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Background Major Depressive Disorder (MDD) requires therapeutic interventions during the initial month after being diagnosed for better disease outcomes. International guidelines recommend a duration of 4–12 weeks for an initial antidepressant (IAD) trial at an optimized dose to get a response. If depressive symptoms persist after this duration, guidelines recommend switching, augmenting, or combining strategies as the next step. Premature discontinuation of IAD due to ineffectiveness can cause unfavorable consequences. We aimed to determine the prevalence and the patterns of strategies applied after an IAD was changed because of a suboptimal response as a primary outcome. Secondary outcomes included the median survival time on IAD before any change; and the predictors that were associated with IAD change. Methods This was a retrospective study conducted in Mental Health Services in Qatar. A dataset between January 1, 2018, and December 31, 2019, was extracted from the electronic health records. Inclusion and exclusion criteria were defined and applied. The sample size was calculated to be at least 379 patients. Descriptive statistics were reported as frequencies and percentages, in addition, to mean and standard deviation. The median time of IAD to any change strategy was calculated using survival analysis. Associated predictors were examined using several cox regression models. Results A total of 487 patients met the inclusion criteria of the study, 431 (88%) of them had an occurrence of IAD change to any strategy before end of the study. Almost half of the sample (212 (49%); 95% CI [44–53%]) had their IAD changed less than or equal to 30 days. The median time to IAD change was 43 days with 95% CI [33.2–52.7]. The factors statistically associated with higher hazard of IAD change were: younger age, un-optimization of the IAD dose before any change, and comorbid anxiety. Conclusions Because almost half of the patients in this study changed their IAD as early as within the first month, efforts to avoid treatment failure are needed to ensure patient-treatment targets are met. Our findings offered some clues to help clinicians identify the high-risk predictors of short survival and subsequent failure of IAD.

SUMMARYNeuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse reaction to drugs. In psychiatric practice, it is mainly associated with antipsychotics. The classic presentation is that of hyperpyrexia, muscle rigidity, mental state changes and autonomic instability. Subtle forms are difficult to recognise owing to symptom overlap with other conditions. This article discusses the clinical presentation of the syndrome, its differential diagnosis and use of supportive care, medication and electroconvulsive therapy in its treatment. It also explores prevention of NMS and reinstatement of treatment after an episode. It is stressed that all but the mildest forms of NMS should be considered a medical emergency that is properly managed in an acute hospital.

The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women's mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71-43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.

Autism spectrum disorders (ASDs) are a group of neurodevelopmental disorders defined by a deficit in social interactions and the presence of restricted and stereotypical behaviors or interests. The etiologies of autism remain mostly unknown. Many genetic and environmental factors have been suspected. Among these environmental factors, exposure to several chemical elements has been previously studied. The purpose of this study was to compare the levels of trace elements in the blood plasma of children with ASD with typically developed children (TDC). The participants in this study consisted of 89 children with ASD (14 girls and 74 boys) and 70 TD children (29 girls and 41 boys). The levels of 33 chemical elements have been analyzed by inductively coupled plasma spectrometry (ICP-MS). We detected significant differences in the levels of eight elements between the two groups, among which there were three rare earth elements (REEs): Eu, Pr, and Sc (p = 0.000, p = 0.023, and p

Background Pathologic changes in cerebral and retinal structures governing the pupillary light reflex occur in Alzheimer's disease (AD). Analysis of pupillary responses originating from different retinal cells may allow for non-invasive detection of cerebral AD pathology. Objective This study aimed to quantify the pupil light reflex using a portable chromatic pupillometer in patients with early stage AD and compare their responses to those of a healthy control group. Methods Participants in this case-control pilot study were recruited from a well-characterized cohort of elderly people participating in a larger prospective study on early AD. Cognitive testing, volumetric brain imaging, and lumbar puncture were performed in all participants to define two groups: early AD, i.e., cognitively impaired subjects with biomarker-confirmed AD pathology, and control group of subjects with normal cognition and normal CSF biomarker profile. Pupil responses to red and blue light stimuli intended to activate cone photoreceptors and melanopsin ganglion cells were recorded under photopic conditions. Results Sixteen patients with AD (mean age 77 years) and sixteen controls (mean age 71 years) were tested. Baseline pupil size was significantly smaller in AD patients. Pupillary contraction amplitude to all red and blue lights was also smaller in AD patients but did not reach statistical significance. The post-illumination pupillary response was the same between the two groups. Conclusion Compared to healthy controls, we found only a smaller resting size of the pupil in patients with early AD. The pupillary dynamics to light stimulation remained relatively preserved.

Background: The coronavirus disease-2019 (COVID-19) pandemic has imposed an unprecedented strain on healthcare systems worldwide. In response, psychiatrist trainees were redeployed from their training sites to help manage patients with COVID-19. This study aimed to examine the attitude of psychiatrist trainees toward redeployment to COVID-19 sites and their perceived preparedness for managing physical health conditions during redeployment. Methods: A cross-sectional researcher-developed online survey was administered among psychiatrist trainees in May 2020 at the Department of Psychiatry, Hamad Medical Corporation, Qatar. Results: Of the 45 psychiatrist trainees, 40 (88.9%) responded to the survey. Most trainees reported being comfortable dealing with chronic medical conditions, but less so with acute life-threatening medical conditions. Half reported feeling anxious about redeployment, and most felt the need for additional training. We found that trainees’ perceived redeployment preparedness was significantly associated with their level of postgraduate training and the time since and duration of their last medical or surgical training. Conclusion: Adequate preparation and training of psychiatrist trainees is important before redeployment to COVID-19 sites to ensure that they can effectively and safely manage patients with COVID-19.

SettingThe State of Qatar has had one of the highest COVID-19 infection rates globally and has used state-managed quarantine and isolation centres to limit the spread of infection. Quarantine and isolation have been shown to negatively affect the mental health of individuals. Qatar has a unique population, with around 90% of the population being economic migrants and a majority being blue-collar workers and labourers.ObjectivesThis study was carried out to evaluate the psychological impact of institutional isolation and quarantine during the COVID-19 pandemic outbreak in Qatar. The study also explored the sociodemographic correlates of this psychological impact.Design, participants and interventionA cross-sectional study involving 748 consenting individuals in institutional quarantine and isolation in Qatar during the months of June and July 2020 was carried out. Relevant sociodemographic data along with depressive and anxiety symptomatology scores were collected from consenting adults at these facilities.Results37.4% (n=270) of respondents reported depressive symptoms and 25.9% (n=189) reported anxiety symptoms. The scores were higher for individuals in isolation facilities and higher for migrants from poor socioeconomic group (pConclusionsOur study reported significantly elevated scores for depression and anxiety during institutional quarantine, which is in keeping with emerging evidence. However, in contrast to other studies reporting mostly from native populations, this study of a population with an overwhelming majority of immigrants highlights the special mental health needs of this specific group and can inform future healthcare policies.

Background: Major Depressive Disorder (MDD) requires therapeutic interventions during the initial month after being diagnosed for better disease outcomes. International guidelines recommend a duration of 4-12 weeks for an initial antidepressant (IAD) trial at an optimized dose to get a response. If depressive symptoms persist after this duration, guidelines recommend switching, augmenting, or combining strategies as the next step. Premature discontinuation of IAD due to ineffectiveness can cause unfavorable consequences. Hence, we aimed to determine the prevalence and the patterns of strategies applied after an IAD was changed because of a suboptimal response as a primary outcome. Secondary outcomes included the median survival time on IAD before any change; and the factors that were associated with IAD change.Methods: This was a retrospective study conducted in Mental Health Services in Qatar. A dataset between January 1, 2018, and December 31, 2019, was extracted from the electronic health records. Inclusion and exclusion criteria were defined and applied. The sample size was calculated to be at least 379 patients. Descriptive statistics were reported as frequencies and percentages, in addition, to mean and standard deviation. The median time of IAD to any change strategy was calculated using survival analysis. Associated factors were examined using three cox regression models.Results: A total of 487 patients met the inclusion criteria of the study, 431 (88%) of them had an occurrence of IAD change to any strategy before end of the study. Almost half of the sample (212 (49%); 95% CI [44% - 53%]) had their IAD changed within less than or equal to 30 days. The median time to IAD change was 43 days with 95% CI [33.2 – 52.7]. Cox regression analysis showed three statistically significant factors were associated with our secondary outcome: age, un-optimization of the dose, and absence of comorbid anxiety.Conclusions: Our findings suggest that clinicians resorted to IAD change within a median time of six weeks. However, this change often occurred without optimization of the IAD dose and might be too late. Future prospective studies with adequate randomization can better investigate the median survival time on IAD and other associated factors.

BackgroundPatients with schizophrenia are at least twice as likely to develop diabetes mellitus compared to the general population. This is of significance in Qatar given the high prevalence of obesity and diabetes. Furthermore, the lifespan of people with schizophrenia and diabetes is shortened by approximately15 years due to long-term microvascular and macrovascular complications. High quality diabetes care can significantly reduce morbidity and mortality. We assessed the level of diabetes care delivered to patients with schizophrenia and diabetes compared to those with diabetes alone.MethodsWe performed a retrospective chart review of patients with diabetes mellitus with (n=73) and without (n=73) schizophrenia. Demographic information and electronic medical records were reviewed for 6-month and 1-year American Diabetic Association standards of diabetes care. Optimal diabetes care was defined as having completed glycated hemoglobin (HbA1c), lipid profile and retinal examination within 12 months. ResultsOptimal diabetes care was significantly lower in patients with schizophrenia and diabetes compared to diabetes alone [26.0% (n=19/73) vs 52.1% (n=38/73), p=0.002]. Patients with diabetes and schizophrenia were also significantly less likely to have had body mass index recorded within six months (p=0.008) and HbA1c (p=0.006), lipid profile (p=0.015), estimated glomerular filtration rate (eGFR) (p=0.001) and order for retinal screening (p=0.004) over 12 months. After adjusting for multiple comparisons, only assessment of eGFR (p=0.01) and order for retinal screening (p=0.04) remained significant. ConclusionPatients with schizophrenia and diabetes in Qatar receive sub-optimal diabetes care compared to those with diabetes alone.

Introduction: Corona Virus Disease 2019 (COVID-19) quarantine has been associated with depression, anxiety, and stress symptoms. We hypothesize these symptoms might even be more pronounced in the elderly, who may be particularly sensitive to social isolation. However, certain individuals might be more resilient than others due to their coping mechanisms, including religious coping. Objectives: We aimed to examine the levels of perceived stress, depressive, and anxiety symptoms in older adults under COVID-19 quarantine in Qatar; and to identify the sociodemographic, psychological, and clinical factors associated with mental health outcomes, with a focus on the role of resilience, and religiosity. Methods: A cross-sectional study assessing depressive, anxiety, and stress symptoms as well as resilience, and religiosity through a phone survey in adults aged 60 years or more under COVID-19 quarantine in the State of Qatar, in comparison to age and gender-matched controls. Results: The prevalence of depressive, anxiety, and stress symptoms in elderly subjects under COVID-19 quarantine in Qatar was not significantly different from the prevalence in gender and age-matched controls. In the quarantined group, higher depressive, anxiety, and stress scores were associated with the female gender and with lower resilience scores but were not linked to age, psychiatric history, medical history, duration of quarantine, or religiosity. Conclusion: The elderly population does not seem to develop significant COVID-19 quarantine-related psychological distress, possibly thanks to high resilience and effective coping strategies developed through the years.

Background: CANMAT 2018 guidelines identify two phases of Major depressive disorder (MDD) treatment: an acute phase (getting to symptomatic remission), and a maintenance phase (preventing relapse and recurrence). CANMAT recommends increasing the antidepressant dose for non-improvers at 2 to 4 weeks if the medication is well- tolerated. If a poor response to initial Antidepressant (IAD) after 4 weeks, clinicians may opt to step 2 in treatment algorithms such as switching, augmentation, combination strategies,etc. There is substantial evidence from our practice that many patients receive inadequate duration of treatment trial (less than 4 weeks before going to step 2 in treatment). The clinician should then consider treatment issues that may affect the clinical response. Primary outcome: To evaluatetime (in Days) between initiation of antidepressant monotherapy and any change strategy such asswitching, combinationand/or augmentation of pharmacotherapy as a result of suboptimal response to initial therapy at physicians documentation. Method: A 12- month audit was initiated in a mental health hospital, HMC, Qatar. Data were collected retrospectively for the 12 months preceded the approval of the audit. Patients were eligible to be included if they werefemale or male aged between 18 and 65 years (inpatients and outpatients) diagnosed with an episode of major depression as diagnosed under (ICD-10, Version 2010) initially treated with a single antidepressant (using a flexible dosage regimen if required) and for whom initial treatment changed/ modified because of a suboptimal response at physicians documentation, which is clearly documented in the patients medical chart. Exclusion criteria were patients who had depression with psychotic features, or if they were pregnant women. Descriptive statistics were applied to the primary and secondary outcomes. Results: A total of 70 patients were included in this study. 60% were females and 40% were males. Median time to any change strategy was 50.5 days. 44.3% (n=31) of the sample has at least one change strategy of their initial antidepressant that occurred Less than 4 weeks.The main change in pharmacological management after a suboptimal response was switching (47%) followed by augmentation (27%). The most prevalent pharmacological classes that used for augmentation were antipsychotics (52%) then antidepressants (29%). Quetiapine and olanzapine were on thetop medications used. Conclusion: Changing treatment in less than 4 weekswas observed in 44% of the sample, which represents rather poor compliance to the international guidelines. Higher sample size is required to avoid variability and increase reliability of the results. Our future plan is to present the results in CME series of lectures focusing on MDD to highlight the gap between the current practice and the international guidelines. The project sponsor will share the results with policymakers to develop facility guidelines for MDD treatment.

Elevated cortisol levels have been associated with poorer cognitive performance in cross-sectional studies; this may be both a factor contributing to neurodegeneration and cognitive decline and a result of developing brain pathologies. However, it is still unclear (1) whether cortisol measures predict later cognitive decline and (2) whether cortisol changes over the years might be associated with cognitive changes. We analyzed data from CoLaus/PsyCoLaus, a prospective population-based study. Salivary cortisol (4 different measures on 1 day) and neuropsychological assessments were performed at a first visit and a follow-up visit 5 years later in 625 dementia-free participants aged ≥65 years. Salivary cortisol levels at waking and 30 minutes after waking, as well as longitudinal changes in cortisol 30 minutes after waking, cortisol awakening response, and cortisol AM-PM difference were associated with decline in global cognition. After controlling for potential confounders, only longitudinal changes in cortisol 30 minutes after waking remained associated with cognitive decline. These mostly negative findings indicate absent or subtle association between salivary cortisol and cognitive decline.

Objective Even though all guidelines recommend generally against antipsychotic polypharmacy, antipsychotic polypharmacy appears to be a very common practice across the globe. This study aimed to examine the prescription patterns of antipsychotics in Qatar, in comparison with the international guidelines, and to scrutinize the sociodemographic and clinical features associated with antipsychotic polypharmacy. Methods All the medical records of all the inpatients and outpatients treated by antipsychotics at the Department of Psychiatry–Hamad Medical Corporation (HMC) in Doha, Qatar (between October 2012 and April 2014) were retrospectively analyzed. We retrieved the available sociodemographic data, psychiatric features, and details on the medication history. Results Our sample consisted of 537 individuals on antipsychotics (2/3 were male; mean age 33.8±10.2 years), prescribed for a psychotic disorder in 57%, a mood disorder in 9.3%, and various other diagnoses in 33.7%. About 55.9% received one antipsychotic, 29.6% received two antipsychotics, and 14.5% received more than two antipsychotics. Polypharmacy was associated with younger age (p = 0.025), being single (p Conclusions Antipsychotic polypharmacy appears to be quite common in Qatar, as it is the case in many other countries, in contrast with most international recommendations. Studies are needed to explore the reasons behind this disparity.

Introduction: Cortisol effects on the brain are exerted through two distinct receptors, inducing complex and even opposite effects on the cerebral structures implicated in the various cognitive functions. High cortisol may also have deleterious effects on the brain structures and contribute to neurodegeneration, in particular Alzheimer’s disease (AD), via different mechanisms. Objective: To examine the interrelationships between cortisol, cognitive impairment and AD. Methods: Review of the literature. Results: Clinical studies found that elevated cortisol was associated with poorer overall cognitive functioning, as well as with poorer episodic memory, executive functioning, language, spatial memory, processing speed, and social cognition; while in animals, glucocorticoid administration resulted in cognitive impairment and abnormal behavior. In cognitively healthy subjects, higher cortisol levels have been associated with an increased risk of cognitive decline and AD. Subjects with dementia and Mild Cognitive Impairment (MCI) due to AD have been found to have higher CSF cortisol levels than cognitively healthy controls. Elevated CSF cortisol may also be associated with a more rapid cognitive decline in MCI due to AD. Elevated cortisol levels have been also found in delirium. High cortisol may mediate the impact of stressful life events, high neuroticism, depression, sleep disturbances, as well as cardiovascular risk factors on cognitive performance, neurodegeneration, and cognitive decline. High cortisol may also exert neurotoxic effects on the hippocampus, and promote oxidative stress and amyloid β peptide toxicity. Further possible underlying mechanisms include the interactions of cortisol with inflammatory mediators, neurotransmitters, and growth factors. Conclusions: Elevated cortisol levels may exert detrimental effects on cognition and contribute to AD pathology. Further studies are needed to investigate cortisol-reducing and glucocorticoidreceptor modulating interventions to prevent cognitive decline.

ObjectiveBenefits of statins in the long term follow-up of ST elevation myocardial infarction (STEMI) have been established, but the short term benefits of early statins prescription remain unproven, especially according to the reperfusion result.Aim of the studyTo assess the benefit of early statins prescription in in-hospital outcome of STEMI patients.MethodsBetween January 1995 and November 2011, 1388 patients admitted for STEMI have been included in the MIRAMI (MonastIR Acute Myocardial Infarction) registry. During this period, statins were introduced in early management of STEMI patients. This enabled us subdivide patients, after excluding those with missing treatment data, into 2 groups: early prescribed statins group (n=561) versus no statins prescribed group (n=804). We compared in-hospital outcome between these two groups and among the subgroups of successful or failure reperfusion therapy.ResultsIn the early statins prescription group, there was a significant reduction of in-hospital mortality (12.1% vs 5.3%, p

Background Despite significant progress made in diagnostic and therapeutic modalities, infective endocarditis (IE) remains a serious affection associated with considerable mortality and morbidity. Aim To describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Methods and results Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 176 patients who fulfilled the modified Duke criteria for native valve IE between January 1993 and December 2008. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 36.1±7.5 years. Diagnosis was definite in 85% of cases. Median time to diagnosis was 19 days. Rheumatic heart disease (RHD) was the predominant (47%) underlying heart condition. Mitral valve location was the most frequent seat of IE (37.7%). One or more vegetations were detected in more than 86.8% of cases. The median size of vegetation was >15 mm in 26% of cases. In 84 cases (48.5%), cultures remained negative. Serology was positive in 16 cases, and in 4 cases leaflet culture identified the agent. Causative microorganisms were mainly Staphylococci (n=42 (24.2%), including 8 coagulase-negative Staphylococcus), and Streptococci (n=32). Overall mortality was 18.6%. On multivariate analysis, congestive heart failure (hazard ratio = 5.62, 95% CI 1.32 to 12.54, p=0.008) and large vegetations (>15 mm; hazard ratio = 4.28, 95% CI 1.91 to 11.69, p=0.004) and neurological complications (hazard ratio = 3.27, 95% CI 1.84 to 9.11, p=0.002) were predictive of in-hospital mortality. Conclusion IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.

Background Hyperglycemia has been shown to be a powerful predictor of worse outcome after ST segment-elevation myocardial infarction (STEMI). The aim of this study was to investigate the relation between acute hyperglycemia and angiographic and clinical outcome after primary or rescue angioplasty for STEMI. Methods We prospectively included 383 patients who underwent revascularization for STEMI: 332 primary angioplasty and 51 rescue angioplasty, Plasma glucose was measured at hospital admission. Acute hyperglycemia (HG) was defined as plasma glucose of 11 mmol/L, regardless of the diabetic status. Results Among the 383 patients with STEMI included in the study, 158 (41.2%) patients had acute hyperglycemia. There was no difference among the two groups with regard to clinical characteristics, cardiovascular risk factors and hemodynamic parameters. Angioplasty success, TIMI 3 flow and ST segment resolution were significantly lower in acute HG group. On multivariate regression, HG wasn’t found to be an independant predictor of angioplasty success (p=0.08; OR=0.9; 95%IC [0.92–1]) or of ST resolution, however diabetes was independently associated with ST segment resolution after achieving TIMI 3 flow (OR= 3.2; 95% CI [1.02 – 8.1]; p=0.014). Acute hyperglycemia (OR: 3.8; p=0.005) was found to be an independent predictor of in-hospital mortality in multivariate analysis. Among the HG patients, mortality predictors were: glycemia level (OR=1.13; 95%CI [1.03–1.23]; p=0.005), Killip class (OR: 2.14; 95% CI [1.36 – 3.35]; p=0.001), blood hemoglobin level (OR: 0.69; 95%CI [0.53 – 0.9]; p=0.007), and angioplasty success (OR: 0.25; 95%CI [0.08–0.82]; p=0.022). Conclusion Acute hyperglycemia in patients with STEMI is an important predictor of mortality with an increasing mortality risk even beyond 11 mmol/L but diabetes is a better predictor of ST resolution after TIMI 3 restoring. This suggests the usefulness of assessment of glycemic metabolism in the setting of reperfusion for acute myocardial infarction and the beneficial effect of strict glycemic control.

Background Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. Objective We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome. Methods and results Two hundred and twenty consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n=144), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n=76, 34.5%). Aortic valve IE, elderly patients were more frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7-9.0); P=0.0013] and 1 year mortality [HR 1.8 (1.1-3.0); P=0.007]. Early surgery was performed in 63% of CHF patients with a peri-operative mortality of 15%. In the CHF group, comorbidity index, anemia, uncontrolled infection, and major neurological events were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR 0.45 (0.22-0.93); P=0.03]. Conclusion Native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.