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Background: Physical activity in the elderly is recommended by international guidelines to protect against cognitive decline and functional impairment. Objective: This Randomized Controlled Trial (RCT) was set up to verify whether medium-intensity physical activity in elderly people living in the community is effective in improving cognitive performance. Design: RCT with parallel and balanced large groups. Setting: Academic university hospital and Olympic gyms. Subjects: People aged 65 years old and older of both genders living at home holding a medical certificate for suitability in non-competitive physical activity. Methods: Participants were randomized to a 12-week, 3 sessions per week moderate physical activity program or to a control condition focused on cultural and recreational activities in groups of the same size and timing as the active intervention group. The active phase integrated a mixture of aerobic and anaerobic exercises, including drills of “life movements”, strength and balance. The primary outcome was: any change in Addenbrooke's Cognitive Examination Revised (ACE-R) and its subscales. Results: At the end of the trial, 52 people completed the active intervention, and 53 people completed the control condition. People in the active intervention improved on the ACE-R (ANOVA: F(1;102)=4.32, p=0.040), and also showed better performances on the memory (F(1;102)=5.40 p=0.022) and visual-space skills subscales of the ACE-R (F(1;102)=4.09 p=0.046). Conclusion: A moderate-intensity exercise administered for a relatively short period of 12 weeks is capable of improving cognitive performance in a sample of elderly people who live independently in their homes. Clinical Trials Registration No: NCT03858114

The prescription of antipsychotics in young children and adolescents is a delicate, complex, and often divisive issue, where official guidelines and real-world prescriptive habits seldom correspond.1 Such discrepancy is even more radical and excruciating in those conditions with an established higher risk of imminent development of an overt psychotic state (ie, Clinical High Risk for Psychosis [CHR-P] and the related diagnostic construct of DSM-5 Attenuated Psychosis Syndrome [APS]) that fall below the severity threshold for a DSM-5 diagnosis of schizophrenia and other psychotic disorders.

Background The prescription of antipsychotics outside overt psychotic conditions remains controversial, especially in youth where it is relatively widespread. Furthermore, some studies seem to indicate that antipsychotic exposure in individuals at ultra-high-risk (UHR) for psychosis is associated with higher conversion rates. This study was set up to test whether the inter-current prescription of antipsychotics in UHR patients was related to the psychometric threshold for a diagnosis of psychosis. Methods The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 125 UHR participants. Standard psychometric criteria were used to quantify conversion to psychosis. Kaplan-Mayer and Cox proportional hazard survival analysis were applied to determine the impact of having or not received the prescription of an antipsychotic drug. Results Over the study period 30 (24%) subjects received the prescription of an antipsychotic. In the sample, there were 31 participants (25%) who had reached the psychometric threshold for conversion to psychosis after 2 years of treatment. UHR people who received a prescription of antipsychotics during the first 2 years of treatment were statistically more likely to reach the psychometric threshold for conversion to psychosis on the BPRS: Hazard ratio = 3.03 (95%CI: 1.49-6.16); p = .003. Conclusion This finding supports the hypothesis that the prescription of antipsychotics within UHR cohorts is to be considered a red flag for higher incipient risk of conversion to psychosis.

BackgroundDepression is considered to be the most difficult to treat phase of bipolar disorder as patients experience residual symptoms causing long-term disability. This work aims to explore the role of add-on stimulant and stimulant-like medication in resistant bipolar depression patients.MethodsSystematic review of add-on stimulants and stimulant-like drugs in resistant bipolar depression by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Analysis was performed using the random-effects models. Heterogeneity was evaluated with Cochran’s Q and I2 statistics.ResultsSix randomized controlled trials of add-on modafinil, armodafinil, and lisdexamphetamine (LDX) (n = 813) vs placebo (n = 815) in the treatment of resistant bipolar depression were included. These drugs were more likely to induce remission from an episode of resistant bipolar depression (relative risk [RR] = 1.37; 95% confidence interval [CI]: 1.06-1.77; number needed to treat for an additional beneficial outcome = 16). Moreover, they did not induce more dropouts than placebo (RR = 1.04; 95% CI: 0.91-1.18), nor did they increase the risk of adverse effects (53/772 vs 41/771) at the end of treatment (RR = 1.30; 95% CI: 0.81-2.10; number needed to treat for an additional harmful outcome = 62). Suicidality and manic switch were not affected by active treatment. Heterogeneity was low (Cochran’s Q: P > .05), but sometimes with a large CI.ConclusionsLDX, modafinil, and armodafinil seem to offer a reasonably well-tolerated and safe treatment in resistant bipolar depression. Treatment guidelines should, therefore, be revised to include these medications earlier in the therapeutic algorithm for resistant acute bipolar depression. Further research is, however, necessary for the elucidation of the clinical usefulness of these and other similar compounds.

Structural brain abnormalities, including decreased gray matter (GM) and white matter (WM) volume, have been observed in patients with schizophrenia. These decrements were found to be associated with positive and negative symptoms, but affective symptoms (depression and anxiety) were poorly explored. We hypothesized that abnormalities in GM and WM volume might also be related to affective symptoms. GM and WM volumes were calculated from high-resolution T1 structural images acquired from 24 patients with schizophrenia and 26 healthy controls, and the associations of positive, negative, and affective symptoms with the brain volumes that showed significant reduction in patients were investigated. Patients demonstrated GM volume reductions in the bilateral prefrontal cortex, and WM volume reductions in the right frontal and left corpus callosum. Prefrontal cortex volume was significantly and inversely associated with both auditory-verbal hallucinations and depression severity. WM volume alterations, in contrast, were related to alogia, anhedonia, and delusions. The combined impact of auditory-verbal hallucinations and depression on similar sub-regions of the prefrontal cortex suggests that depression is involved in hearing voices. Further, this adverse impact of depression on prefrontal GM volume may underlie the impairment demonstrated by these patients in cognitive tasks that rely on executive processes.

Research on Clinical High-Risk for Psychosis (CHR-P) has led to a vigorous change in the field of early detection in psychiatry and is gradually expanding its focus toward early development. The Annual Research Review on psychosis risk in adolescents (Journal of Child Psychology and Psychiatry, 62, 2020 and 657) offers a wide-angle meta-analytical picture of such emerging trends in all areas relevant to CHR-P Research, that is, detection, prognosis, and intervention. This editorial perspective is meant to expand the clinical and conceptual reach of these meta-analytic findings in relation to (a) the influence of age on transition rate and scalability of the early detection model across the child-adolescent vs adult periods; (b) potential latent heterogeneity of the pathogenetic trajectories leading to CHR-P as suggested by comorbid psychopathologies; (c) controversial (or at least problematic) prognostic significance of antipsychotic exposure in CHR-P subjects, especially in children and adolescents.

Background: Restrictions during Covid-19 pandemic lockdown, in which rhythms of life have been compromised, can influence the course of bipolar disorder (BD). This study follows patients with bipolar disorder living in two geographically close cities (Cagliari and Tunis), but with different lockdown conditions: less severe in Tunis.Methods: Two cohorts were evaluated during lockdown (April 2020, t0) and 2 months later with lockdown lifted for a month (t1). Individuals were: over 18 years old without gender exclusion, BD I or II, in care for at least 1 year, received a clinical interview in the month before the start of the lockdown, stable clinically before the lockdown. The assessment was conducted by telephone by a psychiatrist or psychologist with good knowledge of patients. Diagnoses were made according to DSM-5 criteria. Depressive symptoms were collected through the Hamilton Rating Scale for Depression; cut-off 14 indicative of depressive episode. Circadian rhythms were measured using the BRIAN scale.Results: Forty individuals in Cagliari (70%female, age 48.57 ± 11.64) and 30 in Tunis (53.3% Female, age 41.8 ± 13.22) were recruited. In Cagliari at t0 45% had depressive episodes against none in Tunis, a similar difference appeared at t1. At t0 and t1 the Cagliari sample had more dysfunctional scores in the overall BRIAN scale and in the areas of sleep, activities and social rhythms; no differences were found in nutrition, both samples had predominantly nocturnal rhythm. In Cagliari at t0 and t1, the depressive sub-group showed more dysfunctional scores in the BRIAN areas sleep, activity, and nutrition. However, the differences in biological rhythms resulted, through ANCOVA analysis, independent of the co-presence of depressive symptoms.Discussion: A rigid lockdown could expose people with BD to depressive relapse through dysregulation of biological rhythms. The return to more functional rhythms did not appear 1 month after lockdown. The rekindling of the pandemic and the restoration of new restrictive measures will prevent, at least in the short term, the beneficial effect of a return to normality of the two cohorts.This was a limited exploratory study; future studies with larger samples and longer observational time are needed to verify the hypothesis.

To illustrate the main characteristics of the request for and choice of support by a population accessing a dedicated service for people bereaved through suicide.The participants were divided first according to their reason for requesting support and based on their choice of intervention, which were "caring" services (improve knowledge about suicide prevention, postvention and grief support) and "curing" services (psychotherapy, chat groups, and meditation retreats).The study was based on 539 participants, chiefly middle-aged women. Most had lost kin and the time since suicide ranged from 1day to 45 years. The main reasons for contacting the service were: seeking help for symptoms (42%), connecting with other suicide survivors (19%); 15% reported not knowing what to ask for. Among the participants, 30% participated in the "curing" interventions; they were slightly older and had more grief symptoms, some above the threshold for complicated grief. These participants had more often survived a child or partner and more frequently sought contact with other survivors or were more likely to be seeking help for symptoms.The presence on the web of a project specialized in the care of suicide survivors can provide a resource bringing them closer to curing their emotional pain.

Cognitive difficulties are common in people with psychosis and associated with considerable disability. Cognitive remediation (CR) can reduce the burden of cognitive difficulties and improve functioning. While mental health care has predominantly shifted to the community, people with greater illness severity and complexity, and those with poor response to treatment and concomitant greater cognitive difficulties, continue to receive inpatient care. The aim of this study is to review and evaluate the acceptability and efficacy of CR for inpatients with psychosis. A systematic search was used to identify randomized controlled trials of CR for inpatients with psychosis. Demographic and clinical information was extracted by independent raters together with therapy outcomes. Study quality was assessed using the Cochrane Collaboration Risk of Bias Assessment tool. Standardized mean change for cognitive and functional outcomes was calculated using Hedges's g and used to infer therapy effects with meta-analysis. Twenty studies were identified considering 1509 participants. Results from random-effect models suggested that CR was effective in improving processing speed (g = 0.48), memory (g = 0.48) and working memory (g = 0.56). While there was an indication of improvements in the levels of vocational, social and global functioning, these were less reliable. On average, 7% of participants dropped-out of treatment. Studies methodological quality was moderate. CR is an acceptable intervention for inpatients with psychosis and can lead to significant cognitive improvements. Evidence for improvement in functioning requires more robust and converging evidence. Future research should extend the evaluation of inpatient CR to subsequent post-discharge community functioning and further need for care.

BackgroundWorking memory (WM) refers to the capacity system for temporary storage and processing of information, which is known to depend on the integrity of the prefrontal cortex. Impairment in working memory is a core cognitive deficit among individuals with psychotic disorders. The Corsi block-tapping test is a widely-used instrument to assess visuospatial working memory. The traditional version is composed of 9 square blocks positioned on a physical board. In recent years, the number of digital instruments has increased significantly; several advantages might derive from the use of a digital version of the Corsi test.MethodsThis study aimed to compare the digital and traditional versions of the Corsi test in 45 patients with psychotic disorders and 45 healthy controls. Both groups completed a neuropsychological assessment involving attention and working memory divided into the two conditions.ResultsResults were consistent between the traditional and digital versions of the Corsi test. The digital version, as well as the traditional version, can discriminate between patients with psychosis and healthy controls. Overall, patients performed worse with respect to the healthy comparison group. The traditional Corsi test was positively related to intelligence and verbal working memory, probably due to a more significant effort to execute the test.ConclusionsThe digital Corsi might be used to enhance clinical practice diagnosis and treatment.The digital version can be administered in a natural environment in real-time. Further, it is easy to administer while ensuring a standard procedure.

BackgroundThe clinical high-risk (CHR) for psychosis paradigm is changing psychiatric practice. However, a widespread confounder, i.e. baseline exposure to antipsychotics (AP) in CHR samples, is systematically overlooked. Such exposure might mitigate the initial clinical presentation, increase the heterogeneity within CHR populations, and confound the evaluation of transition to psychosis at follow-up. This is the first meta-analysis examining the prevalence and the prognostic impact on transition to psychosis of ongoing AP treatment at baseline in CHR cohorts.MethodsMajor databases were searched for articles published until 20 April 2020. The variance-stabilizing Freeman-Tukey double arcsine transformation was used to estimate prevalence. The binary outcome of transition to psychosis by group was estimated with risk ratio (RR) and the inverse variance method was used for pooling.ResultsFourteen studies were eligible for qualitative synthesis, including 1588 CHR individuals. Out of the pooled CHR sample, 370 individuals (i.e. 23.3%) were already exposed to AP at the time of CHR status ascription. Transition toward full-blown psychosis at follow-up intervened in 112 (29%; 95% CI 24–34%) of the AP-exposed CHR as compared to 235 (16%; 14–19%) of the AP-naïve CHR participants. AP-exposed CHR had higher RR of transition to psychosis (RR = 1.47; 95% CI 1.18–1.83; z = 3.48; p = 0.0005), without influence by age, gender ratio, overall sample size, duration of the follow-up, or quality of the studies.ConclusionsBaseline AP exposure in CHR samples is substantial and is associated with a higher imminent risk of transition to psychosis. Therefore, such exposure should be regarded as a non-negligible red flag for clinical risk management.

Offspring of individuals with serious mental illness (SMI) constitute a special population with a higher risk of developing psychiatric disorders, which is also highly prevalent among referrals to child and adolescent mental health services (CAMHS). They often exhibit more or less subclinical conditions of vulnerability, fueled by mutually potentiating combinations of risk factors, such as presumed genetic risk, poor or inadequate affective and cognitive parenting, and low socio-economic status. Despite this evidence, neither specific preventive programs for offspring of parents with SMI are usually implemented in CAMHS, nor dedicated supportive programs for parenting are generally available in adult mental health services (AMHS). Needless to say, while both service systems tend to focus on individual recovery and clinical management (rather than on the whole family system), these blind spots add up to frequent gaps in communication and continuity of care between CAMHS and AMHS. This is particularly problematic in an age-range in which an offspring's vulnerabilities encounter the highest epidemiological peak of incident risk of SMI. This paper offers a clinical-conceptual perspective aimed to disentangle the complex intertwine of intergenerational risk factors that contribute to the risk of developing SMI in offspring, taking schizophrenia spectrum disorders as a paradigmatic example.

Background: The impact of the comorbidity between Obsessive-Compulsive Disorder (OCD) and Bipolar Disorder Spectrum (BDS) remains to be clarified. The objective of this study was to examine the lifetime prevalence of OCD, the strength of the association of OCD with comorbid BDS and the role of comorbidity of OCD with BDS in the impairment of health-related quality of life (HRQoL) in an Italian community survey.Methods: The study is a community survey. The sample (N = 2,267; women: 55.3%) was randomly selected after stratification by sex and four age groups from the municipal records of the adult population of one urban, one suburban, and at least one rural area in six Italian regions. Physicians using a semi-structured interview (Advanced Tools and Neuropsychiatric Assessment Schedule, ANTAS-SCID) made Diagnostic and Statistical Manual of Mental Disorders – 4th revision (DSM-IV) diagnoses of OCD, Major Depressive Disorder (MDD) and Bipolar Disorder (BD). HR-QoL was measured by the Health Survey Short Form (SF-12). Lifetime Hypomania and subthreshold hypomania were screened by the Mood Disorder Questionnaire (MDQ). BDS was defined as the sum of people shown to be positive for hypomania by the MDQ—with or without a mood disorder diagnosis—plus people with a BD-DSMIV diagnosis even if negative for hypomania at the MDQ.Results: Overall, 44 subjects were diagnosed with OCD, 6 with MDD and 1 with BD. The lifetime prevalence of OCD was 1.8% in men (n = 18) and 2.0% in women (n = 26). MDD with lifetime subthreshold hypomania (i.e., people screened positive at the MDQ, even without diagnosed mania or hypomania at the interview) was associated with OCD (OR = 18.15, CI 95% 2.45–103.67); MDD without subthreshold hypomania (and screened negative at the MDQ) was not (OR = 2.33, CI 95% 0.69–7.01). People with BDS were strongly associated with OCD (OR = 10.5, CI 95% 4.90–12.16,). People with OCD and BDS showed significantly poorer HR-QoL than people with OCD without BDS (F = 9.492; P < 0.003).Discussion: The study found a strong association between BDS and OCD. BDS comorbid with OCD was associated with more severe impairment of HR-QoL than OCD without comorbid BDS. Identification of symptoms of hypomania, including subthreshold symptoms, may therefore be important in people with OCD as they might predict a course with poorer HR-QoL.

The strategic value of early, preventive intervention in psychosis has been a catalytic stepping stone to promoting early intervention in Mental Health. Central to such momentum is the construct of clinical high risk states for psychosis (CHR). While CHR emerge in developmental years, the meta-analytical risk of psychosis among children and adolescents (age 9-18 years) at CHR is still unknown. We conducted a meta-analysis according to PRISMA guidelines including all studies that assessed CHR in children and adolescents (age ≤ 18 years) with validated instruments and provided follow-data on transition to psychosis up to December 31, 2018. We identified 11 eligible studies. Mean age was 15.8 ± 0.8 years, range: 13.8 to 16.8. Transition to psychosis occurred in 93 CHR subjects out of 533 that were enrolled at inception, over a follow-up period ranging from 6 to 72 months. Conversion prevalence was 17.5% (95% CI: 9.9% to 26.5%) in the random-effects model (Q = 30.9; p

QuestionRecent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression. The literature on panic disorder (PD) comorbid with BD has been systematically reviewed and subject to meta-analysis.Study selection and analysisThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were thoroughly followed for literature search, selection and reporting of available evidence. The variance-stabilising Freeman-Tukey double arcsine transformation was used in the meta-analysis of prevalence estimates. Both fixed-effect and random-effects models with inverse variance method were applied to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran’s Q and I2 statistics.FindingsOverall, 15 studies (n=3391) on cross-sectional prevalence and 25 independent lifetime studies (n=8226) were used to calculate pooled estimates. The overall random-effects point prevalence of PD in patients with BD, after exclusion of one potential outlier study, was 13.0% (95% CI 7.0% to 20.3%), and the overall random-effects lifetime estimate, after exclusion of one potential outlier study, was 15.5% (95% CI 11.6% to 19.9%). There were no differences in rates between BD-I and BD-II. Significant heterogeneity (I2 >95%) was found in both estimates.ConclusionsEstimates that can be drawn from published studies indicate that the prevalence of PD in patients with BD is higher than the prevalence in the general population. Comorbid PD is reportedly associated with increased risk of suicidal acts and a more severe course. There is no clear indication on how to treat comorbid PD in BD. Findings from the current meta-analysis confirm the highly prevalent comorbidity of PD with BD, implicating that in patients with BD, PD might run a more chronic course.

The time from symptom onset to reperfusion is a critical determinant of myocardial salvage and clinical outcomes in patients with acute myocardial infarction (AMI). This time period could be delayed if people do not seek help promptly and/or if the health system is not efficient in responding quickly and attending to these individuals. The aim of this study was to identify psychological factors associated with pre-hospital delay (PHD) or patients’ decisional delay (PDD) in people with an ongoing AMI. A search in PubMed/Medline from 1990 to 2021 with the keywords “pre-hospital delay” OR “prehospital delay” OR “patient delay” OR “decisional delay” OR “care seeking behavior” AND “psychological factors” OR “alexithymia” AND “myocardial infarction” was performed. Thirty-six studies were included, involving 10.389 patients. Wrong appraisal, interpretation and causal beliefs about symptoms, denial of the severity of the symptoms and high levels of alexithymia were found related to longer PHD or PDD. Alexithymia may be an overarching construct that explains the disparate findings of the studies exploring the role of psychological factors in PHD or PDD. Further studies are needed in order to analyse the role of alexithymia in patients with risk factors for AMI to prevent delay.

Background Suicide bereavement is frequently related to clinically significant psychological distress and affected by stigma. This study was designed to evaluate the relationship between psychological distress by psychopathological domains and stigma, in a sample of individuals bereaved by suicide (suicide survivors). Methods The data were collected between January 2012 and December 2014 and included information on sociodemographic variables (gender, age, marital status and education level) and responses to the Stigma of Suicide Survivor scale (STOSSS) and the Brief Symptom Inventory (BSI). One hundred and fifty-five suicide survivors completed the evaluation and were included in the study. Results Levels of psychological distress in suicide survivors, as measured by BSI, were positively related to levels of perceived stigma toward suicide survivors, as measured by STOSSS. The association was not affected by age and gender, or by marital status, education level, days from suicide or a personal history of suicide attempt. Participants with higher scores on almost all subscales of the BSI, particularly the interpersonal sensitivity and paranoid ideation subscales, reported the highest levels of perceived stigma toward suicide survivors. Conclusion Levels of distress in subjects bereaved by the suicide of a relative or friend were positively associated with levels of perceived stigma toward suicide survivors. Specific interventions dedicated to the bereavement of suicide survivors might help to alleviate not only psychological distress but also stigma towards loss by suicide.

Background Obsessive-compulsive disorder (OCD) is often comorbid with Bipolar Disorder (BD), complicating its presentation and management. OCD prevalence rates in BD vary widely across studies and recent meta-analyses. Objective We performed a comprehensive systematic review and meta-analysis of studies reporting cross-sectional or lifetime OCD prevalence in BD, assessed by meta-regression various determinants of estimated prevalence and compared it with major depressive disorder (MDD) patients and general population subjects included in extracted studies. Methods Relevant articles published up to January 2019 in PubMed/MEDLINE were retrieved. Prevalence rates underwent Freeman–Tukey double arcsine transformation before meta-analysis. Results We included 29 studies reporting cross-sectional prevalence (N = 6109) and 39 studies reporting lifetime prevalence (N = 8205); eight studies reported both. The pooled lifetime and cross-sectional prevalence of comorbid OCD in BD was estimated at 10.9% (95% CI: 7.8–14.4%) and 11.2% (7.6–15.3%), respectively, in the random-effects model. Respective estimates in the general population were 2.5% and 1.6%. Study setting (epidemiological or clinical), diagnostic criteria and procedures, gender, BD subtype and remission status could not explain heterogeneity of prevalence estimates in meta-regressions. Age had a small yet significant negative correlation with lifetime prevalence. OCD prevalence in BD was not significantly different than in MDD. Limitations Search was limited to English-language literature. Conclusions Lifetime OCD prevalence in BD was 4.4 times higher than in the general population. Cross-sectional prevalence was as high as lifetime, suggesting that OCD in BD is more chronic/ persistent than in the general population, where cross-sectional stands at about two thirds the lifetime prevalence.

Background: The assessment of pain and its impact on quality of life is central to the evaluation of chronic pain syndromes. However, most available tools focus on the nociceptive experience of pain, and at best only consider the occurrence of anxious, depressive, or cognitive problems. Here is a new questionnaire aimed at measuring the multifaceted impact of pain in chronic pain syndromes, the Bodily and Emotional pErception of Pain (BEEP). Methods: All consecutive patients who accessed a center for the treatment of pain were invited to take part in the study. The sample included 222 participants (51 with fibromyalgia, 84 with low back pain; 87 with other chronic pain syndromes). Women were 77% of the sample, the mean age was 61 ± 15. Participants completed the BEEP, the Patient Health Questionnaire-9 (PHQ-9), and the Mood Disorder Questionnaire (MDQ). Results: Reliability was good for all questionnaires. The expected three dimensions of the BEEP were confirmed by confirmatory factor analysis, and a bifactor model with three orthogonal factors showed a good fit as well. Participants diagnosed with fibromyalgia showed higher scores on the BEEP than the participants who had been diagnosed with low back pain or other chronic pain syndromes. The prevalence of probable cases of major depression and bipolar disorder in the sample was higher than expected for non-clinical samples. Levels of depression, as measured by the PHQ-9, were associated with the three dimensions of the BEEP and with the intensity of pain. Conclusions: The BEEP is a promising measure of the impact of pain in daily life and differentiates fibromyalgia from other chronic pain syndromes. The BEEP may be helpful to evaluate the patient's response to the treatment over time and may favor the identification of unmet needs in patients' personal, social, and daily functioning.

Introduction: Persistent Depressive Disorder (PDD) is a nosological entity introduced with DSM-5, encompassing numerous different conditions including Dysthymia, recurrent Major Depressive Disorder, Double Depression and Chronic Major Depression. PDD is a particularly significant cause of disease burden in the general population. Areas covered: In the present paper, the authors explore the controversies surrounding the definition of PDD, the current approach to its treatment endorsed by the major scientific bodies, along with the available evidence on the efficacy of said treatments. Expert opinion: Clinicians need to be particularly vigilant and always gather a thorough history. In this diagnostic group, there is a relevant risk of having an undiagnosed Bipolar Disorder as affected individuals typically fail to recognize the pathological components of hypomanic episodes. In this setting, it is crucial to reconsider the diagnosis and to frequently verify compliance with the treatment plan. Numerous technological advances, particularly in the neuroimaging field, offer new insight and new challenges in defining the pathophysiological mechanisms of depressive syndromes. In the future, these advances may offer guidance towards an improved treatment approach and diagnostic process.

Introduction: The aim of the study was to measure the lifetime prevalence of Post-Traumatic Stress Disorder (PTSD) among women of an Italian community sample, the comorbidity of PTSD with mood and anxiety disorders and the burden attributable to PTSD in worsening the Quality of Life (QoL). Methods: Community survey on a sample of 1961 adult women randomly selected. Tools: psychiatric clinical interview ANTAS partially derived from the SCID-DSM-IV, administered by psychologists or medical doctors; Short Form Health Survey (SF-12); Mood Disorder Questionnaire (MDQ). Results: Lifetime prevalence of PTSD in women was 1.3%, (1.4% in44 years aged; p=0.8). In order of risk of comorbidity, PTSD was associated with: Bipolar Spectrum Disorders (MDQ+), Panic Disorders (PD) and Major Depressive Disorder (MDD). People with PTSD showed an SF-12 mean score lower than women of the same sample without PTSD (standardized by gender and age), with a mean difference (attributable burden) of 3.9±0.9 similarly to MDD and Eating Disorders and higher than PD. Among the analyzed nonpsychiatric diseases, Multiple Sclerosis and Carotid Atherosclerosis showed a higher burden in impairing QoL than PTSD; Wilson’s Disease showed a similar burden and Celiac Disease was found less impairing on QoL than PTSD. Conclusion: The attributable burden in worsening women’ perceived QoL due to a lifetime diagnosis of PTSD was found comparable to those caused by MDD, Eating Disorders or by neurological condition such as Wilson’s Disease. The comorbidity of PTSD with Bipolar Spectrum Disorders was remarkable, even further studies are needed to clarify the direction of causality.

Introduction:Physical activity helps to improve several clinical outcomes of people with severe psychosocial disabilities. The aims of this study were; 1) to assess the efficacy of a psychosocial rehabilitative intervention focused on sailing in a crew on: a) social functioning; b) severity of the psychosocial disability; c) general functioning; d) dysregulation of biorhythms of people with severe psychosocial disabilities, and 2) to evaluate the attenders’ satisfaction about the project.Methods:A randomized waitlist controlled trial with parallel groups was carried out involving 51 people with severe psychosocial disabilities. The intervention was a 3 months-lasting course to learn sailing in a crew. Just after the randomization, a group began the sailing course and the other group (wait list) attended the sailing course after 3 months of treatments as usual. Before and after the sailing course, as well as the waiting list period, all attenders were assessed by HoNOS, GAF, CGI-S and BRIAN. At the end of the sailing course, they completed also a self-report satisfaction questionnaire.Results:Social functioning significantly improved after the sailing course (HoNOS total score “time X group”: p=0.011), mainly because of the improvement of psychopathological symptoms (HoNOS symptoms score “time X group”: p=0.003). Furthermore, participants greatly appreciated the rehabilitative program based on sailing in a crew.Conclusions:When compared to more traditional rehabilitative activities that are usually carried out in mental health services, a psychosocial rehabilitative intervention based on sailing in a crew significantly improve the social functioning of people with severe psychosocial disabilities.

Aim: The aim of this study was to evaluate the differences between teachers' knowledge about early psychosis among three different Italian cities and a UK sample. Methods: The sample consisted of 556 secondary school teachers from three different cities in Italy (Milan, Rome and Lamezia Terme) and London (UK). The research was based on the Knowledge and Experience of Social Emotional Difficulties Among Young People Questionnaire. The Italian version of the questionnaire was used in Italy. Results: Overall, 67.6% of English teachers, 58.5% of Milan's teachers, 41.8% of Rome’s teachers and 33.3% of Lamezia Terme’s teachers were able to recognise psychotic symptoms from a case vignette. Logistic regression analysis showed that 'city' was the only independent variable significantly related to the correct/wrong answer about diagnosis. Conclusions: We found statistically significant differences between the three Italian samples and the UK sample regarding teachers' knowledge about first signs of psychosis. English teachers showed a better knowledge than Italian teachers in general. Teachers from Milan, where a specific early detection program was established in 2000, seemed to be more familiar with early signs of psychosis than teachers in the other two Italian towns.

Despite the evidence of risks related to the use of anabolic steroids for the improvement of athletic performances, the diffusion of such drugs appears to be increasing. An exploratory study was conducted in Cagliari, Italy, to assess the level of information on this issue, to esteem the use of steroids among athletes, to measure the wellbeing of athletes and the risks related to steroid use. A sample of 192 athletes, including 142 non-agonists and 50 agonists (age range: 18 to 36) was invited to fill in a booklet including several self-report questionnaires. The questionnaire for the assessment of the beliefs regarding the effects of anabolic steroids was developed and validated for the study, while the Self Reporting Questionnaire was used for the assessment of the mental health aspects. A general lack of information on the specific effects of steroid use on general and psychic health, as well as on sportive performances was found. Athletes were also quite unaware of the diffusion of steroids among them. Since the sportive environment seems to be the main source of information, this channel should be targeted to address the prevention and information campaigns. The use of more specific tools and the investigation of the perception of reliability of the information sources as well as the social desirability issues should be explored in future studies.

Treatment in early intervention services (EIS) seems superior to treatment as usual on several outcomes, but the extent of heterogeneity in response is unclear. In this study, treatment response trajectories up to 2 years in first-episode psychosis (FEP) patients enrolled in an Italian early intervention service (EIS) have been quantified. The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 129 participants. Conditional growth modeling and latent class growth analysis were used to test changes over time in the BPRS and separation into independent classes over time. Group differences were tested on socio-demographic and clinical variables known to be related to outcome in psychosis. Scores on the BPRS showed a statistically significant decrease in overall scores across all tested models. Four trajectories were identified across 2 years. Most patients showed a progressive decrease in the BPRS scores; a scant fraction showed a more stepped decrease from very high levels of psychopathology. No potential predictor was statistically related to the time course of BPRS scores. Most patients that undergo treatment within an EIS are characterized by amelioration, but patients that have higher baseline scores of psychopathology require more intensive treatment.

Gender is associated with several features of psychotic disorders, including age of illness onset, symptomatology, a higher prevalence of history of childhood sexual abuse (CSA) and needs for care. Childhood sexual abuse is associated with adverse mental health consequences but as there is a gender difference in stress reactivity, there may be a differential impact of CSA on psychopathology, age of psychosis onset and needs for care in First Episode Psychosis (FEP) patients. We hypothesized that a history of abuse would be associated with lowering of age of onset, increased symptomatology and more unmet needs in women but not men. A total of 444 FEP patients have been recruited within the context of the GET UP trial. Symptomatology has been assessed using the PANSS scale, needs for care with the CAN scale and childhood abuse with the CECA-Q scale. Childhood sexual abuse was more frequent among female patients [22.6% in women vs 11.6% in men (OR = 0.45, p 0.01)], whereas there was no gender difference in the prevalence of childhood physical abuse (29.0% in women vs 31.7% in men). Childhood abuse was associated with higher levels of negative symptoms in both men and women, with a reduced age of onset in women only and little increase in needs for care in both men and women. Our results seem to suggest that childhood sexual abuse in female FEP patients may be linked to a more severe form of psychosis whose presentation is characterized by earlier age of onset and higher levels of negative symptoms and we can also speculate that gender-specific protective factors in women, but not in men, may be outweighed by the consequences of childhood abuse.

Populations fleeing war have often suffered or have witnessed violence, persecution, and imprisonment; they are at high risk of exposure to traumas and consequently to manifesting psychopathologies, stress-related disorders, and post-traumatic stress disorder (PTSD). Regarding the condition of refugees, factors inherent in the conditions of escaping, traveling, and reception in the host country can also aggravate the psychopathology linked to previous traumas, or even add new ones. The prevalence of PTSD in refugee camps in Africa varies from 15.8% in Ethiopia to 37.4% in Algeria. The presence of any severe mental disorder ranged from 17.5% in Ethiopian to 60.5% in Algerian refugees. In people of three Sub-Saharan refugee camps in postwar scenarios in Darfur Hamid and Musa, 54% of people were found positive at a screening test for PTSD and 70% positive in a screening test for general distress. The literature contains several studies on small cohorts in refugee camps suffering from disorders who had been subjected to specific treatments. However, studies on population samples or entire refugee populations repeated over time are infrequent. One of the studies, considered as a milestone in this field, shows in Bosnian refugees in Croatia that 45% of those who met the DSM-IV criteria for depression or PTSD presented these disorders 3 years later, and 16% of asymptomatic persons developed the disorders. A decrease in psychiatric symptoms at follow-up was shown 10 years later, but people suffering from PTSD showed an upward trend and the presence of PTSD was found associated with the unsuccessful extinction of traumatic memories. The few studies found in the literature do not clarify what social mechanisms may occur in the processes of recovery of hope, also because the different circumstances studied probably present specific variables that characterize each situation. However, the results of some studies, even on minors, appear to suggest that restoring a condition of safety and responding to primary needs is not always associated with an improvement in general and stress-related psychopathology. We had previously evaluated a sample of refugees of Tuareg ethnicity who were living in the Subgandé refugee camp in Burkina Faso. At that time (immediately after the crisis in Mali), refugees in the camp were faced with strong tensions and fear. There were no international organizations guaranteeing security and survival. These refugees had fled from Mali with very little information on those who had remained behind. Meanwhile, interventions by Islamic extremists meant that the political and military situation was not going well for the Tuaregs, who were fighting for independence. The majority of the Tuareg rebels were in fact engaged in the MLNA (Mouvement de Liberation de l’Azawar), the lay and losing party of the Malian rebels (1). At that time, around 60% of our sample had screened positive for the contemporary presence of both psychopathological stress-related symptoms (as positivity to Short Screening Scale for PTSD) and for the presence of general psychopathological symptoms and impairment linked to psychopathology [as positivity to the K6 screening scale], thus indicating severe mental distress and probable PTSD. Women aged 40 and older were found to be at higher risk of PTSD symptoms. Younger women (39 or younger) had higher frequencies of K6 positivity, but the distribution of people with both PTSD and K6 scales positivity was homogeneous by gender and age. During the 2-year period, many people had left the Subgandé camp and had been relocated to other camps where they appeared to be better supported. In this follow-up study 2 years later, we retraced a substantial portion of the first sample, but many were about to return to Mali. The aim of the follow-up is to ascertain the health status of those previously interviewed and those we were able to trace. We wanted to see whether the amended general conditions (e.g., protection provided by international organizations and the conclusion of negotiations) had contributed to changes in the levels of mental distress.

Background: Schizotypal traits are expressions of underlying vulnerability to psychotic disorders which have a potential impact on mental health status, neurocognition, quality of life, and daily functioning. To date, little research has examined epidemiologic landscape of schizotypal traits at the cross-national level. Our aim was to study the expression of schizotypal traits by sex, age, and country in a combined sample gathered from 12 countries. Methods: A total of 27,001 participants completed the Schizotypal Personality Questionnaire (SPQ). The mean age of participants was 22.12 (SD = 6.28); 37.5% (n = 10,126) were males. Results: Schizotypal traits varied according to sex, age, and country. Females scored higher than males in the positive dimension, whereas males scored higher in the disorganization dimension. By age, a significant decrease in the positive schizotypal traits was observed. Epidemiological expression of schizotypal traits varied by country. Moreover, several interactions by sex, age, and country were found. Conclusions: This pattern is similar to those found in patients with psychosis and psychotic-like experiences. These findings provide new insights and the opportunity to explore the phenotypic expression of schizotypal traits at cross-national level. © 2018

Background: The aim was to study the association between mood and anxiety disorders and the Tako-Tsubo Syndrome (TTS) and to determine the role of antidepressants and the impairment of quality of life due the comorbid psychiatric disorder. Methods: Case-control study: 19 consecutive patients (17 female) with TTS compared to 76 controls without TTS, were randomly selected from the database of a nationwide epidemiological study after matching (gender, age and residence) by controls. Psychiatric diagnoses were carried out according to the ICD-10 using semi-structured interview tools (ANTAS-SCID) administered by clinical staff. Quality of Life (Qol) was assessed by means of SF-12. Results: Only Major Depressive Disorders (MDD) showed higher frequencies in cases with statistical significance difference (p=0.014) as well as at least one Mood Disorder Diagnosis [MDD or BD] (p=0.002). The lifetime prevalence of at least one anxiety disorder with no comorbid mood disorder did not show a higher frequency in cases (p=0.57). The score at SF-12 in the TTS group was similar to those of controls (p=0.71)In the TTS group, the score at SF-12 in people with one mood or anxiety diagnosis (N=7) was similar to those without mood or anxiety diagnosis (p=0.75). The use of antidepressants was higher in TTS group (15.79% vs 1.31%; p=0.030). Conclusion: The study shows an association between TTS with depressive disorders and antidepressants use and does not confirm the association with anxiety syndromes. The study suggests the need to investigate the possible interactions between antidepressants use and mood disorders in studies with appropriate design and sample size.

Adjustment disorder is a condition of subjective emotional distress triggered as a consequence of a meaningful change in life. The diagnosis of adjustment disorder is hindered by the difficult operational definition of stress and of its related concept of “vulnerability,” by the problem of disentangling symptoms of adjustment disorder from those attributable to comorbid anxiety and mood disorders, and by the poor boundaries of the disorder with other stress-related conditions on the one hand and with common adaptation to life events on the other. Despite the high frequency of its diagnosis in clinical settings, there has been relatively little research on the adjustment disorder and, consequently, very few hints about its treatments. Several psychotherapies have been developed to deal with patients diagnosed with adjustment disorder, with inconclusive evidence on their effectiveness. Antidepressants may abate the symptoms and help patients reacquire occupational and social functioning. The medium-term outcome of adjustment disorder is good, with 70 to 80% of those diagnosed with it showing no evidence of psychopathology when reassessed 5 years from the episode. However, when comorbid with a personality disorder or a substance use disorder, the short-term risk of suicide may be increased. The long-term outcome of adjustment disorder seems to be worse in children and adolescents than in adults. In particular, adolescents diagnosed with adjustment disorder were more likely than adults to have received a diagnosis of a severe mental disorder at the 5-year follow-up, including schizophrenia, schizoaffective disorder, and bipolar disorder. This review contains 1 figure, 6 tables, and 52 references. Key words: adaptation, adjustment disorder, anxiety, depression, stress, trauma, treatment, vulnerability

Aim This is the first comprehensive, nationwide survey aimed at collecting evidence about the process of implementation and development of early intervention in psychosis (EIP) services (EIPs) in Italy, following the establishment of the pilot program ‘Programma 2000’ in 1999 and the publishing of the Italian National Guidelines in 2007. This survey covers all the Departments of Mental Health (DMHs) operating in Italy in 2013. Methods Using a purpose-designed form to assess EIP implementation, all directors of public mental health services for adults throughout Italy (n = 216) were asked to provide information about the activities of EIP-relevant local services. The initial delivery was followed by a request for a prompt response. Results Out of 216 enquired DMHs, 103 provided computable answers to the survey (response rate = 48%). Among responders, 45 (44%) reported the implementation of EIP (one out of five DMHs operating in Italy). About a half of the active EIPs also targeted patients at ultra-high risk of psychosis (n = 27). Strict application of guidelines related to drug prescription was reported in 35% of EIPs. Conversely, 90% provided some kind of structured psychotherapy and psychoeducation. Among EIPs, a minority reported willingness to provide initial assessment/contact at the patient's home. Conclusion Albeit slowly, the implementation of EIP is spreading throughout the Italian public network of mental health. There is still a wide variability in the distribution of EIP services across the Italian territory. Further efforts are necessary to stimulate policy endorsement and resource allocation, as well as to support the poorest zones.

The aim of this study was to evaluate whether the number of women recruited for studies to establish the efficacy of medications approved for treatment of alcohol dependence (AD) and of alcohol withdrawal syndrome (AWS) is sufficient to reveal possible gender differences in the response to these medications and in suggesting the use of different doses in female patients. Our results show that the rates of women recruited for studies evaluating the efficacy of disulfiram (1%), benzodiazepines (3%), and anticonvulsants (13%) were too low to establish possible gender differences. The rates of women recruited for studies evaluating the efficacy of acamprosate (22%), naltrexone (23%), and nalmefene (30%) were higher and allowed evaluation of data obtained for female patients. Women receive medications for treatment of AD and/or AWS for which efficacy has been demonstrated in studies in which men were more largely represented.

Background:The migrants crossing the Mediterranean towards Europe have dramatically been increased in 2015 as the number of incidents and deathsObjective:This editorial summarizes the results of our work and highlights some critical aspects that hinder the care to asylum seekers with stress disorders.Method:Screening for mental disorders was performed in all migrants joint three camps in Sardinia (January-September 2015) using K6, Short Screening Scale for Post Traumatic Stress Disorder (PTSD) and with an interview. Positives were evaluated by psychiatrists and if they needed, have been treated and evaluated at the start of treatment and three months later.Results:22.1% of the sample, (22.6% female, 38.5±12.9 years) were positive for at least one screener; 8.7%, (24% female) had a diagnosis of depressive or bipolar DSM5 disorders and 7.6%, (25% female) of PTSD. After three months of treatment: 51 treated people (26.8%) had left the camps. 53.1% of those remaining declared had relatives in northern Europe that they wanted to reach. Only 8.3% showed a significant clinical improvement.Conclusion:Clinical improvement was dramatically poor in people who stay in the camps. Dissatisfaction and feeling they could not join relatives may have had a negative impact. In PTSD, with the experience of torture and seeing family members killed, staying with surviving relatives in stable conditions would be an important part of treatment. From this point of view the UE Dublin Regulation seems not to be in agreement with the UN Convention on the rights of persons with disabilities

Lutgens et al' s interesting paper[1][1] describes the results of their meta-analytic study on the effect of psychosocial interventions on negative symptoms for people with psychosis. Despite commending the aims of the study we have some methodological reservations on the results presented. We

Cardio-vascular diseases (CVDs) and CVD-related disorders (including cerebrovascular diseases; CBVDs) are a major public health concern as they represent the leading cause of mortality and morbidity in developed countries. Patients with CVDs and CBVDs co-morbid with mood disorders, especially bipolar disorder (BD) and major depressive disorder (MDD), suffer reduced quality-of-life and significant disability adjusted for years of life and mortality. The relationship between CVDs/CBVDs and mood disorders is likely to be bidirectional. Evidence for shared genetic risk of pathways involved in stress reaction, serotonin or dopamine signalling, circadian rhythms, and energy balance was reported in genome-wide association studies. There is some evidence of a neuroprotective effect of various antidepressants, which may be boosted by physical exercise, especially by aerobic ones. Patients with CVDs/CBVDs should be routinely attentively evaluated for the presence of mood disorders, with tools aimed at detecting both symptoms of depression and of hypomania/mania. Behavioural lifestyle interventions targeting nutrition and exercise, coping strategies, and attitudes towards health should be routinely provided to patients with mood disorders, to prevent the risk of CVDs/CBVDs. A narrative review of the evidence is herein provided, focusing on pharmacological and physical therapy interventions. © 2017 Institute of Psychiatry and Johns Hopkins University.

Background:Research literature suggests that burnout, depression, and a low mental quality of life (QOL) are common among health care workers. Economic crisis might have increased the burden of burnout, depression and low QOL in health care workers.Objectives:To identify depression risk, burnout levels, and quality of life in a sample of workers of an Italian university hospital.Method:Cross sectional study with comparison with two community surveys database results (n = 2000 and 1500, respectively). Overall, 522 workers accepted to take part in the study, representing a 78% response rate (out of 669 individuals).Results:The frequency of positivity at the screener for Major Depressive Disorder among health care workers was more than double than that in the standardized community sample (33.3% vs 14.1%, pi.e.those who do not have contact with patients), showed a statistically higher frequency of positivity for depressive episodes compared to the controls. Among the medical staff, the highest risk was found in the surgeon units, while the lowest one was in the laboratories. Surgeons also were those most exposed to high risk of burnout, as measured by the Maslach Burnout Inventory.Conclusion:Since burnout is linked to patient safety and quality of patient care, and contribute to medical errors, dedicated interventions aimed at reducing poor mental health and low quality of life in medical staff are indicated.

INTRODUCTION: Cognitive deficits can precede the onset of psychotic episodes and predict the onset of the illness in individuals with schizotypy traits. In some studies, high levels of schizotypy were associated with impairments in memory, attention, executive functions, and verbal fluency. This review provides a more comprehensive understanding of cognitive impairments related to schizoytpy. METHODS: A systematic review of "schizotypy and neuropsychological measures" was conducted, and it retrieved 67 studies. All papers with case-control design showing means and standard deviations from neuropsychological measures were included in a meta-analysis (n = 40). A comparison between our finding and another metaanalysis with patients with schizophrenia-spectrum disorders [Fatouros-Bergman, H., Cervenka, S., Flyckt, L., Edman, G., & Farde, L. (2014). Meta-analysis of cognitive performance in drugnaive patients with schizophrenia. Schizophrenia Research. doi: 10.1016/j.schres.2014.06.034 ] was performed to study the similarities on the MATRICS domains between the two disorders. RESULTS: We found evidence of worse functioning of verbal and visual-spatial working memory, and of language in people with schizotypy or with schizotypal traits. Working memory deficit is present in both schizotypy and schizophrenia with larger effect sizes compared to other domains. CONCLUSIONS: :Working memory deficit might be a cognitive marker of the risk of psychosis. Interventions targeting cognitive deficits early may be crucial to the prevention of psychosis.

Cognitive remediation (CR) is a treatment targeting cognitive difficulties in people with schizophrenia. Recent research suggested that CR may also have a positive effect on negative symptoms. This meta-analysis investigates the effect of CR on negative symptoms. A systematic search was used to identify all randomized-controlled trials of CR in people with schizophrenia reporting negative symptoms outcomes. Levels of negative symptoms at baseline, post-therapy and follow-up, sample demographics and treatment length were extracted. Study methodological quality and heterogeneity were addressed. Negative symptoms standardized mean change was calculated using Hedges's g and used as the main outcome. The search identified 45 studies reporting results for 2511 participants; 15 studies reported follow-up outcomes. CR was associated with a reduction of negative symptoms (most conservative model g = − 0.30; 95% CI: − 0.36, − 0.22) at post-therapy compared with treatment as usual and this effect was larger at follow-up (g = − 0.36; 95% CI: − 0.51, − 0.21). Drop-out rate was comparable between conditions. Network meta-analysis confirmed CR was superior to TAU and TAU plus active control or adjunctive treatment. No evidence of publication bias was found. Studies with more rigorous methodology were associated with larger negative symptom reduction (g = − 0.40; 95% CI: − 0.51 to − 0.30). Although negative symptoms have not been considered a primary target for CR, this intervention can have small to moderate beneficial effects on this symptom cluster. Future research should explore in detail the active mechanisms responsible for negative symptom reduction and the relationship between cognitive and negative symptoms in schizophrenia.

This study set out to evaluate the effectiveness of a sailing and learning-to-sail rehabilitation protocol in a sample of patients diagnosed with severe mental disorders. The study was a randomized, crossover, waiting-list controlled trial, following recruitment in the Departments of Mental Health of South Sardinia. Participants were outpatients diagnosed with severe mental disorders, recruited through announcements to the directors of the Departments of Mental Health of South Sardinia. Out of the 40 patients enrolled in the study, those exposed to rehabilitation with sailing during a series of guided and supervised sea expeditions near the beach of Cagliari (Sardinia), where the aim to explore the marine environment while sailing was emphasized, showed a statistically significant improvement of their clinical status (measured by BPRS) and, as well, of their general functioning (measured by HoNOS Scale) against the control group. The improvement was maintained at follow-up for some months only: after 12 months, the patients returned to their baseline values on the measures of psychopathology and showed a worsening trend of their quality of life. Sailing can represent a substitute of important experiences that the patients with severe mental disorders miss because of their illness.

Aim In November 2005 the Italian Center on Control of Maladies, a department operating under the Ministry of Health, financed a project aimed at evaluating the feasibility of a protocol of intervention based on the early intervention in psychosis (EIP) model within the Italian public mental health-care network. Methods The study was carried out between March 2007 and December 2009. It involved five centres operating under the Departments of Mental Health of Milan (Programma 2000), Rome (area D), Grosseto, Salerno (Nocera) and Catanzaro (Soverato). Results Enrolment lasted 12 months, at the end of which 43 patients were enrolled as first-episode psychosis (FEP), and 24 subjects as ultra high-risk (UHR) patients. Both FEP and UHR samples included a preponderance of male patients. A family history of psychosis was rarely reported in both samples. The FEP incidence rate was lower than expected on the basis of international estimates of the incidence of schizophrenia but within the expected figure for the estimated Italian rates in three centres out of five. Conclusions Overall, the study proved that an EIP centre can be established within the public Department of Mental Health to reach a good fraction of the cases in need of treatment. Since then, several studies have been set up to assess the feasibility of EIP in the Italian public mental health sector in Lombardy and Tuscany, and in 2012 the Emilia-Romagna Regional Authority started an educational plan aimed at implementing the EIP model in all the Mental Health Departments in the region.

The underlying structures of clinical caseness and need of care in prodromal (i.e., at-risk) and early phases of schizophrenia remain poorly characterized in their essential psycho-behavioral coherence. To identify the schizophrenia proneness-related subtypes within a population of young help-seekers referred to a dedicated, community-based early detection program (Programma 2000). A sample of consecutive referrals (n = 168) for suspected psychosis or first-episode schizophrenia spectrum psychosis received a detailed clinical assessment, including the early recognition inventory for the retrospective assessment of the onset of schizophrenia checklist. We used exploratory factor analysis (EFA) to determine the underlying dimensional structure and latent class analysis (LCA) to identify putative vulnerability subtypes. EFA identified four factors: dysphoria (irritability tension), paranoid autocentrism, introversive withdrawal, and disturbed subjective experience. LCA distinguished three classes, interpretable as carrying different degrees of "proneness to schizophrenia psychosis," which best captured the underlying continuum of clinical severity. The validity of the three classes was supported by distinct patterns of association with major clinical variables (i.e., diagnostic staging at referral). Vulnerability to schizophrenia psychosis in young help-seekers may manifest in three major clinical prototypes, presenting common levels of dysphoria and social withdrawal but different degrees of paranoid autocentrism and disturbed subjective experience. Overall, the results provide the empirical background to dissect shared features of clinical caseness from more schizophrenia-specific vulnerability components. This is of value for the refinement of the clinical staging model as well as for the pragmatic implementation of multiple-gate screening programs.

Background and Purpose: A large number of subjective experiences and beliefs with some degree of affinity with psychotic symptoms can be found in the general population. However, the appraisal of these psychotic-like experiences in terms of associated distress, raised preoccupation, and the conviction with which the experience is held can be more discriminative in distinguishing people in need for care from those who simply hold unusual or uncommon beliefs because of cultural reasons. Method: In this study, 81 patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia or an affective disorder with psychotic features were compared on the Peters et al Delusions Inventory (PDI) to 210 people from the same local area, who had never received a formal diagnosis of a mental disorder. Results: Patients scored higher than controls on the PDI total score and on its distress, preoccupation, and conviction subscales. A stepwise logistic regression model showed PDI-preoccupation (odds ratio, 2.46; 95% confidence interval, 1.52-3.98) and, marginally, PDI-distress (odds ratio = 1.58; 95% confidence interval, 0.93-2.58) adding discriminative power to PDI total score in distinguishing patients from controls. Conclusions: The evaluation of the severity of delusion-like experiences and beliefs is important in discriminating patients diagnosed with psychosis from people who are not in need of care. Keywords: Delusions, psychosis-proneness, diagnostic accuracy, receiver operating characteristic curves, Peters et al Delusions Inventory

Background Current early screeners for psychosis-risk states have still to prove ability in identifying at-risk individuals. Among screeners, the 92-item Prodromal Questionnaire (PQ-92) is often used. We aimed to assess the validity of its Italian translation in a large Italian adolescent and young adult help-seeking sample. Methods We included all individuals aged 12–36 years seeking help at psychiatric mental health services in a large semirural Roman area (534,600 population) who accepted to participate. Participants completed the Italian version of the PQ-92 and were subsequently assessed with the Structured Interview of Prodromal/Psychosis-Risk Syndromes (SIPS). We examined diagnostic accuracy (sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios) and content, concurrent, and convergent validity between PQ-92 and SIPS using Cronbach's alpha , Cohen's kappa , and Spearman's rho , respectively. We tested the validity of adopted cut-offs through Receiver Operating Characteristic (ROC) curves plotted against SIPS diagnoses and the instrument's factor-structure through Principal Component Analysis. Results PQ-92 showed high internal consistency, acceptable diagnostic accuracy and concurrent validity, and excellent convergent validity. ROC analyses pointed to scores of 18 on the Positive subscale and 36 on the total PQ-92 as best cut-offs. The Scree-test identified a four-factor solution as fitting best. Conclusions Psychometric properties of Italian PQ-92 were satisfactory. Optimal cut-offs were confirmed at ≥ 18 on the positive subscale, but at ≥ 36 on the total scale was able to identify more SIPS-positive cases.

Question Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression; however, less attention has been paid to comorbidity of anxiety disorders with BD. Generalised anxiety disorder (GAD) is one of the most prevalent anxiety disorders that is highly comorbid with other mental disorders. We carried out a systematic review and meta-analysis to assess the degree of comorbidity between GAD and BD. Study selection and analysis We searched for all studies, which included primary data concerning the existence of GAD in patients with BD. The literature search strategy, selection of publications and the reporting of results have been conducted with PRISMA guidelines. The meta-analysis calculated prevalence estimates using the variance-stabilising Freeman-Tukey double arcsine transformation. We applied the inverse variance method using both fixed-effects and random-effects models to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran9s Q and I 2 statistics, respectively. Findings The current meta-analysis analysed data from 28 independent studies and a total of 2975 patients from point prevalence studies and 4919 patients from lifetime studies. The overall random-effects point prevalence of GAD in patients with BD was 12.2% (95% CI 10.9% to 13.5%) and the overall random-effects lifetime estimate was 15.1% (95% CI 9.7% to 21.5%). Both estimates reported significant heterogeneity (94.0% and 94.7%, respectively). Conclusions Published studies report prevalence rates with high heterogeneity and consistently higher than those typically reported in the general population. It is believed that comorbid GAD might be associated with a more severe BD course and increased suicidality, and it is unknown how best to treat such conditions. The current meta-analysis confirms that GAD is highly prevalent in BD and the rate is higher in comparison to those in the general population.

Aims Using data from a population survey in two communities in the region of Sardinia, Italy, we examined the association between illness definition and attribution of personal characteristics to people with alcoholism. Methods Quota samples, stratified by gender and age, were drawn from the general population (males: 48%; mean age 48 ± 18; range: 15–90). A fully-structured interview was conducted face-to-face with 404 respondents. The assessment of the public view of ‘alcoholics’ was measured by their reactions to stimulus words rated on bipolar scales, and defined with adjectives with opposite meanings at each end. Results 322 participants (80%) rated the ‘alcoholic’ as ‘ill’. The definition of the ‘alcoholic’ as being ill showed a statistically higher odd of stigma across all the dimensions of personal attributes. Conclusions The expectation that people adopting the illness model would tend to blame less those afflicted for their condition and, consequently, stigmatize them less, was not confirmed.

People who suffer from mental illness have high self-stigmatizing attitudes. This study aims to test the effect of psychopathological distress on stigma toward attempted suicide in a population of suicide attempters. Data were collected through an interview and 2 questionnaires (90-item Symptom Checklist; Stigma of Suicide Attempt scale) administered to 67 patients hospitalized after an attempted suicide. Participants with a history of past attempted suicide had higher scores on the Stigma of Suicide Attempt scale (t58.9 = -2.51, p = 0.014). Higher levels of psychological distress were related to greater perceived stigma only in individuals with a history of past attempted suicide (standardized coefficient = 0.37; t = 2.36; p = 0.024; R2 = 14%; adjusted R2 = 11.5%). A previous experience of attempted suicide is related to greater self-stigmatizing attitudes toward suicidal behavior. Among those who have previously attempted suicide in particular, psychopathological distress may significantly contribute to increase the perception of stigma.

Aim: Duration of untreated psychosis (DUP) can influence the prognosis of schizophrenia. Previous studies have suggested that gender may influence the length of DUP. This study reports the result of the first systematic literature review and meta-analysis on the role of gender in influencing DUP in first-episode psychosis. Method: Systematic literature search in PubMed/Medline and Ovid/PsychINFO. Twenty-seven studies presenting data on 4721 patients diagnosed with psychosis at their first episode (2834 males and 1887 females) were included in the analysis. Results: Samples had a higher proportion of males: odds ratio = 2.5 (95% confidence interval: 1.8–3.3). Mean age at first contact was 25.4 for males and 27.5 for females. Patients from non-Western countries were older at first contact than patients from Western countries. Average DUP in schizophrenia was 64 weeks and did not differ between genders but was shorter in Western compared with non-Western countries. Conclusion: Earlier age at first contact and larger incidence in males support the existence of specific gender differences in first-episode psychosis; however, these are not associated with DUP length.