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Brain-derived neurotrophic factor (BDNF) has a crucial function in the central nervous system and in sensory structures including olfactory and auditory systems. Many studies have highlighted the protective effects of BDNF in the brain, showing how it can promote neuronal growth and survival and modulate synaptic plasticity. On the other hand, conflicting data about BDNF expression and functions in the cochlear and in olfactory structures have been reported. Several clinical and experimental research studies showed alterations in BDNF levels in neurodegenerative diseases affecting the central and peripheral nervous system, suggesting that BDNF can be a promising biomarker in most neurodegenerative conditions, including Alzheimer’s disease, shearing loss, or olfactory impairment. Here, we summarize current research concerning BDNF functions in brain and in sensory domains (olfaction and hearing), focusing on the effects of the BDNF/TrkB signalling pathway activation in both physiological and pathological conditions. Finally, we review significant studies highlighting the possibility to target BDNF as a biomarker in early diagnosis of sensory and cognitive neurodegeneration, opening new opportunities to develop effective therapeutic strategies aimed to counteract neurodegeneration.

Since the first descriptions of superior canal dehiscence (SCD) syndrome, it has been widely demonstrated how a bony defect overlying the superior semicircular canal (SSC) can result in a low-imped...

In 1978, in Italy, approval of Basaglias reform law marked a shift from an asylum-based to a community-based mental health system. The main aim of the reform was to treat patients in the community and no longer in psychiatric hospitals. Following the Italian model, similar reforms of mental health care have been approved worldwide. The community-based model aims to promote integration and human rights for people with mental disorders on the basis of their freedom to choose treatment options. By 2000, all psychiatric hospitals had been closed and all patients discharged. Mental health care is organized through the Department of Mental Health, which is the umbrella organization responsible for specialist mental health care in the community; this includes psychiatric wards located in general hospitals, residential facilities, mental health centres, and day-hospital and day-care units. Approval of Law 180 led to a practical and ideological shift in the provision of care to patients with mental disorders. In particular, the reform highlighted the need to treat patients in the same way as any other patient, and mental health care moved from a custodialistic to a therapeutic model. Progressive consolidation of the community-based system of mental health care in Italy has been observed in the past 40 years. However, some reasons for concern still exist, including low staffing levels, potential use of community residential facilities as long-stay residential services, and a heterogeneity in the availability of resources for mental health throughout the country.

Background The 11th revision of the International Classification of Diseases and Related Disorders (ICD-11) has been released. In order to test the clinical consistency and the clinical utility of the proposed guidelines the World Health Organization (WHO) has carried out the Ecological Implementation Field Studies in various countries. In this paper the results of the Italian field trials on the clinical utility of the ICD-11 diagnostic guideline concerning schizophrenia and related disorders will be presented. Methods In Italy, field trials have been carried out at the Department of Psychiatry of the University of Campania “L. Vanvitelli”. All patients showing any psychotic symptom and referring to the outpatient and inpatient units have been recruited. Patients were interviewed by two clinicians with whom they had not had any prior clinical contact. At the end of each interview, clinicians were asked to complete 12 questions about the clinical utility of the diagnostic guidelines as applied to each patient. Results Fourteen clinicians and 100 patients have been involved. The ICD-11 clinical guidelines were perceived as easy to use, with an adequate goodness of fit, clear and understandable and with an adequate level of details and specificity to describe the essential features of the diagnoses. Clinicians rated very positively their usefulness in describing the threshold between patient’s disorder and normality. Despite still very positive, the guidelines have been perceived as less useful to select a treatment, to assess patients’ prognosis and to communicate with other mental health professionals. Conclusions The 11th revision of the chapter on Mental, Behavioural and Neurodevelopmental Disorders has made substantive changes to the conceptualization of mental disorders which could have impacted on their reliability and clinical utility. Results of the Italian field studies, in line with those reported by the international sample, highlight that ICD-11 has been rated as highly clinically useful by participating clinician, more than the ICD-10. This could be considered a good reason to be optimistic about the implementation of the ICD-11 among global clinicians. Trial registration The study has been approved by the Ethical Review Board of the University of Campania “L. Vanvitelli” (N. 416, 2016)

The COVID-19 pandemic has represented a new form of traumatic event, affecting the general population worldwide and causing severe disruption of daily routine. A new urgent concern is related to the burden associated with COVID-19 symptoms that persist beyond the onset of infection, the so-called long-COVID syndrome. The present paper aims to: (1) describe the most frequent psychiatric symptoms reported by patients affected by long-COVID syndrome; (2) evaluate methodological discrepancies among the available studies; (3) inform clinicians and policy-makers on the possible strategies to be promoted in order to manage the psychiatric consequences of long-COVID syndrome. Twenty-one papers have been included in the present review, mostly with a cross-sectional or cohort design. Significant heterogeneity of long-COVID syndrome definitions was found. The presence of psychiatric symptoms was evaluated with very different assessment tools. The most common psychiatric symptoms of the long-COVID syndrome included fatigue, cognitive disturbances/impairment, depression, and anxiety symptoms. The rate of fatigue varied from 93.2–82.3% to 11.5%, cognitive impairment/cognitive dysfunction from 61.4% to 23.5% and depressive-anxiety symptoms from 23.5%to 9.5%.

Background: The aims of the present study are to: (1) assess the frequency of maternity blues (MB); (2) identify the clinical and social characteristics more frequently associated with the onset of depressive symptoms after delivery; and (3) verify the hypothesis that the presence of maternity blues is a risk factor for the onset of a full-blown depressive episode in the 12 months after delivery.Methods: This is a longitudinal observational study. All pregnant women who gave birth at the inpatient unit of Gynecology and Obstetrics of the University of Campania “Luigi Vanvitelli” from December 2019 to February 2021 have been invited to participate in the study. Upon acceptance, women were asked to complete the Italian version of the Edinburgh Postnatal Depression Scale along with an ad-hoc questionnaire on the women's sociodemographic, gynecological and peripartum characteristics as well as their psychiatric history. Women have been reassessed after one, 3, 6 and 12 months.Results: A total of 359 women were recruited within 3 days from delivery, with a mean EPDS total score of 5.51 (±4.20). Eighty-three women (23.1%) reported the presence of maternity blues. Mean EPDS total scores were 12.8 (±0.2) in the MB group vs. 4.26 (±0.2) in the group without MB (p p p < 0.000), almost three times higher after 3 months (OR: 2.98; CI: 0.50–5.46, p < 0.01) and almost six times higher after 12 months (OR: 5.88; CI: 3.20–8.54, p < 0.000).Conclusions: Although MB was a self-limiting condition in the majority of cases, depressive symptoms arose quite often immediately after the childbirth. Professionals should be trained to monitor symptoms of MB and its transition toward a depressive episode.

Background: The aim of this study was to compare, in users of bimodal cochlear implants, the performance obtained using their own hearing aids (adjusted with the standard NAL-NL1 fitting formula) with the performance using the Phonak Naìda Link Ultra Power hearing aid adjusted with both NAL-NL1 and a new bimodal system (Adaptive Phonak Digital Bimodal (APDB)) developed by Advanced Bionics and Phonak Corporations. Methods: Eleven bimodal users (Naìda CI Q70 + contralateral hearing aid) were enrolled in our study. The users’ own hearing aids were replaced with the Phonak Naìda Link Ultra Power and fitted following the new formula. Speech intelligibility was assessed in quiet and noisy conditions, and comparisons were made with the results obtained with the users’ previous hearing aids and with the Naída Link hearing aids fitted with the NAL-NL1 generic prescription formula. Results: Using Phonak Naìda Link Ultra Power hearing aids with the Adaptive Phonak Digital Bimodal fitting formula, performance was significantly better than that with the users’ own rehabilitation systems, especially in challenging hearing situations for all analyzed subjects. Conclusions: Speech intelligibility tests in quiet settings did not reveal a significant difference in performance between the new fitting formula and NAL-NL1 fittings (using the Naída Link hearing aids), whereas the performance difference between the two fittings was very significant in noisy test conditions.

The effects of the COVID-19 pandemic on mental health are now well documented, however, few studies have been focused on the role of coping strategies and resilience in counterbalancing these detrimental effects. Data are derived from the COvid Mental hEalth Trial (COMET), a national multicentric trial carried out in the Italian general population. The final sample consisted of 20,720 participants, 53.1% (n = 11,000) of the sample reported low levels of resilience. Adaptive coping strategies and resilience levels did not have any significant protective impact on the levels of depressive, anxiety, and stress symptoms. Only self-distraction was a risk factor for poor mental health (Beta Coefficient, B = 0.1, 95% Confidence Interval, CI: 0.003 to 0.267 for stress symptoms, B = 0.2, 95% CI: 0.077 to 0.324 for anxiety symptoms and B = 0.2, 95% CI: 0.105 to 0.382 for depressive symptoms). High levels of resilience were predicted by adaptive coping strategies, such as acceptance (B = 1.8, CI 95% = 1.4–2.7). Exposure to the different weeks of lockdown, being infected by COVID-19, and being a healthcare professional did not influence the levels of resilience. Our findings should be carefully considered, since the low levels of resilience may represent the missing link between the pandemic and the current increase in mental health problems.

Background and objectives: Bipolar disorder (BD) is one of the most burdensome psychiatric illnesses, being associated with a negative long-term outcome and the highest suicide rate. Although affective temperaments can impact on BD long-term outcome, their role remains poorly investigated. The aims of the present study are to describe the clinical characteristics of patients with BD more frequently associated with the different affective temperaments and to assess the relation between affective temperaments and severity of clinical picture in a sample of patients with BD. Materials and Methods: A total of 199 patients have been recruited in the outpatients units of two university sites. Patients&rsquo, psychiatric symptoms, affective temperaments, and quality of life were investigated through validated assessment instruments. Results: Predominant cyclothymic and irritable temperaments are associated to higher number of relapses, poorer quality of life, higher rates of aggressive behaviors, and suicide attempts. Conversely, the predominant hyperthymic disposition was a protective factor for several outcome measures, including relapse rate, severity of anxiety, depressive and manic symptoms, suicidality, and earlier age at onset. One limitationo of the present study is that the recruitment took place in two university sites, therefore, our findings cannot be fully generalized to the whole community of BD patients. Other limitations are the lack of a control group and the cross-sectional design of the study. Conclusions: The early identification of affective temperaments can help clinicians to identify those BD patients who are more likely to show a poor long-term outcome. An early screening of affective temperaments can be useful to develop targeted integrated pharmacological and psychosocial interventions.

Introduction: Tinnitus is a common and disabling symptom often associated with hearing loss. While clinical practice frequently shows that a certain degree of psychological discomfort often characterizes tinnitus suffers, it has been recently suggested in adults as a determining factor for cognitive decline affecting attention and memory domains. The aim of our systematic review was to provide evidence for a link between tinnitus, psychological distress, and cognitive dysfunction in older patients and to focus on putative mechanisms of this relationship. Methods: We performed a systematic review, finally including 192 articles that were screened. This resulted in 12 manuscripts of which the full texts were included in a qualitative analysis. Results: The association between tinnitus and psychological distress, mainly depression, has been demonstrated in older patients, although only few studies addressed the aged population. Limited studies on cognitive dysfunction in aged patients affected by chronic tinnitus are hardly comparable, as they use different methods to validate cognitive impairment. Actual evidence does not allow us with certainty to establish if tinnitus matters as an independent risk factor for cognitive impairment or evolution to dementia. Conclusion: Tinnitus, which is usually associated with age-related hearing loss, might negatively affect emotional wellbeing and cognitive capacities in older people, but further studies are required to improve the evidence.

Background The Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented traumatic event influencing the healthcare, economic, and social welfare systems worldwide. In order to slow the infection rates, lockdown has been implemented almost everywhere. Italy, one of the countries most severely affected, entered the “lockdown” on March 8, 2020. Methods The COvid Mental hEalth Trial (COMET) network includes 10 Italian university sites and the National Institute of Health. The whole study has three different phases. The first phase includes an online survey conducted between March and May 2020 in the Italian population. Recruitment took place through email invitation letters, social media, mailing lists of universities, national medical associations, and associations of stakeholders (e.g., associations of users/carers). In order to evaluate the impact of lockdown on depressive, anxiety and stress symptoms, multivariate linear regression models were performed, weighted for the propensity score. Results The final sample consisted of 20,720 participants. Among them, 12.4% of respondents (N = 2,555) reported severe or extremely severe levels of depressive symptoms, 17.6% (N = 3,627) of anxiety symptoms and 41.6% (N = 8,619) reported to feel at least moderately stressed by the situation at the DASS-21. According to the multivariate regression models, the depressive, anxiety and stress symptoms significantly worsened from the week April 9–15 to the week April 30 to May 4 (p p Conclusions Although physical isolation and lockdown represent essential public health measures for containing the spread of the COVID-19 pandemic, they are a serious threat for mental health and well-being of the general population. As an integral part of COVID-19 response, mental health needs should be addressed.

COVID-19 pandemic and its related containment measures have been associated with increased levels of stress, anxiety and depression in the general population. While the use of digital media has been greatly promoted by national governments and international authorities to maintain social contacts and healthy lifestyle behaviors, its increased access may also bear the risk of inappropriate or excessive use of internet-related resources. The present study, part of the COVID Mental hEalth Trial (COMET) study, aims at investigating the possible relationship between social isolation, the use of digital resources and the development of their problematic use. A cross sectional survey was carried out to explore the prevalence of internet addiction, excessive use of social media, problematic video gaming and binge watching, during Italian phase II (May–June 2020) and III (June–September 2020) of the pandemic in 1385 individuals (62.5% female, mean age 32.5 ± 12.9) mainly living in Central Italy (52.4%). Data were stratified according to phase II/III and three groups of Italian regions (northern, central and southern). Compared to the larger COMET study, most participants exhibited significant higher levels of severe-to-extremely-severe depressive symptoms (46.3% vs. 12.4%; p < 0.01) and extremely severe anxiety symptoms (77.8% vs. 7.5%; p < 0.01). We also observed a rise in problematic internet use and excessive gaming over time. Mediation analyses revealed that COVID-19-related general psychopathology, stress, anxiety, depression and social isolation play a significant role in the emergence of problematic internet use, social media addiction and problematic video gaming. Professional gamers and younger subjects emerged as sub-populations particularly at risk of developing digital addictions. If confirmed in larger and more homogenous samples, our findings may help in shedding light on possible preventive and treatment strategies for digital addictions.

The decision to use coercive measures (restraint, seclusion and forced medication) in psychiatric practice is controversial in mental health care. The EUNOMIA study was funded by the European Commission and carried out in 11 countries in order to develop European recommendations for good clinical practice on the use of coercive measures. The aim of the study is to identify sociodemographic and clinical predictors of the levels of perceived coercion in a sample of Italian patients with severe mental disorders at hospital admission. A total of 294 patients were recruited in five Italian psychiatric hospitals and screened with the MacArthur Perceived Coercion Scale to explore the levels of perceived coercion. Patients were assessed three times: within the first seven days after admission as well as after 1 and 3 months. At each time point, data on changes of perceived coercion, assessed by the Cantril Ladder of Perceived Coercion Scale, information on coercive measures received during hospitalization and the levels of satisfaction with the received treatments were collected. According to the multivariable regression model, being compulsorily admitted (OR: 2.5; 95% CI: 1.3–3.3, p < .000), being male (OR: 0.7; 95% CI: 0.9-1.4; p < .01), being older (OR: 0.03; 95% CI: 0.01–0.06) and less satisfied with received treatments (OR: -0.2; 95% CI: -0.3 to - 0.1; p < .05) are all associated with higher levels of perceived coercion, even after controlling for the use of any coercive measure during hospitalization. Satisfaction with received treatment predicts the levels of perceived coercion and this should represent an important challenge for mental health professionals.

Perinatal depression (PD) is a severe and disabling condition impacting negatively on children in terms of adverse neonatal outcomes and on the well-being of women and their families. All pregnant women attending the unit of Gynecology and Obstetrics Service of the University of Campania "L. Vanvitelli" will be screened for PD using the Edinburgh Postpartum Depression Scale (EPDS). Women with a score ≥10 at the EPDS will be invited to receive a full psychiatric assessment. The required sample size is of 126 women with PD which will be randomly allocated to either an experimental group, receiving a uni-familiar psychoeducational intervention, or to a control group, receiving the Best Treatment Option (BTO). Patients will be evaluated through several assessment instruments: Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Global Assessment of Functioning (GAF), Clinical Global Impression (CGI), Manchester Short Assessment of Quality of Life (MANSA), Family Assessment Device (FAD), Family Coping Questionnaire (FCQ), and Pattern of Care Schedule (PCS). Patients will be evaluated at baseline, 3, 6, 9, and 12 months post-randomization. The severity of depressive symptoms at the HAM-D scale has been selected as primary outcome. Other outcome measures include improvement in the severity of anxiety symptoms, of global and personal functioning, an improvement in family members' coping strategies and in the level of quality of life. It has been highlighted the importance of developing screening and treating programs for PD, and our study will use rigorous study design to evaluate the efficacy of the adaption of a well-known family psychoeducational model to the treatment of PD. The aims of present trial are to: (1) develop an informative package for pregnant women with PD; (2) promote a screening programme for PD; (3) identify those (socio-demographic and pregnancy-related environmental) factors associated with a higher risk to develop a perinatal or postnatal depression; (4) evaluate the efficacy of a new experimental psychoeducational intervention in reducing the depressive symptoms during pregnancy compared to the BTO.

Parathyroid hormone (PTH), vitamin D and serum calcium play a key role in several physiological and pathological conditions. Vitamin D and PTH receptors are largely expressed in the central nervous system and are involved in the modulation of inflammatory responses. Few studies investigated the association between calcium homeostasis imbalance and psychiatric disorders. This study aims to assess calcium homeostasis imbalance in patients with bipolar disorder (BD) and its impact on clinical outcome. We recruited 199 patients with BD, who were administered with validated assessment instruments to investigate depressive, manic and anxiety symptoms, affective temperaments, childhood trauma and global functioning. Serum calcium, vitamin D and PTH levels were assessed in all patients. Levels of PTH correlated with several clinical characteristics, including the diagnosis of bipolar disorder type I (BD-I), the presence of psychotic symptoms, lithium treatment, suicidality, total number of acute episodes and of hospitalizations (p < 0.0001) and seasonality (p < 0.05). At the regression analyses, higher levels of PTH were predicted by early age at onset, number of hospitalizations, aggressive behaviors (p < 0.05), higher Childhood Trauma Questionnaire total score (CTQ) (p < 0.001) and treatment with lithium (p = 0.01). Our findings suggest that the calcium homeostasis could play a role in BD patients, and that PTH levels are correlated with the clinical severity of the disorder.

Gaia Sampogna,1 Mario Luciano,1 Valeria Del Vecchio,1 Claudio Malangone,1,2 Corrado De Rosa,1 Vincenzo Giallonardo,1 Giuseppina Borriello,1 Benedetta Pocai,1 Micaela Savorani,1 Luca Steardo Jr,1 Debora Lampis,3 Franco Veltro,4 Francesco Bartoli,5 Francesco Bardicchia,6 Anna Maria Moroni,7 Giusy Ciampini,8 Emanuele Orlandi,9 Silvia Ferrari,10 Silvia Biondi,11 Sonia Iapichino,11,12 Enrico Pompili,13 Massimiliano Piselli,14 Alfonso Tortorella,15 Giuseppe Carrà,5,16 Andrea Fiorillo1 1Department of Psychiatry, University of Campania “Luigi Vanvitelli”, Naples, 2Mental Health Centre of Ravello, Mental Health Unit, Ravello, 3Mental Health Centre of Lanusei, Mental Health Unit, Lanusei, 4Mental Health Department of Campobasso, Campobasso, 5Department of Medicine and Surgery, University of Milano Bicocca, Monza, 6Mental Health Centre of Grosseto, Mental Health Unit, Grosseto, 7Niguarda Hospital, Department of Psychiatry, Milan, 8Mental Health Centre of Lanciano, Mental Health Unit, Lanciano, 9Mental Health Centre of Sassuolo, Mental Health Unit, Sassuolo, 10University of Modena and Reggio Emilia, Department of Psychiatry, Reggio Emilia, 11Mental Health Centre of Montecatini, Mental Health Unit, Montecatini, 12Auditor Psychiatrist, for the activities of Clinical Risk Management and safety of treatments, Tuscany Region, 13Mental Health Centre of Rome, Mental Health Unit, Rome, 14Mental Health Centre of Foligno, Mental Health Unit, Foligno, 15Department of Medicine, Section of Psychiatry, University of Perugia, Perugia, Italy; 16Division of Psychiatry, University College of London, London, UK Background: Psychoeducational family intervention (PFI) has been proven to be effective in improving the levels of family burden and patients’ personal functioning in schizophrenia and bipolar disorders (BDs). Less is known about the impact of PFI on relatives’ coping strategies in BD. Methods: A multicenter, controlled, outpatient trial funded by the Italian Ministry of Health and coordinated by the Department of Psychiatry of the University of Campania “Luigi Vanvitelli” has been conducted in patients with bipolar I disorder (BD-I) and their key relatives consecutively recruited in 11 randomly selected Italian community mental health centers. We aim to test the hypothesis that PFI improves problem-oriented coping strategies in relatives of BD-I patients compared to the Treatment As Usual (TAU) group. Results: The final sample was constituted of 123 patients and 139 relatives. At baseline assessment (T0), the vast majority of relatives already adopted problem-oriented coping strategies more frequently than the emotion-focused ones. At the end of the intervention, relatives receiving PFI reported a higher endorsement of adaptive coping strategies, such as “maintenance of social interests” (odds ratio [OR]=0.309, CI=0.04–0.57;p=0.023), “positive communication with the patient” (OR=0.295, CI=0.13–0.46;p=0.001), and “searching for information” (OR=0.443, CI=0.12–0.76;p=0.007), compared to TAU relatives, after controlling for several confounders. As regards the emotion-focused coping strategies, relatives receiving the experimental intervention less frequently reported to adopt “resignation” (OR=-0.380, CI=-0.68 to -0.08; p=0.014) and “coercion” (OR=-0.268, CI=-0.46 to -0.08;p=0.006) strategies, compared to TAU relatives. Conclusion: PFI is effective in improving the adaptive coping strategies of relatives of BD-I patients, but further studies are needed for evaluating the long-term benefits of this intervention. Keywords: coping strategies, family burden, psychoeducation family intervention, bipolar disorder, social functioning

Background:The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication.Methods:The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders’ representatives. The national recommendations have been subsequently summarized into a European shared document.Results:Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients’ dignity, privacy and safety shall be preserved at all times.Conclusion:The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

Background It has been frequently reported a higher incidence of psychotic disorders in immigrants than in native populations. There is, however, a lack of knowledge about risk factors which may explain this phenomenon. A better understanding of the causes of psychosis among first-generation migrants is highly needed, particularly in Italy, a country with a recent massive migration. Methods/Design The “Italian study on first-episode psychosis and migration (PEP-Ita)” is a prospective observational study over a two-year period (1 January 2012–31 December 2013) which will be carried out in 11 Italian mental health centres. All participating centres will collect data about all new cases of migrants with first-episode psychosis. The general purpose (“core”) of the PEP-Ita study is to explore the socio-demographic and clinical characteristics, and the pathways to care of a population of first-episode psychosis migrants in Italy. Secondary aims of the study will be: 1) to understand risk and protective factors for the development of psychotic disorders in migrants; 2) to evaluate the correlations between psychopathology of psychotic disorders in migrants and socio-demographic characteristics, migration history, life experiences; 3) to evaluate the clinical and social outcomes of first-episode psychoses in migrants. Discussion The results of the PEP-Ita study will allow a better understanding of risk factors for psychosis in first-generation migrants in Italy. Moreover, our results will contribute to the development of prevention programmes for psychosis and to the improvement of early intervention treatments for the migrant population in Italy.

BackgroundMental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment.AimsTo explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment.MethodA multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission.ResultsA total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement.ConclusionsCaregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

The World Health Organization (WHO) is developing the 11th edition of the International Classification of Diseases and Related Health Problems (ICD-11), whose publication is currently expected in the year 2015. The WPA is partnering with the WHO in the production of the chapter on mental and behavioural disorders. The principles guiding the development of that chapter have been summarized by the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders in a paper published in World Psychiatry in June 2011 1. That paper emphasizes that the chapter is being produced in consultation with relevant stakeholders, including WHO member countries, several professional groups, and users of mental health services and their families. Attention to the cultural framework is being a key element. The revision is seen as an opportunity to improve the classification's clinical utility, particularly in primary care settings and in low- and middle-income countries (see also2–3). The ICD-11 classification will remain based on descriptions of the prototypes of the various mental disorders rather than on operational diagnostic criteria. The advantages and possible limitations of this approach have been discussed in several World Psychiatry articles and commentaries (e.g.,4–11). A major argument in favour of this approach is that it is congruent with the spontaneous clinical process, which does not involve checking in a given patient whether each of a series of symptoms is present or not, but rather checking whether the characteristics of the patient match one of the templates of mental disorders that the clinician has built up in his/her mind through his/her training and clinical experience (see also12). Moreover, some recent research focusing on various classes of mental disorders (i.e., personality, eating, anxiety and mood disorders) suggests that a diagnostic system based on refined prototypes may be as reliable as one based on operational criteria, while being more user friendly and having greater clinical utility (e.g.,13–14). Eleven Working and Consultation Groups have been appointed by the WHO for the development of the ICD-11 chapter on mental and behavioural disorders. These groups include several WPA officers and experts among their chairpersons and members (see15–16). Several of these groups have recently published background papers or preliminary reports on their activities. Highlights of the expected convergences and divergences between the ICD-11 and DSM-5 approaches to the classification of mood disorders have been presented in several papers in various journals (e.g.,17–18) and in a supplement to World Psychiatry 19. Among the convergences are the inclusion of activation/energy as a defining symptom for mania, and the acknowledgement that a manic/hypomanic syndrome emerging during antidepressant treatment, and persisting beyond the physiological effect of that treatment, qualifies for the diagnosis of manic/hypomanic episode. Furthermore, the ICD-11, as the DSM-5, will allow the clinician to record the occurrence of a subsyndromal anxiety syndrome in a patient with a major depressive episode, by using a specifier. Bipolar II disorder is expected to be recognized as a distinct diagnostic entity in the ICD-11, while in ICD-10 it is just mentioned among “other bipolar affective disorders”. Expected divergences between the ICD-11 and the DSM-5 will include a different characterization of mixed states and schizoaffective disorders. Furthermore, the ICD-11 is going to exclude from the diagnosis of depressive episode, in line with the ICD-10 but differently from the DSM-5, “normal bereavement reactions appropriate to the culture of the individual concerned” (see20–26). Highlights of the expected convergences and divergences between the ICD-11 and the DSM-5 in the classification of stress-related disorders have been presented in a recent World Psychiatry paper 27. In the ICD-11, the proposed new grouping of “disorders specifically associated with stress” will include adjustment disorder (whose description will undergo a major revision, involving an increased specification of symptoms), post-traumatic stress disorder (PTSD) (whose diagnosis is going to be based on three well-identified core symptoms), and complex PTSD (a new category marked by disturbance in the domains of affect, self-concept and relational functioning in addition to the three core features of PTSD). Acute stress reaction will be conceptualized as a normal reaction and thus classified in the chapter corresponding to ICD-10 “Factors influencing health status and contact with services” (while “acute stress disorder” is still included in the section on trauma- and stress-related disorders in the DSM-5). Proposals for the ICD-11 section on feeding and eating disorders have been summarized in another World Psychiatry article 28. These include a broadening of the category of anorexia nervosa through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations. Furthermore, a severity qualifier “with dangerously low body weight” is expected to distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis. The bulimia nervosa category is likely to be extended to include subjective binge eating, and binge eating disorder will be included as a specific diagnostic category, in agreement with the DSM-5. The input of the ICD-11 Working Group on Intellectual Developmental Disorders has been presented in a paper published in World Psychiatry in 2011 29 and is further discussed in this issue of the journal 30. Intellectual developmental disorders (a term replacing “mental retardation”) are proposed to be defined as “a group of developmental conditions characterized by significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills”. The Working Group further advised that intellectual developmental disorders be incorporated in the larger grouping of neurodevelopmental disorders, that current subcategories based on clinical severity be maintained, and that problem behaviours be described as associated features. The Chairman of the ICD-11 Working Group on Psychotic Disorders recently reported 31 about the expected convergences and divergences in the ICD-11 and DSM-5 approaches to the classification of those disorders. In the ICD-11, as in the DSM-5, Schneider's first-rank symptoms are going to be deemphasized in the description of schizophrenia, and the subtypes of the disorder are going to be omitted. These subtypes will be replaced by six symptom specifiers (positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive impairment). Contrary to the DSM-5, the ICD-11 is expected to keep the one month duration criterion for the diagnosis of schizophrenia, and not to include functional impairment as a mandatory criterion. Preliminary reports about the development of the ICD-11 sections on mental disorders in children and adolescents 32, somatic distress and dissociative disorders 33 and personality disorders 34 are also available in the recent literature. A more general discussion of diagnostic topics related to DSM-5 and ICD-11 classifications can be found in recent issues of World Psychiatry 35–45. Internet-based field testing of proposals for ICD-11 will be implemented through the Global Clinical Practice Network, currently consisting of more than 7,000 individual mental health and primary care practitioners (http://www.globalclinicalpractice.net).

PURPOSE: The helping alliance (HA) between patient and therapist has been studied in detail in psychotherapy research, but less is known about the HA in long-term community mental health care. The aim of this study was to identify typical courses of the HA and their predictors in a sample of people with severe mental illness across Europe over a measurement period of one year.METHODS: Self-ratings of the HA by 588 people with severe mental illness who participated in a multicentre European study (CEDAR; ISRCTN75841675) were examined using latent class analysis.RESULTS: Four main patterns of alliance were identified: (1) high and stable (HS, 45.6 %), (2) high and increasing (HI, 36.9 %), (3) high and decreasing (HD, 11.3 %) and (4) low and increasing (LI, 6.1 %). Predictors of class membership were duration of illness, ethnicity, and education, receipt of state benefits, recovery, and quality of life.CONCLUSIONS: Results support findings from psychotherapy research about a predominantly stable course of the helping alliance in patients with severe mental illness over time. Implications for research and practice indicate to turn the attention to subgroups with noticeable courses.

Bernardo Dell’Osso,1,2,* Umberto Albert,3,* Anna Rita Atti,4 Claudia Carmassi,5 Giuseppe Carrà,6 Fiammetta Cosci,7 Valeria Del Vecchio,8 Marco Di Nicola,9 Silvia Ferrari,10 Arianna Goracci,11 Felice Iasevoli,12 Mario Luciano,8 Giovanni Martinotti,13 Maria Giulia Nanni,14 Alessandra Nivoli,15,16 Federica Pinna,17 Nicola Poloni,18 Maurizio Pompili,19 Gaia Sampogna,8 Ilaria Tarricone,20 Sarah Tosato,21 Umberto Volpe,8 Andrea Fiorillo8 1Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy; 2Bipolar Disorders Clinic, Stanford Medical School, Stanford University, CA, USA; 3Rita Levi Montalcini Department of Neuroscience, University of Turin, Torino, 4Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, 5Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; 6Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK; 7Department of Health Sciences, University of Florence, Florence, 8Department of Psychiatry, University of Naples SUN, Naples, 9Institute of Psychiatry and Psychology, Catholic University of Sacred Heart, Rome, 10Department of Diagnostic-Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Modena, 11Department of Molecular Medicine and Clinical Department of Mental Health, University of Siena, Siena, 12Department of Neuroscience, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, 13Department of Neuroscience, Imaging, and Clinical Science, University G.d Annunzio, Chieti-Pescara, 14Section of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, 15Psychiatric Institute, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; 16Bipolar Disorder Unit, CIBERSAM, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain; 17Department of Public Health, Clinical and Molecular Medicine, Unit of Psychiatry, University of Cagliari, Cagliari, 18Department of Clinical and Experimental Medicine, Psychiatric Division, University of Insubria, Varese, 19Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’ Andrea Hospital, Sapienza University of Rome, Rome, 20Department of Medical and Surgical Sciences, Bologna University, Bologna, 21Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy *These authors contributed equally as first authors Abstract: More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review. Keywords: benzodiazepines, psychiatric clinical practice, teaching issues, risks and benefits

In the past twenty years there has been a growing concern that psychiatry as a profession is in crisis 1–3 and that there is a shortage of psychiatrists worldwide 4, which may have an impact on the delivery of effective mental health care. Attempts to counterbalance this trend have been on the agenda of many international associations, including the WPA, the European Psychiatric Association (EPA) and the American Psychiatric Association, amongst others 5–7. Many of these associations have established specific workstreams aimed at addressing the educational needs of early career psychiatrists, and identifying the reasons behind low levels of interest and recruitment into psychiatry among medical students (e.g., 8). The WPA was one of the first associations to give attention to early career psychiatrists, with a specific young psychiatrist scientific track made available at World Congresses, starting from Hamburg in 1999 up to Buenos Aires in 2011. At these meetings a range of activities were dedicated to early career psychiatrists, including scholarships, training seminars, scientific symposia, and informal get-together meetings. The WPA Executive Committee, in the triennium 2008-2011, placed great emphasis on developing and inspiring early career psychiatrists, with one of the Action Plan goals being “to promote the professional development of early career psychiatrists worldwide” 9. A WPA Council of Early Career Psychiatrists was appointed, with 60 countries from all continents each nominating an early career psychiatrist to participate and represent their peers. The Council has implemented a specific action plan aimed at identifying problems concerning early career psychiatrists and promoting their professional development through a series of activities 10,11. Three surveys have been conducted by this group: one dealing with training in psychotherapy 12, one with training and practice of early intervention in mental health 13, and one dealing with the transition from psychiatric training to independent practice 14, which represents a crucial step in the professional development of every psychiatrist. Also based on this experience within the WPA, early career psychiatrists are now being considered equal partners in research activities as well. For example, within a large European Commission funded project, the ROAMER, a survey was conducted on priorities for mental health research, with the participation of different categories of stakeholders 15. Associations of psychiatric trainees were included, as well as associations of psychiatrists, of other mental health professionals, and organizations of users and/or carers. Moreover, the European Federation of Psychiatric Trainees (EFPT) and the Early Career Psychiatrists Committee of the EPA have recently created a task force on research, with several projects carried out so far 6, and many others still ongoing. The importance of supporting early career psychiatrists is now well recognized worldwide, and the majority of national psychiatric associations have now a section for this category of psychiatrists, with its own rules and by-laws. There are also some transnational groups, for example in East Africa, Asia and Europe, whose common interest is the professional development of early career psychiatrists 16–18. Many educational activities worldwide are now co-organized with early career psychiatrists, who have identified the areas where they have the most significant educational needs and gaps, including psychopathology, forensic psychiatry, leadership and research skills, and comorbidity of mental disorders with physical diseases 6,7,19–21. Several actions have been taken to address these educational needs, including the organization of scientific events and the production of books 22 and educational modules. For example, the EPA runs a highly successful annual summer school that brings together many early career psychiatrists working in Europe every year. Other courses have been organized in collaboration with various EPA sections, such as those on philosophy and psychiatry and on consultation and liaison psychiatry. A further educational activity, run by the Association for the Improvement of Mental Health Care Programmes, includes courses on leadership and research skills, and promotes research projects conducted by early career psychiatrists (e.g., 23). Among the educational activities of the WPA 24, the Section on Education, which has several early career psychiatrists among its members, is currently promoting a range of initiatives aimed to improve the availability and quality of psychiatric education. An important challenge for early career psychiatrists today is the promotion of the public image of psychiatry 25,26. The specific skills needed to interact effectively with families, administrators, journalists and the legal system should become a formal component of post-graduate training and continuing medical education of every early career psychiatrist 6. Many further activities promoted by or devoted to early career psychiatrists could be listed here. However, what we wanted to highlight with this letter is that psychiatry is still alive, growing and developing and will certainly survive the current “crisis”. We should consider the present one as a developmental phase, that can help us improve our training, research and practice. This in turn will take us further towards our ultimate aim – that of improving the health and well-being of our patients. The WPA, with its early career psychiatrists' programmes and initiatives, has played a crucial role in these developments. Early career psychiatrists are ready to contribute to further activities.

Background and aims:In Italy, the reform of the mental health system in 1978 should have drastically changed the provision of care and pathways of patients seeking to obtain it. The aim of this article is to examine the current pathways to psychiatric care in Italy.Methods:We used a method developed in the World Health Organization international collaborative studies to investigate pathways to care in 15 Italian mental health centers. We recruited 420 patients with a psychiatric illness and explored the care pathways they took to reach to psychiatric services and the delays from the onset of illness to reaching psychiatric care.Results:The majority of patients (33.8%) had direct access to mental health care, whereas the others arrived to a specialist in psychiatry through general hospitals (20.3%), general practitioners (33.0%) or private practitioners (9.8%). The main diagnosis for referral was neurotic disorder (36.6%), followed by affective disorder (35.4%) and psychotic disorder (11.5%). The delay from onset of illness to psychiatric care was greater for patients with psychotic disorders than for those with affective and neurotic disorders. The most frequently prescribed treatments were pharmacotherapy (56%), psychological support (8%), and psychotherapy (7.0%); 15% of the patients received no treatment.Conclusions:Our multicenter study shows that although general practitioners and hospital doctors are still the main referral point for mental health care, a greater proportion of patients are first seen in private settings or directly reach mental health centers, compared to previous surveys conducted in Italy. However, a stronger collaboration of psychiatrists with general practitioners and psychologists is still needed.

Within the ROAMER project, funded by the European Commission, a survey was conducted with national associations/organizations of psychiatrists, other mental health professionals, users and/or carers, and psychiatric trainees in the 27 countries of the European Union, aiming to explore their views about priorities for mental health research in Europe. One hundred and eight associations/organizations returned the questionnaire. The five most frequently selected research priorities were early detection and management of mental disorders, quality of mental health services, prevention of mental disorders, rehabilitation and social inclusion, and new medications for mental disorders. All these areas, except the last one, were among the top ten research priorities according to all categories of stakeholders, along with stigma and discrimination. These results seem to support the recent argument that some rebalancing in favor of psychosocial and health service studies may be needed in psychiatric research.

Major depressive disorder is reported to be the most common mental disorder, and one of the leading causes of disability-adjusted life years. It causes high levels of family burden and of expressed emotions. Research interest in family functioning in mental disorders has recently shifted from schizophrenia to unipolar and bipolar affective disorders. However, studies on family burden and on the effect of family psychoeducational interventions on major depression are still very few in number and lack a rigorous methodology, clear outcome measures and adequate follow-ups. Despite this, the few available studies on the efficacy of psychoeducational family intervention in unipolar major depression have had promising results. A comprehensive management of unipolar major depression should include psychoeducational family intervention.

Background Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. Methods 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. Results When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. Conclusions Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.