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Aims: The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic. Background: Mood disorders are one of the leading causes of all non-fatal burden of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle income countries (LMICs) and in vulnerable populations. Objectives: 1. Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders. 2. Study socio-demographic and clinical correlates of mood disorders 3. Assess the association between mood disorders and quality of life 4. Study the impact of the COVID-pandemic on the prevalence of mood disorders 5. Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic Method: This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered: Result: Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about headache. In addition, socio-demographic and clinical data will be collected. Conclusion: This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19 related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia, and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

Objectives: The global crisis of COVID-19 and its consequential strict public health measures placed around the world have impacted mental health. New scales and tools have been developed to measure these mental health effects. This narrative review assesses the psychometric properties of these scales and tools and methodological aspects of their development. Methods: PubMed, PubMed Central, and Google Scholar were searched for articles published from 15 May 2020 to 15 August 2020. This search used three groups of terms (“tool” OR “scale” AND “mental” OR “psychological”; AND “COVID-19” OR “coronavirus”). The identified scales were further evaluated for their psychometric properties and methodological aspects of their development. Results: Though the studies developing these scales ( n = 12) have demonstrated their robust psychometric properties, some methodological concerns are noteworthy. Most of the scales were validated using internet-based surveys, and detailed descriptions of the mode of administration, sampling process, response rates, and augmentation strategies were missing. Conclusions: The heterogeneous and inadequate reporting of methods adopted to evaluate the psychometric properties of the identified scales can limit their utility in clinical and research settings. We suggest developing guidelines and checklists to improve the design and testing, and result in reporting of online-administered scales to assess the mental health effects of the COVID-19 pandemic.

BACKGROUND Early identification and prevention research has provided huge advances in our understanding of early screening and identification of young people at clinical high-risk (CHR). Most of these procedures were developed in high-income countries, yet middle-income countries in North Africa such as Tunisia can benefit from these empirically-based assessment approaches. METHODS Using established procedures, nine Tunisian psychiatric raters were trained on structured assessments: the CAARMS, BPRS, and SCID to high standards of interrater reliability. These raters developed a clinical high-risk program (CHiRP) in Tunisia and recruited 10 patients who were exhibiting possible signs of CHR. These patients were evaluated to determine if they met criteria for a CHR group, such as Attenuated Psychosis. RESULTS Trained raters met the following interrater reliability criteria for the CAARMS and BPRS (ICC = .80 or greater) and the SCID (Kappa = .75 or greater). Of 10 pilot patients, six were classified as CHR and belonging to the Attenuated Psychosis Group. One of the six patients converted to psychosis 3 months after study entry for a conversion rate of 17% which is comparable with currently published rates globally. DISCUSSION The first CHR program has been established in Tunisia, a middle-income country using methods developed in high income countries. Efforts aimed at assembling a group of prevention-oriented psychiatrists, obtaining administrative support, and training raters to high levels of interrater reliability were successful. The feasibility was demonstrated for screening, assessing, treating, and following-up of 10 CHR patients suggesting that conversion rates are comparable to those of Western and European countries.

Purpose: Telepsychiatry, a subset of telemedicine, has been increasingly studied to meet the growing demands for psychiatric care. The utility of telepsychiatry is relevant now more than ever as the world endures the COVID-19 global pandemic. This paper describes the prior state and the changes that the COVID-19 outbreak brought to telepsychiatry in a selected group of Arab countries of the Middle East and North Africa (MENA) region. Patients and Methods: We invited twelve early-career psychiatrists from different Arab nations to share information related to telepsychiatry in their respective countries before and during the COVID-19 pandemic. The information was collected using a semi-structured guide. This was complemented by a search for relevant articles in five search engines using terms such as "COVID-19," "telepsychiatry," and "Arab world". Results: Before the pandemic, digital mental health services were provided in several Arab countries, mainly through hotlines and messaging services. The COVID-19 pandemic has marked a major shift in digital psychiatric services in the Arab MENA world, through the transformation of many clinics and some hospitals into digital mental health systems. Many non-governmental organizations also started remote initiatives for psychological support and psychiatric counseling. Three main barriers of patient-related, healthcare-related, and system-related hurdles of using telepsychiatry emanated from the analysis. Conclusion: The use of digital mental health services varies between different Arab countries. Even though some nations have laws that regulate the provision of such services, most struggle with multifactorial barriers. As affordable and attainable solutions cannot only rely on training and recruiting more psychiatrists, telepsychiatry would help meet the exceeding demands in the Arab world, particularly after the COVID-19 outbreak.

Recent advances in information technology (IT) provided us with novel teaching solutions, with the potential of a new enhanced learning experience, that is, more adapted to the needs and preferences of the younger generations of psychiatric trainees. These tools include the use of online/virtual whiteboards, live surveys/polls, live quizzes, virtual classrooms, and virtual reality. In the present paper, we describe the implementation of modern technology in psychiatric training in Tunisia, a North-African middle-income country. We discuss the potential benefits arising from this implementation, and we report the challenges and difficulties. Overall, the implementation of these modern technology-based tools in psychiatric training has been successful, with a very few obstacles. It seems that the integration of these novel approaches is possible even in middle and low-income countries without much hassle. These tools can enhance trainees' participation, motivation, and engagement, thereby potentially improving learning outcomes. Most disadvantages are related to potential technical glitches, and are likely to improve as technology progresses. Teaching is the art of tailoring the educational tools to the learning objectives and to the learners' characteristics and preferences. To achieve optimal learning outcomes, it is often needed to use a mixture of different "modern" and "less modern" techniques.

Background With the uncertainties of COVID-19, people infected by coronavirus present with diverse psychiatric presentations. Some centers have had to manage their patients with existing protocols, others have had to come up with innovations. We aim to report the challenges and good practices recorded in the management of psychiatric conditions and delirium coexisting with COVID-19 and during the COVID-19 era across continents. Material and Methods Early Career Psychiatrists (ECPs) from across five continents were approached to provide their perspective on the management of psychiatric conditions in patients with COVID-19 and during the current pandemic. Results We collected information about the experiences from ten countries. Commonalities were similar psychiatric presentations and poor preparedness across countries. Differences were varying innovations and adjustments made in the management of psychiatric conditions coexisting with COVID-19. Good practices which can be adopted by other countries are novel approaches such as telepsychiatry, proactive consultation-liaison units and enhanced community services targeted at circumventing challenges faced yet providing mental health services. Conclusions This publication highlights the need for global preparedness in the mental health sector during outbreaks of infectious diseases. With our results we can conclude that there is the need for concerted efforts targeted at global and locally sensitive adaptation of existing protocols and the development of new guidelines for the management of psychiatric conditions for the present pandemic and subsequent occurrences., Highlights • Twenty-one Early Career Psychiatrists (ECPs) from thirteen countries across five continents, provided their perspective on the management of psychiatric conditions in patients with COVID-19. • We found commonalities such as similar psychiatric presentations, poor preparedness and alterations in the management of psychiatric conditions coexisting with COVID-19. • There are shared similarities and differences, likewise modifications in pre-existing protocols in the management of delirium and other psychiatric conditions in patients with COVID-19 and during the current era across continents. • A common factor is the need for preparedness in the mental health sector; the need for concerted efforts targeted at globally and locally sensitive adaptation of guidelines and protocols for the management of psychiatric conditions for the present pandemic and subsequent occurrences.

Highlights • This review provides a synopsis of the status of geriatric psychiatry in the Arab countries of the Middle and North Africa (MENA) region and narrates the mental health interventions implemented during the COVID-19 outbreak for both the general public and the geriatric population. • The mental health of the geriatric population in this part of the world is overlooked, especially during the COVID-19 pandemic. Although several measures are implemented to address mental health during the COVID-19 outbreak, these are generally insufficient in targeting the geriatric population. • An effective task force is needed to strengthen the geriatric mental health response to the COVID-19 outbreak at both national and regional levels in the Arab countries of the MENA region., While the detrimental ramifications of the COVID-19 outbreak on the mental wellbeing of the general public continue to unravel, older adults seem to be at high risk. As the geriatric population continues to grow in the Middle East and North Africa (MENA) region, it is essential to explore the influence of this outbreak on geriatric mental health, a topic often neglected. In this review, we depict the status of geriatric psychiatry in the Arab countries of the MENA region, exploring the variations from one nation to another. While some have a null exposure to the field, resources and expertise in other countries range from very limited to extensive. Furthermore, we highlight the measures implemented in the Arab region to address mental health during the COVID-19 outbreak; these tend to be insufficient when targeting the geriatric population. Finally, we provide short- and long-term recommendations to stakeholders that aim at enhancing the mental healthcare of older adults in the Arab countries of the MENA region, particularly during this pandemic.

The collaborative effort of an international research team from the Early Career Psychiatrists section of the World Psychiatry Association has brought about an easy-to-use, quick and stepwise mental health care toolkit for the identification and appropriate referral of those in need of mental health care during the pandemic. This simple guide can be applied in the general outpatient setting and is catered for all healthcare professionals, regardless of their expertise within the mental health field with minimal training. It is our hope that by incorporating this toolkit into our daily clinical care during the pandemic for high-risk patients and patients with non-specific complaints, we will be able to bridge the mental health gap present in our society.

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The pathogenic mechanisms underlying Schizophrenia (SZ), one of the most frequent mental disorders, are complex and poorly understood. Several evidences suggest that inflammatory processes may underpin some of its neurobiological correlates. The aim of this study was: (i) to analyze the potential association between circulating levels of the C-reactive protein (CRP), a crucial inflammatory marker, and Schizophrenia in Tunisian patients and healthy controls (HC) cohorts; (ii) to investigate the genetic diversity of three CRP variants (rs1417938, rs1130864 and rs1205) and; (iii) to analyze a potential relationship between expression and genetic data and clinical and socio demographical characteristics. CRP polymorphisms were exanimated for 155 patients and 203 HC by taqMan5′-nuclease. High-sensitivity CRP (hs-CRP) serum level was measured in 128 clinically stable out-patient SZ patients and 63 HC subjects via an automated biochemical analyzer. We found that hs-CRP levels were significantly higher in SZ patients as compared to HC. No significant differences were found when the proportions of CRP variants were compared in patients and HC. Further analysis according to clinical and socio demographical characteristics revealed a positive association with age and hypertension. Our data on an original Tunisian sample confirm the previous finding in others population groups.

Highlights • Mental health (MH) problems are difficult to address in pandemic and may have devastating consequence if remains untreated. • An appropriate conceptual framework can provide better opportunity to address the MH problems during epidemic. • Sixteen early career psychiatrists across the world attempted to develop a conceptual framework (CF). • CF can guide for development, implementation, and evaluation of MH interventions during the ongoing pandemic., The emergence of mental health (MH) problems during a pandemic is extremely common, though difficult to address due to the complexities of pandemics and the little evidence about the epidemiology of pandemic-related MH problems and the potential interventions to tackle them. Little attention has been devoted so far to this topic from policymakers, stakeholders and researchers, what could be due to a lack of replicable, scalable and applicable frameworks to plan, develop and deliver MH care during pandemics. As a response, we have attempted to develop a conceptual framework (CF) that could guide the development, implementation, and evaluation of MH interventions during the ongoing COVID-19 pandemic. This CF was developed by early career psychiatrists, from 16 countries that cover all the WHO regions. Their opinions were elicited via semi-structured questionnaire. They were asked to provide their views about the current MH situation of their countries, existing myths and misinformation, and the possible resources available. They were also asked to propose solutions and approaches to provide accessible and affordable care. The CF’s were prepared based on the extant literature and the views expressed; they illustrate the epidemiology of MH issues, preparedness plans, stage-specific plans/innovative solutions, opportunities to integrate those plans and probable outcomes at policy level. This CF can serve as a technical guide for future research in pandemic. It can be used to monitor trends and to optimize efforts and to develop evidence based MH interventions. However further research focusing on the individual components of this framework is needed.

Background Schizophrenia is a highly heritable disease; yet heritability rate could never exceed 80% in most studies. Genetic factors could never then, by their own, account for the whole risk for developing schizophrenia. Thus, environmental factors co-play a major role. Urbanity is now well established to be one of the most influential environmental factors for developing severe mental illnesses. A strong association between exposure to urban environment and the risk of developing schizophrenia, was demonstrated and several studies have shown that living in an urban environment increases the risk for developing schizophrenia. The aim of this study was to examine the clinic biological characteristics of patients with schizophrenia according to their rural or urban condition. Methods This study was based on 106 patients with a DSM 5 diagnosis of schizophrenia in period of remission. Sociodemographic and clinical characteristics were assessed. PANSS scale, Calgary depression scale, CGI scale were used to assess different features of the disease and biological variables (CBC, renal and liver markers, inflammatory markers: CRP and CRP hs) were evaluated. Two groups were formed according to the patient’s urban or rural birth and early living. Results There were 71 urban and 35 rural patients. The mean age was 42,7 years in the urban group and 42,3 years in the rural group. Socio demographic characteristics were similar between the two groups. Patients with urban background had a higher score on the negative subscale (p=0,01) and the general psychopathology subscale (P=0,025) of the PANSS compared with rural patients. Otherwise, compared to patients with a rural birth and early living, urban patients showed more depressive symptoms on the Calgary depression scale (p=0,039). There were no significant differences between the two groups regarding the biological variables tested. Discussion The association between urban upbringing and risk for developing schizophrenia is well established. Nevertheless, relationship between epidemiological factors and different symptom dimensions is still poorly understood. Our study found a significant association between patients’ urban background and negative as well as disorganization and depressive symptoms. Most of published studies found a correlation between urban upbringing and positive psychotic symptoms in schizophrenia. To our knowledge, no similar result has ever been found before. Otherwise, there were several studies showing an association between disorganization and depressive symptoms with urban upbringing of the patients.

Background Suicide is the leading cause of surmortality among patients with schizophrenia. Despite efficient antipsychotic treatments, suicide rates reaches up to 15% of death causes and near half of the patients had at least once attempted suicide. Thereby, the early identification of clinical profiles and risk factors is important for the development of management strategies. Methods A cross-sectional and retrospective descriptive study was conducted at the “F” psychiatry department at the Razi Hospital, Manouba including 56 patients with schizophrenia in period of clinical stability. The evaluation focused on sociodemographic and clinical characteristics (using the positive and negative syndrome scale (PANSS); The Calgary Depression Scale for Schizophrenia (CDSS); The Global Assessment of Functioning (GAF); The Clinical Global Impression (CGI) rating scales). Personal history of suicidal attempts was assessed. Results In this study, fourteen patients with schizophrenia (25%) never attempted suicide. 58 % (N=32) committed one or two suicide attempts. Only 8.5% (N= 5) had 3 and 4 attempts each. Number of suicide attempts was negatively correlated with the age of onset (p=0.024, r=-0.442) and the GAF score (p= 0.002, r=- 0.483). An association was found between the personal history of suicidal attempts and the existence of a triggering factor of the onset (p=0.03). A positive correlation was found with the number of hospitalization (p=0.14, r=0.663), with the PANSS items: delusions (p=0.41, r=0.358), hallucinations (p=0.12, r=0.402), Suspiciousness/persecution (p=0.35, r= 0.342) and Somatic concern (p=0.048, r=0.322); with the CDSS guilty ideas of references (p=0.008, r=0.426) and with the CGI efficacy index (p=0.32, r=0.348). Discussion The rates of suicide are the highest among patients with schizophrenia. Previous studies have estimated the prevalence of suicide attempts in individuals with schizophrenia up to 50%. The increase in suicide attempts is associated with depressive symptoms which are very common within schizophrenia. The risk of suicide is not constant during the evolution of schizophrenia: it is the highest during the first years. A meta-analysis of 29 studies (Hawton et al., 2005) related that risk factors for suicide was higher in schizophrenic Caucasian men, those who live alone, who have recently experienced a loss, who have a family history of depression, who are more educated and have a higher IQ. Alteration of the abnormality the serotonin system may provide a biologic base to this phenomenon. It is essential to try to early detect and carefully assess the demographic and clinical profiles of patients with high risk of suicide.

Background Schizophrenia is an invalid and severe neurodevelopmental disorder. The implication of vitamin D in the etiopathogenesis of schizophrenia shows through the activation of cellular and inflammatory pathways. It is especially vitamin D deficiency that has been associated with schizophrenia. It is within this framework that this study aims to explore the relationship between vitamin D levels and the clinical characteristics in a cohort of Tunisian patients with schizophrenia. Methods A cross-sectional and retrospective descriptive study was conducted at the “F” psychiatry department at the Razi Hospital, Manouba over a twelve-month period from June 1st, 2015 to May 31st, 2016, including 80 patients with schizophrenia in period of clinical remission. The evaluation focused on sociodemographic and clinical characteristics. A dosage of vitamin D was performed. Results The patients had an average age of 42.5 years and 70% were male. The average vitamine D level was 10,57ng/ml ±5,9. 49% of patients had vitamin D insufficiency (between 10 and 30 ng/ml) and 51% had vitamin D deficiency (

Background Vitamin D modulate the course of many neurologic diseases and conditions. Moreover, the prevalence of vitamin D deficiency might be higher in psychiatric patients, in particular with schizophrenia. Likewise, there is an inverse relationship between vitamin D levels and several cardiovascular risk factors, including the metabolic syndrome, that patients with schizophrenia are predisposed to develop. It is within this framework that this study aims to explore the relationship between vitamin D levels in a cohort of Tunisian patients with schizophrenia and to determine the cardiovascular risk according to whether they had hypovitaminosis D or not. Methods A cross-sectional and retrospective descriptive study was conducted at the “F” psychiatry department at the Razi Hospital, Manouba over a twelve-month period from June 1st, 2015 to May 31st, 2016, including 80 patients with schizophrenia in period of clinical remission. The evaluation focused on anthropometric parameters and cardiovascular risk factors. A dosage of vitamin D was performed. Results The patients had an average age of 42.5 years and 70% were male. 25 patients had metabolic syndrome. 49% of patients had vitamin D insufficiency and 51% had vitamin D deficiency. Vitamin D levels had not been affected by the clinical characteristics of the disease. However, there was no significant association between vitamin D levels and metabolic syndrome. A significant negative correlation was found between the total sum of the various cardiovascular risk factors and the vitamin D deficiency (p