: 26155299
5.  Treatment of puberty trichotillomania with low-dose aripiprazole 
The present case is of a 14-year-old female with trichotillomania (TTM) that was treated with a low dose of aripiprazole (ARP) 1.5 mg/day. To our knowledge, this is the first published report to show an improvement of pubertal TTM using an ultra-low dose of ARP. In this case, a 50-mg fluvoxamine monotherapy for 2 years and a subsequent 4-month comprehensive cognitive behavioral therapy (CBT) monotherapy did not improve her hair-pulling symptoms. However, the treatment with a low-dose ARP of 1.5 mg/day dramatically improved her TTM symptoms without extrapyramidal symptoms. In this regard, low-dose ARP treatment for TTM might be a safe alternative to antidepressants, which carry the risk of agitation with suicidal ideation in adolescents.
doi:10.1186/s12991-015-0056-0
PMCID: PMC4472163  PMID: 26089954
Trichotillomania; Aripiprazole; Puberty
6.  Differences between subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia: a qualitative pilot study 
Background
In cases of untreated schizophrenia, the patients’ entourage often does not recognize the psychotic symptoms of the patient and the possibility that the patient may attempt suicide. The aim of this study was to investigate the discrepancies between the subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia.
Methods
A semi-structured interview was carried out with seven near-fatal suicide attempters with untreated schizophrenia to examine the subjective experiences at the time of the suicide attempt. The families of the patients were also interviewed to determine their recognition of the patients’ psychotic symptoms and the suicidal ideation. The interview data were analyzed qualitatively.
Results
Six subjects were undergoing exacerbation of the psychotic symptoms at the time of exhibiting the suicide-related ideation. One subject had been in a prolonged depressive state before attempting suicide. Although all the patients experienced severe distress due to psychotic symptoms and depressive mood, they all exhibited only low level or no help-seeking behavior, and six of seven families had not recognized the change in the patient’s mental condition.
Conclusions
Appropriate information about schizophrenia should be provided to the general public so that any help-seeking by the patients with this disease is not overlooked. In addition, accessible early intervention services for psychosis should be established.
doi:10.1186/s12991-015-0055-1
PMCID: PMC4405822  PMID: 25904969
Untreated schizophrenia; Suicide; Help-seeking; Family; Psychoeducation
7.  Risky HIV sexual behaviour and depression among University of Nairobi students 
Background
Prevalence rates of human immunodeficiency virus (HIV) infection among the youth are disproportionately high compared to that of other age groups in Kenya. Poor mental health has been linked to risky HIV behaviour, yet few local studies have explored these aspects. This study sought to determine associations between HIV risky sexual behaviour and depression among undergraduate students at the University of Nairobi.
Method
A random sample of 923 (525 males and 365 females) undergraduate students was interviewed using a questionnaire to record sociodemographic variables and risky sexual behaviour including having multiple sexual partners, inconsistent condom use and engaging in sex after drinking. Depressive symptoms were measured using the Centre for Epidemiological Studies Short Depression Scale (CES-D 10).
Results
The students’ mean age was 23 years (s.d.4.0). Overall, 41.33% of the students scored above the cut-off point of 10 on the CES-D 10 scale, with 35.71% having moderate symptoms and 5.62% having severe depressive symptoms. The percentage of those who had ever been diagnosed with sexually transmitted infections (STIs) was 9.71% (males 8.65%; females 11.01%); and for HIV 3.04% (males 2.02%; females 4.05%). Nearly 30% reported having had multiple partners in the previous 12 months, 27.4% of the students did not use condoms with sexual partners and 21% had engaged in sex after drinking within the previous 3 months. In multivariable-bivariate logistic regression, being older, having depressive symptoms, alcohol use/binge drinking, tobacco use, sex after drinking, previous diagnosis of STI, physical abuse, sexual coercion and history of sexual abuse as a child were significantly associated with having multiple partners. Further, younger age, being female, tobacco use and previous diagnosis of STI were significantly associated with inconsistent condom use.
Conclusion
The prevalence of HIV rate infection is low compared to the national average but risky sexual behaviour is common among the students and is positively linked to depressive symptoms among other factors. Programmes aimed at HIV prevention should be integrated with mental health interventions.
doi:10.1186/s12991-015-0054-2
PMCID: PMC4396741  PMID: 25873984
Students; Depression; Risky sexual behaviour; HIV
8.  Revisiting loxapine: a systematic review 
Loxapine is an antipsychotic used in psychiatry for over 40 years with a well-established profile. Loxapine is a dibenzoxazepine tricyclic antipsychotic agent, available for oral, intramuscular and inhalatory administration. In the light of the recent approval by the regulatory agencies of inhaled loxapine for use in the acute treatment of mild-to-moderate agitation in adults affected with schizophrenia or bipolar disorder, this article aims to critically review the available literature on loxapine, irrespective of its formulation.
This review examines the efficacy and tolerability of the various formulations of loxapine in the treatment of agitation and aggression in patients affected with schizophrenia, bipolar disorder and other psychiatric conditions.
A comprehensive and systematic literature search of PubMed/MEDLINE was conducted, and relevant pharmacodynamic and pharmacokinetic data was included. The findings from the literature were critically reviewed and synthesized.
The available data suggests that the antipsychotic efficacy of loxapine is similar to the efficacy of other typical or atypical antipsychotics, with an adverse effects profile comparable to that of the typical antipsychotics at high doses for chronic treatment. As an acute treatment in agitation associated with schizophrenia or bipolar disorder, inhaled loxapine was developed as an innovative and rapid option which appears to be efficacious and tolerable.
Electronic supplementary material
The online version of this article (doi:10.1186/s12991-015-0053-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12991-015-0053-3
PMCID: PMC4391595  PMID: 25859275
Loxapine; Antipsychotic; Agitation; Bipolar disorder; Schizophrenia
9.  Saliva secretion disorder in a schizophrenic patient - a problem in dental and psychiatric treatment: a case report 
Objective
Saliva secretion disorder may appear in patients at any age and represents a serious problem in interdisciplinary treatment. It is manifested by hyposecretion or hypersecretion of saliva. One of the major groups of patients who have been diagnosed with saliva secretion disorder includes those treated with neuroleptics. Among patients taking neuroleptics, schizophrenic patients represent the least cooperative group in terms of doctor-patient relationship. Schizophrenia is a mental disorder exacerbated by uncontrolled neuroleptic dose reduction or regardless of applied pharmacotherapy.
Method
This paper presents a clinical case of a 30-year-old schizophrenic patient with saliva secretion problems.
Results
In schizophrenia, thought disorders (TD) and social functioning impairment have a negative impact on patients’ somatic health care. Saliva hyposecretion and its health consequences, such as parodontitis and caries, are the reasons why the patients decide to have a dental appointment.
Conclusion
This paper contains important information for dentists, psychiatrists, and psychologists, as it raises an issue of a proper interdisciplinary care approach provided to schizophrenic patients. It emphasises the importance of psychoeducation and draws attention to social functioning of mentally ill patients.
doi:10.1186/s12991-015-0052-4
PMCID: PMC4373030  PMID: 25810747
Dental plaque; Neuroleptic; Saliva secretion; Schizophrenia
10.  Intractable hiccups (singultus) abolished by risperidone, but not by haloperidol 
Hiccups or singulata are rhythmic involuntary movements of the diaphragm, caused by a variety of conditions that interfere with the functions of the nerve nuclei in the medulla and supra-spinal hiccup center. Although neurotransmitters and receptors involved in the pathophysiology of hiccups are not defined well, dopamine has been considered to play an important role. In some cases, chlorpromazine or other antipsychotics are used for the treatment of intractable hiccups but their efficacy is often limited. This report involves an 18-year-old patient who experienced two episodes of intractable hiccups triggered by stress, which lasted for weeks or even months. In both episodes, haloperidol was initially used, but there was no significant effect. In contrast, risperidone, the second-generation antipsychotic that possesses a dopamine-serotonin antagonist property, completely abolished the hiccups 6 hours after administration. This is one of few case reports in which two antipsychotics were challenged for a single patient with hiccups, and the effects of the drugs were obviously different. Our finding suggests that, in addition to dopaminergic system, the serotonergic systems may be involved in the pathophysiology of some hiccup cases and that the serotonin-acting antipsychotics such as risperidone should be considered as a choice in the drug treatment of intractable hiccups.
doi:10.1186/s12991-015-0051-5
PMCID: PMC4355965  PMID: 25763097
Hiccups; Dopamine; Serotonin; Antipsychotic; Risperidone
11.  The effect of dietary education on ADHD, a randomized controlled clinical trial 
Background
The purpose of this research was to study the effectiveness of the overall dietary intervention rather than a single nutrient on children with attention deficit hyperactivity disorder (ADHD).
Methods
This is a randomized controlled trial conducted at a child psychiatry clinic in Iran. Participants were 106 children and adolescents with ADHD.
One group received methylphenidate plus dietary recommendations, while the other group only received methylphenidate. ADHD DSM-IV checklist was used to assess inattentiveness and hyperactivity/impulsivity scores at baseline and at the end of the trial.
Results
The results revealed no significant difference between the two groups regarding mean age, gender ratio, body mass index, baseline inattentiveness score, and baseline hyperactivity score. Linear regression analysis considering the covariant variables showed that the inattentive score at the end of the trial was significantly associated with the mean change of favorite diet scores.
Conclusion
This is the first clinical trial examining the effect of overall dietary characteristics rather than a single nutrient on the children formally diagnosed with ADHD. According to the results, un-favorite diet had no effects on inattentive or hyperactivity/impulsivity score. Encouraging the children with ADHD to increase their intake of recommended diet markedly improves their attention.
Trial registration
The trial was registered at the Iranian Clinical Trials Registry (Irct ID: IRCT201311303930N29).
doi:10.1186/s12991-015-0050-6
PMCID: PMC4357187  PMID: 25767556
ADHD; Attention; Diet; Clinical trial; Sugar; Cacao; Artificial food color
12.  The development and trial of a medication discontinuation program in the department of forensic psychiatry 
Background
When treating mentally ill criminal offenders, improving medication adherence is essential to achieving goals, such as long-term stabilization of symptoms and the prevention of recidivism. Most subjects who are treated under the Medical Treatment and Supervision Act have schizophrenia, which is considered a particularly difficult disorder for which to improve medication adherence. For such patients, we developed a Medication Discontinuation Program (MDP) that aims to improve medication adherence by discontinuing antipsychotic drugs and monitoring changes in psychiatric symptoms. We examined whether there was any utility for the MDP on a trial basis as well as whether it would be worthwhile to introduce the MDP to psychiatric programs.
Methods
We conducted the MDP with an intervention group (n = 7) and compared Drug Attitude Inventory-30 (DAI-30) scores before and after implementation of the MDP. We also categorized 30 questions of the DAI-30 into three subscales: “awareness of the need for medication”, “awareness of the effects of psychiatric drugs”, and “impression of medication”, and examined factors affecting improvement in medication adherence.
Results
The total DAI-30 score significantly increased after completion of the MDP (P = 0.002). Significant elevations after completion of the MDP were also observed in the scores for three subscales of the DAI-30.
Conclusions
Our study suggests that the MDP has a possibility of improving medication adherence, and this program might have multidirectional and stimulatory effects on each factor related to the improvement of medication adherence.
doi:10.1186/s12991-015-0049-z
PMCID: PMC4363327  PMID: 25788969
Medical Treatment and Supervision Act; Adherence; Medication Discontinuation Program; Schizophrenia; Drug Attitude Inventory-30
13.  Computer-assisted cognitive behavior therapy for obsessive-compulsive disorder: a randomized trial on the impact of lay vs. professional coaching 
Background
The purpose of the study was to examine the impact of computerized cognitive behavior therapy (CBT) self-help treatment for obsessive-compulsive disorder (OCD) (BT Steps) both alone and when supported by coaching from either a lay non-therapist coach or an experienced CBT therapist.
Methods
Eighty-seven subjects with clinically significant OCD were recruited through newspaper ads and randomly assigned to receive 12 weeks of treatment with either BT Steps alone (n = 28), BT Steps with non-therapist coaching (n = 28), or BT Steps with CBT therapist coaching (n = 31). Subjects worked on BT Steps at their own pace. Subjects receiving BT Steps alone received a welcome call from the project manager. Subjects randomized to either of the coaching arms received regularly scheduled weekly phone calls for coaching, encouragement, and support. No formal therapy was provided by the coaches; thus, both lay and CBT coaches completed the same tasks.
Results
All three treatment arms showed a significant reduction in Yale-Brown Obsessive Compulsive Scale (YBOCS) scores, with mean (SD) changes of 6.5 (5.7), 7.1 (6.1), and 6.5 (6.1) for the no coaching, lay coaching, and therapist coaching arms, respectively (all p’s < .001). These represent effect sizes of 1.16, 1.41, and 1.12, respectively. No significant differences were found between treatment arms on YBOCS change scores, F(2) = 0.10, p = .904, or number of exposures sessions done (F(2) = 0.033, p = .967). When asked which method of therapy (computer vs. clinician) they preferred, 48% said computer, 33% said face-to-face therapy, and 19% had no preference.
Conclusions
Results support the use of online self-help for the treatment of moderate OCD. The addition of coaching by either a lay coach or a CBT therapist coach did not significantly improve outcomes.
doi:10.1186/s12991-015-0048-0
PMCID: PMC4341882  PMID: 25722737
Computerized self-instruction program; Cognitive behavior therapy; Obsessive compulsive disorder
14.  Annals of general psychiatry reviewer acknowledgement 2014 
Contributing reviewers
The editors of Annals of General Psychiatry would like to thank all of our reviewers who have contributed to the journal in volume 13 (2014).
doi:10.1186/s12991-015-0044-4
PMCID: PMC4333244  PMID: 25699087
15.  Dromokaition Psychiatric Hospital of Athens: from its establishment in 1887 to the era of deinstitutionalization 
Dromokaition Psychiatric Hospital opened its doors in 1887, following the donation made by Zorzis Dromokaitis from the island of Chios. Private donations and all forms of charities had contributed to a large extent in the establishment of hospitals across Greece, during the late 19th and the early 20th century. Dromokaition was one of them but it was also unique, as it was the first psychiatric hospital in Athens, admitting patients from every part of the country. This paper aimed at highlighting the long service of the institution through the different historical periods the country went through. We present the chronicle of its foundation, the development of its inner structure, and the medical and organizational influences which it received, along the way. The therapeutic methods used during the first decades of its operation reflected the corresponding European standards of the time. As a model institution from its foundation, it followed closely the prevailing European guidelines, throughout its historical path, either as an independent institution or as an integrated one within the National Health Service.
doi:10.1186/s12991-015-0047-1
PMCID: PMC4332453  PMID: 25694790
Dromokaition Psychiatric Hospital; Internment; Biological psychiatry; Psychosurgery; Occupational therapy; Deinstitutionalization; Private donation
16.  Adjuvant low-frequency rTMS in treating auditory hallucinations in recent-onset schizophrenia: a randomized controlled study investigating the effect of high-frequency priming stimulation 
Background
Repetitive transcranial magnetic stimulation (rTMS) has been found to be effective in reducing frequency and duration of auditory verbal hallucinations (AVH). Priming stimulation, which involves high-frequency rTMS stimulation followed by low-frequency rTMS, has been shown to markedly enhance the neural response to the low-frequency stimulation train. However, this technique has not been investigated in recent onset schizophrenia patients. The aim of this randomized controlled study was to investigate whether the effects of rTMS on AVH can be enhanced with priming rTMS in recent onset schizophrenia patients.
Methods
Forty recent onset schizophrenia patients completed the study. Patients were randomized over two groups: one receiving low-frequency rTMS preceded by priming and another receiving low-frequency rTMS without priming. Both treatments were directed at the left temporo-parietal region. The severity of AVH and other psychotic symptoms were assessed with the auditory hallucination subscale (AHRS) of the Psychotic Symptom Rating Scales (PSYRATS), the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI).
Results
We found that all the scores of these ratings significantly reduced over time (i.e. baseline through 1, 2, 4 and 6 weeks) in both the treatment groups. We found no difference between the two groups on all measures, except for significantly greater improvement on loudness of AVH in the group with priming stimulation during the follow-ups (F = 2.72; p < .05).
Conclusions
We conclude that low-frequency rTMS alone and high-frequency priming of low-frequency rTMS do not elicit significant differences in treatment of overall psychopathology, particularly AVH when given in recent onset schizophrenia patients. Add on priming however, seems to be particularly better in faster reduction in loudness of AVH.
doi:10.1186/s12991-015-0046-2
PMCID: PMC4333242  PMID: 25699086
Schizophrenia; Priming TMS; Transcranial magnetic stimulation; Auditory verbal hallucinations; Randomized controlled trial; Recent onset
17.  Clinical Global Impression-severity score as a reliable measure for routine evaluation of remission in schizophrenia and schizoaffective disorders 
Aims
This study aimed to compare the performance of Positive and Negative Syndrome Scale (PANSS) symptom severity criteria established by the Remission in Schizophrenia Working Group (RSWG) with criteria based on Clinical Global Impression (CGI) severity score. The 6-month duration criterion was not taken into consideration.
Methods
A convenience sample of 112 chronic psychotic outpatients was examined. Symptomatic remission was evaluated according to RSWG severity criterion and to a severity criterion indicated by the overall score obtained at CGI-Schizophrenia (CGI-SCH) rating scale (≤3) (CGI-S).
Results
Clinical remission rates of 50% and 49.1%, respectively, were given by RSWG and CGI-S, with a significant level of agreement between the two criteria in identifying remitted and non-remitted cases. Mean scores at CGI-SCH and PANSS scales were significantly higher among remitters, independent of the remission criteria adopted. Measures of cognitive functioning were largely independent of clinical remission evaluated according to both RSWG and CGI-S. When applying RSWG and CGI-S criteria, the rates of overall good functioning yielded by Personal and Social Performance scale (PSP) were 32.1% and 32.7%, respectively, while the mean scores at PSP scale differed significantly between remitted and non-remitted patients, independent of criteria adopted. The proportion of patients judged to be in a state of well-being on Social Well-Being Under Neuroleptics-Short Version scale (SWN-K) were, respectively, 66.1% and 74.5% among remitters according to RSWG and CGI-S; the mean scores at the SWN scale were significantly higher only among remitters according to CGI-S criteria.
Conclusions
CGI severity criteria may represent a valid and user-friendly alternative for use in identifying patients in remission, particularly in routine clinical practice.
doi:10.1186/s12991-015-0042-6
PMCID: PMC4332923  PMID: 25699085
18.  Prognostic influence of witness/victim experiences and PTSD-specific symptoms on working and educational capacity: a comparison between two groups of individuals post-trauma 
Background
Trauma exposure depends of the type of trauma and can result in the development of posttraumatic stress disorder (PTSD). The type of traumatization (such as Holocaust experiences and other sources of trauma) and specific symptoms of PTSD have influences on the outcome, and specific symptoms of PTSD influence personal and professional outcomes. Another factor is the role of the victim in their traumatization. Some patients are actively traumatized through being victims of torture, while others are passively traumatized by witnessing the traumatization of others.
Methods
We compared two groups of victim/witness trauma sufferers (PTSD vs. Holocaust-experience PTSD (HE-PTSD)) with regard to PTSD symptoms, educational and working capacity, and functional outcome parameters.
Results
HE-PTSD survivors with victim/witness trauma experience showed substantially more specific PTSD symptoms and higher symptom-specific intensities but had high social function and education levels. The intensity and type of intrusive memories and sociodemographic factors do not seem to have a prognostic influence on working or educational outcomes.
Conclusions
Identifying the combined victim/witness experience seems to play an important prognostic role in the assessment of PTSD victims. Further studies should consider these findings within other specific traumatization groups.
doi:10.1186/s12991-015-0045-3
PMCID: PMC4329647  PMID: 25688282
PTSD symptoms; Educational/working capacity; Prognostic outcome
19.  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.
doi:10.1186/s12991-015-0043-5
PMCID: PMC4328044  PMID: 25685172
Psychiatric inpatients; Smoking reduction; Nursing intervention
20.  How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study 
Background
Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners’ (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription.
Methods
This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs’ age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis.
Results
The high prescribers were middle-aged (40–59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs’ workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population.
Conclusions
Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP’s practice.
Electronic supplementary material
The online version of this article (doi:10.1186/s12991-015-0041-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12991-015-0041-7
PMCID: PMC4308843  PMID: 25632295
Antidepressants; General practice; General practitioners; Cross-sectional study; Pharmaco-epidemiology
21.  Long-term efficacy and tolerability of quetiapine in patients with schizophrenia who switched from other antipsychotics because of inadequate therapeutic response—a prospective open-label study 
Background
While the frequency and importance of antipsychotic switching in patients with schizophrenia, there is insufficient evidence with regard to switching strategy. Quetiapine is one of the drugs of choice for switch because of its unique receptor profile. However, there were no data on the long-term clinical and neurocognitive effect of quetiapine in patients who had responded inadequately to prior antipsychotics. The purpose of this study is to examine the long-term efficacy and tolerability of quetiapine in patients with schizophrenia who switched from other antipsychotics because of inadequate therapeutic response. We hypothesized that quetiapine would show long-term effectiveness in broad symptom dimensions including negative and neurocognitive symptoms while having good tolerability.
Methods
Twenty-nine subjects with schizophrenia who did not respond to their current monotherapy of antipsychotic or who could not tolerate the treatment were switched to quetiapine and assessed at baseline and at 3, 6, and 12 months. The outcome measures included the brief assessment of cognition in schizophrenia (BACS), the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impressions Scale (CGI), the Schizophrenia Quality of Life Scale Japanese version (JSQLS), the Athens Insomnia Scale (AIS), and the Drug Attitude Inventory with 30 items (DAI-30). The Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS), HbA1c, prolactin (PRL), and body weight were also evaluated.
Results
Statistically significant improvements were observed in all subscores of the PANSS, the GAF, and the symptoms and side effects subscale of the JSQLS, the DIEPSS, the AIS, and the PRL level, and nearly significant improvements were observed in the DAI-30. Quetiapine monotherapy was associated with significant improvement in the verbal memory test, even after controlling for the practice effect. Although quetiapine was well tolerated, three subjects dropped out because of the worsening of the psychotic symptoms and two additional subjects dropped out because of somnolence.
Conclusion
In this open-label, single-arm study of 29 patients, quetiapine improved both the clinical symptoms and the neurocognitive impairment in chronic schizophrenia patients who failed to respond to prior antipsychotic treatment.
Electronic supplementary material
The online version of this article (doi:10.1186/s12991-014-0039-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12991-014-0039-6
PMCID: PMC4308846  PMID: 25632293
Schizophrenia; Quetiapine; Switching; Antipsychotic; Negative symptom; Cognitive impairment; Treatment resistance
22.  Clinical and economic outcomes of adjunctive therapy with pregabalin or usual care in generalized anxiety disorder patients with partial response to selective serotonin reuptake inhibitors 
Background
This study is done to compare the effect of adjunctive therapy with pregabalin versus usual care (UC) on health-care costs and clinical and patients consequences in generalized anxiety disorder (GAD) subjects with partial response (PR) to a previous selective serotonin reuptake inhibitor (SSRI) course in medical practice in Spain.
Methods
Post hoc analysis of patients with PR to SSRI monotherapy enrolled in a prospective 6-month naturalistic study was done. PR was defined as a Clinical Global Impression (CGI) scale score ≥3 and insufficient response with persistence of anxiety symptoms ≥16 in the Hamilton Anxiety Rating Scale (HAM-A). Two groups were analyzed: 1) adjunctive therapy (AT) with pregabalin (150–600 mg/day) to existing therapy and 2) UC (switching to a different SSRI or adding another anxiolytic different than pregabalin). Costs included GAD-related health-care resources utilization. Consequences were a combination of psychiatrist-based measurements [HAM-A, CGI, and Montgomery-Asberg Depression Rating Scale (MADRS)] and patient-reported outcomes [Medical Outcomes Study Sleep (MOS-sleep) scale, disability (World Health Organization Disability Assessment Schedule II (WHO-DAS II) and quality-of-life (Euro Qol-5D (EQ-5D)]. Changes in both health-care costs and scale scores were compared separately at end-of-trial visit by a general linear model with covariates.
Results
Four hundred eighty-six newly prescribed pregabalin and 239 UC GAD patients [mean (SD) HAM-A 26.7 (6.9) and CGI 4.1 (0.5)] were analyzed. Adding pregabalin was associated with significantly higher mean (95% CI) score reductions vs. UC in HAM-A [−14.9 (−15.6; −14.2) vs. −11.2 (−12.2; −10.2), p < 0.001] and MADRS [−11.6 (−12.2; −10.9) vs. −7.8 (−8.7; −6.8), p < 0.001]. Changes in all patient-reported outcomes favored significantly patients receiving pregabalin, including quality-of-life gain; 26.4 (24.7; 28.1) vs. 19.4 (17.1; 21.6) in the EQ-VAS, p < 0.001. Health-care costs were significantly reduced in both cohorts yielding similar 6-month costs; €1,565 (1,426; 1,703) pregabalin and €1,406 (1,200; 1,611) UC, p = 0.777. The effect of sex on costs and consequences were negligible.
Conclusion
In medical practice, GAD patients with PR to SSRI experienced greater consequence improvements with adjunctive therapy with pregabalin versus UC, without increasing health-care cost. The effect of pregabalin was independent of patient gender.
doi:10.1186/s12991-014-0040-0
PMCID: PMC4308936  PMID: 25632294
Cost analysis; Generalized anxiety disorder; Pregabalin; SSRI; Partial response; Usual care; Routine medical practice
23.  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.
doi:10.1186/s12991-014-0038-7
PMCID: PMC4269099  PMID: 25520742
Alexithymia; Anxiety; Depression; Psoriasis; TAS-20
24.  Standardization of the NEO-PI-3 in the Greek general population 
Background
The revised NEO Personality Inventory (NEO-PI-3) includes 240 items corresponding to the Big Five personality traits (Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience) and subordinate dimensions (facets). It is suitable for use with adolescents and adults (12 years or older). The aim of the current study was to validate the Greek translation of the NEO-PI-3 in the general Greek population.
Material and methods
The study sample included 734 subjects from the general Greek population of whom 59.4% were females and 40.6% males aged 40.80 ± 11.48. The NEO-PI-3 was translated into Greek and back-translated into English, and the accuracy of the translation was confirmed and established. The statistical analysis included descriptive statistics, confirmatory factorial analysis (CFA), the calculation of Cronbach’s alpha, and the calculation of Pearson product–moment correlations. Sociodemographics groups were compared by ANOVA.
Results
Most facets had Cronbach’s alpha above 0.60. Confirmatory factor analysis showed acceptable loading of the facets on their own hypothesized factors and very good estimations of Cronbach’s alphas for the hypothesized factors, so it was partially supportive of the five-factor structure of the NEO-PI-3.The factors extracted with Procrustes rotation analysis can be considered reasonably homologous to the factors of the American normative sample. Correlations between dimensions were as expected and similar to those reported in the literature.
Discussion
The literature suggests that overall, the psychometric properties of NEO-PI-3 scales have been found to generalize across ages, cultures, and methods of measurement. In accord with this, the results of the current study confirm the reliability of the Greek translation and adaptation of the NEO-PI-3. The inventory has comparable psychometric properties in its Greek version in comparison to the original and other national translations, and it is suitable for clinical as well as research use.
doi:10.1186/s12991-014-0036-9
PMCID: PMC4263201  PMID: 25505930
Five-factor personality inventory; NEO-PI-3; Standardization; Psychometrics
25.  Depression and attempted suicide under pregabalin therapy 
Originally developed for the treatment of epilepsy, pregabalin has become a compound with a wide spectrum of indications comprising anxiety disorders and chronic pain and is therefore largely prescribed. Thus, it is important for clinicians to be aware of rare, but serious adverse effects. The following report illustrates the case of a 20-year-old male with a severe depressive syndrome following pregabalin medication which even led to a suicide attempt.
doi:10.1186/s12991-014-0037-8
PMCID: PMC4258812  PMID: 25489334
Depression; Anticonvulsants; Suicide; Pregabalin

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