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Bipolar Disorder (BD) and Major Depressive Disorder (MDD) have a huge impact on functioning and quality of life; moreover, they are linked to extensive direct and indirect costs. This systematic review with meta-analysis aims to evaluate the utility of pharmacogenetic tests (PGT) in terms of efficacy and tolerability into the routine clinical treatment of mood disorders.The first part of the review is a qualitative overview of the PGTs used in the included studies. The second part aims to compare, in terms of efficacy and tolerability, patients affected by BD and MDD treated as usual (TAU), according to the clinicians' prescribing attitude, versus patients whose psychopharmacological treatments were set up following the PGT suggestions.6 studies on MDD and 2 studies on BD were included. Regarding MDD, the meta-analysis shows a significantly higher number of patients achieving better outcome in terms of efficacy, through the evaluation of response rate and remission rate at the HDRS (Hamilton Depression Rating Scale) in the group of patients treated under the PGT suggestions; regarding BD the meta-analysis does not show any significant difference in terms of efficacy. In terms of adverse events, the available data suggest promising results about the utility of PGT to set more tolerated therapies.Although the limited number of studies, results confirm the importance of PGT in setting up psychopharmacological therapies as a support to clinicians' choices.

Daniele Zizolfi, Nicola Poloni, Ivano Caselli, Marta Ielmini, Giulia Lucca, Marcello Diurni, Greta Cavallini, Camilla CallegariDepartment of Medicine and Surgery, Psychiatry, University of Insubria, Varese, VA 21100, ItalyBackground: Personal resources have been identified as important factors in predicting patient healing or symptoms control in schizophrenia. This observational retrospective study aims to explore the influence of resilience and recovery style on the modalities of clinical presentation of the disease, as well as individual functioning and quality of life.Methods: Participants were patients affected by schizophrenia spectrum disorders assessed at different mental health facilities. The rating scales considered are the following: Resilience Scale 10-items (RS); Recovery Style Questionnaire (RSQ); Montreal Cognitive Assessment (MoCA); Schizophrenia Quality of Life Scale (SQLS); Life Skills Profile (LSP); Positive and Negative Syndrome Scale (PANSS).Results: Forty-four patients fulfilled the inclusion criteria. The mean age was 46 years; the average length of the history of the disease at recruitment was 23 years with an average age at first episode of psychosis (FEP) of 23 years. General psychopathology, neurocognition, and integration recovery style can predict psychosocial functioning and explain ∼54% of the LSP variance; RS total score and PANSS general psychopathology score can predict and explain ∼29% of the LSP variance. A negative association between PANSS general psychopathology and LSP total score supports the need to reduce first the symptomatology, and then successfully apply other types of interventions. A strong positive association between neurocognition and life functioning was detected, showing that deficits in neurocognition have proved to be important predictors of the functional outcome. Integration was also proven to be significantly associated with a good functional outcome. Psychotic symptoms turn out to be a negative predictive factor, whereas resilience can be hypothesized as a protective factor.Conclusions: Resilience and recovery style “integration” can be considered as two complementary predictive resources for a good outcome; this result supports the need to set up personalized treatments, based on the characteristics of the patients.Keywords: mental health recovery, psychological resilience, schizophrenia, cognition, life quality, community functioning

Nicola Poloni, Daniele Zizolfi, Marta Ielmini, Roberto Pagani, Ivano Caselli, Marcello Diurni, Anna Milano, Camilla Callegari Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Varese, Italy Objective: Resilience is a multidimensional process of adaptation aimed to overcome stressful or traumatic life experiences; only in the last few years it has been considered as a personal resource in psychosis and schizophrenia. This study aimed to assess the relationship between intrapersonal and interpersonal resilience factors and schizophrenia, particularly whether and how resilience can improve the course of psychotic illness. Patients and methods: In this observational study, all patients recruited had to fulfill the following inclusion criteria: diagnosis of schizophrenia spectrum disorder (Diagnostic and Statistical Manual of Mental Disorders-5); aged between 18 and 65 years; provided written informed consent; to be clinically stable (Clinical Global Impression Scale

A systematic search for all case reports and case series of adult patients with factitious disorders (FD) in the databases MEDLINE, Scopus, and PsycINFO was conducted. FD is a psychiatric disorder in which sufferers intentionally fabricate physical or psychological symptoms in order to assume the role of a patient, without any obvious gain. The clinical and demographic profile of patients with FD has not been sufficiently clear. Thus, the aims of this study were to outline a demographic and clinical profile of a large sample of patients with FD and to study the evolution of the position of FD in the Diagnostic and Statistical Manual of Mental Disorders. One thousand six hundred thirty-six records were obtained based on key search terms, after exclusion of duplicate records. Five hundred seventy-seven articles were identified as potentially eligible for the study, of which 314 studies were retrieved for full-text review. These studies included 514 cases. Variables extracted included age, gender, reported occupation, comorbid psychopathology, clinical presentation, and factors leading to the diagnosis of FD. In the sample, 65.4% of patients were females. Mean age at presentation was 33.5 years. A health care profession was reported most frequently (n=113). Patients were most likely to present in psychiatry, neurology, emergency, and internal medicine departments. The broad survey of sociodemographic profile of the sample has highlighted some important points for early diagnosis and early psychiatric treatment. The study showed that the patients did not meet Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria in 11.3% of cases.

Despite mixed results found in literature, long-acting injectable antipsychotics (LAIs) should offer better efficacy and tolerability, compared to oral antipsychotics due to improved adherence and more stable pharmacokinetics. From this perspective, authors evaluated 153 patients, diagnosed with Schizophrenia Spectrum Disorder and residing in the province of Varese (Italy), in order to compare oral antipsychotics’ and LAIs’ efficacy in terms of accesses to emergency room, number and length of hospitalizations. Data analysis showed a substantial reduction in all considered variables after the introduction of long-acting therapy, especially for those who received LAI treatment from disease’s onset. Authors emphasised the use of long-acting antipsychotic as first-line treatment in the early stage of disease, since available data seem to confirm the hypothesis of a better prognosis for patients who received antipsychotic depot from illness’s onset.

BACKGROUND: Medically unexplained physical symptoms (MUPS) are physical symptoms without a medical explanation. The study provided for the collection of data from hospitalized patients presenting MUPS, aiming to draw a clinical and sociodemographic profile of patients with somatic symptoms disorder (SSD), and to estimate economic costs related to hospital management. METHODS: This observational retrospective study consisted in the evaluation of data referring to all hospitalized patients admitted between 2008 and 2018 in the wards of a teaching hospital in Northern Italy. RESULTS : A total of 273 patients presenting with MUPS have been hospitalized. The sample showed a prevalence of female, married, and workers patients. The most frequent ward involved is neurology, followed by internal medicine and Short Stay Unit. The most common symptoms found are headache, pain, syncope and vertigo. No evidence that having a medical disease predict the developing of somatic symptoms disorder emerged. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association also emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for MUPS is € 475,409.73. C ONCLUSIONS : Further investigations are needed to extend the study on other clinical areas and to clarify the correlates.

Dissociative experiences are common in traumatized individuals who can use dissociation as a psychological escape from emotional and physical distress associated with overwhelming traumatic events. Traumatic experiences and the cultural interpretation of trauma-related symptoms often serve to explain the wide range of dissociative phenomenology; in fact, dissociation is a complex and ubiquitous construct present in a variety of mental disorders. The Six-Dimensions Model of National Culture has been used as a tool to compare patients' different cultural background that could have accounted for the different clinical manifestations. This paper reports three clinical cases in which the focus of interest is represented by the dissociative alterations of consciousness, as a response to trauma, specifically related to migration, and their correlation with cultural environment. The study shows as Hofstede's model has been used for the first time as a tool to explain how different cultural background could shape clinical manifestations.

BACKGROUND: The impact of menopause is a consequence of social, physical and mental changes; hormonal changes play an important role in inducing an increased risk of developing depressive symptoms. It is essential to treat mood and vasomotor symptoms and to prevent their onset to promote an improvement in the quality of life, both in terms of clinical and psychological conditions. OBJECTIVE: This observational study aims to compare paroxetine and vortioxetine in a sample of patients affected by postmenopausal depression attending the Anxiety and Depression Clinic in terms of: efficacy in determining clinical remission (HDRS ≤ 7) and tolerability; improvement of autonomic and cognitive symptoms. METHODS: 39 female outpatients with a diagnosis of Postmenopausal Depression (according to DSM-5 criteria) were evaluated as the routine clinical practice through the following scales: Hamilton Depression Rating Scale (HDRS); Menopause Rating Scale (MRS); Montreal Cognitive Assessment (MoCA); Antidepressant Side-Effect Checklist (ASEC); data from/of baseline, after 8 weeks and 12 weeks were recorded. RESULTS: Both antidepressants resulted to be effective in clinical remission (HDRS ≤ 7) without statistical differences between the two groups (p = 0.3), although paroxetine showed a faster remission than vortioxetine (p = 0.01). Autonomic symptoms showed a higher improvement in the vortioxetine group (p = 0.002). Paroxetine group referred insomnia and sexual problems while patients taking vortioxetine referred diarrhoea and palpitations. Data show a superiority of cognitive performance in the Paroxetine group (p = 0.005), contrary to what stated in literature. CONCLUSIONS: Data are related to a small sample retrospectively assessed trough a 6-month observation period. Thus, the preliminary results need further research to be confirmed.

Lithium is among the best proven treatments for patients diagnosed with Bipolar Disorder, however response to Lithium appears to be considerably variable among individuals and it has been suggested that this inconstancy in Lithium response could be genetically determined. Starting from this perspective, in the last few decades, a number of pharmacogenetic studies have attempted to identify genetic variants, which might be associated with response to Lithium in bipolar patients, in order to develop a pharmacogenetics test to tailor treatment on patients, identifying who will benefit the most from therapy with Lithium. Within this context, authors have critically reviewed pharmacogenetic studies of Lithium response in bipolar disorder, suggesting strategies for future work in this field. Computerized searches of PubMed and Embase databases, for studies published between 1998 and January 2018, was performed: 1162 studies were identified but only 37 relevant papers were selected for detailed review. Despite some interesting preliminary findings, the pharmacogenetics of Lithium and the development of a specific pharmacogenetics test in bipolar disorder appears to be a field still in its infancy, even though the advent of genome-wide association studies holds particular promise for future studies, which should include larger samples.

Medically Unexplained Physical Symptoms (MUPS) are physical symptoms without a medical explanation. This study collected data from hospitalized patients presenting MUPS, aiming to draw a clinical and socio-demographic profile of patients with MUPS, to explore psychopathological correlations of Somatic Symptoms Disorder (SSD) diagnosis, and to estimate economic costs related to hospital management for MUPS. The cross-sectional study consisted in the evaluation of data referring to hospitalized patients admitted between 2008 and 2018 in a teaching hospital in Northern Italy. A total of 273 patients presenting MUPS have been hospitalized. The sample showed a prevalence of female, married and employed patients. The most frequent wards involved are Neurology, Internal Medicine and Short Unit Stay. The most common symptoms found are headache, pain, syncope and vertigo. There is no evidence that a history of medical disease is associated with a diagnosis of SSD. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for patients with MUPS is 475'409.73 &euro, The study provides the investigation of a large number of patients with MUPS and a financial estimate of related hospitalization costs.

Despite the enormous costs associated to mood disorders&rsquo, few studies evaluate potential cost saving from the use of pharmacogenetic tests (PGT). This study compares 12 months before the execution of the PGT versus 12 months after, in terms of number and days of hospitalization and accesses to emergency services, in a sample of 30 patients affected by bipolar disorder. Secondarily, the study gives an economic value to the data based on the diagnosis-related group (DRG). Patients included in the study were required to be aged &ge, 18 years, sign an informed consent, have a score of Clinical Global Impression item Severity (CGIs) &ge, 3, and have a discordant therapy compared to the PGT in the 12 months preceding it and a therapy consistent with it for the following 12 months. Cost saving has been evaluated by paired t-tests in a mirror analysis. Statistically significant differences in all the comparisons (p &lt, 0.0001) emerged. Important cost saving emerged after the use of PGT (&euro, 148,920 the first year versus &euro, 39,048 the following year). Despite the small sample size and lack of a control group in this study, the potential role of PGT in cost saving for the treatment of bipolar disorder treatment emerged. To confirm this result, larger and clinical trials are needed.

BACKGROUND: Depressive disorders are expected to be the second highest cause of morbidity in the world until few years. Moreover, patients with depression frequently show many side effects and low compliance to therapy. To find a more tolerated and more efficacy therapy is a growing need. OBJECTIVE: This observational study investigates the efficacy, safety and tolerability of paroxetine hydrochloride comparing slow versus standard titration in a population affected by Depressive Disoders (according to DSM 5). METHODS: 186 outpatients were assessed throught the following scales: Hamilton Depression Rating Scale (HDRS) for depression and World Health Organization Quality of Life Scale Bref for the perceived quality of life (WHOQOL BREF). Treatment-emerged Adverse Events (TEAEs) were recorded throught self-reports. Statystical analysys was performed by GraphPad Prism Version 5.1. RESULTS: The efficacy of paroxetine was confirmed in both titrations by the number of clinical remitters (HDRS ≤ 7 at 12 weeks for 53% of the standard titration group and 58% of the slow titration group), without differences. About safety and tolerability there were more frequent TEAEs among the standard titration group (p < 0.01). Comparing WHOQOL BREF between the two groups at the recruitment and at the twelth week emerged a statistically significant difference (p = 0.003), with highest scores reached in slow titration group. CONCLUSIONS: Although the short observation period is an evident limit, this study is consistent to the literature about the efficacy of both titrations of paroxetine to improve depression and shows promising results about the increased tolerability of paroxetine slow titration.

Introduction: "Medically Unexplained Physical Symptoms" (MUPS) defines a subgroup of patients presenting physical symptoms of unclear origin. The study aims to profile clinical and socio-demographic characteristics of patients with MUPS. Materials and Methods: This 9-years observational retrospective study assesses all patients admitted between 2008 and 2016 in the divisions of neurology and gastroenterology. Socio-demographic and clinical variables were evaluated: gender, age, diagnosis or diagnostic hypothesis, presence of psychiatric comorbidities, psychiatric evaluation, pharmacological treatment, number of admissions/visits. Results: Among 2,479 neurological patients 10.1% presented MUPS. Patients were more frequently women (63.5%), with a mean age of about 50 years. Reported symptoms were headache (22.6%), seizures (8.7%), vertigo (5.9%), fibromyalgia (5.5%), paresthesia (5.1%), visual disturbances (5.1%), amnesia (3.9%). The diagnosis was somatoform disorder in 6.3% of cases, conversion disorder in 2.7%, and somatic symptom disorder in 1.5% only. 2,560 outpatients were evaluated in gastroenterology division. 9.6% (n = 248) of patients had MUPS; 62.1% of them were women. The most affected age group ranged between 15 and 45 years. The most frequent diagnoses were functional abdominal pain (50%), dysmotility-like dyspepsia (26.6%), irritable bowel syndrome (10.4%), meteorism of unknown cause (2.4%), hiccup (1.6%), burning mouth syndrome (1.2%). No patients received a diagnosis of somatic symptom disorder. Discussion: Patients with MUPS are more often women, of middle age, with self-referred specific symptomatology. While neurological patients received a diagnostic-therapeutic approach in line with the literature, gastroenterological patients mainly received antipsychotics. A more comprehensive assessment and a development of psychoeducational interventions are needed to improve patients' quality and quantity of life.

Objective: The resilience is the ability to face and overcome the adversities of life. The first aim of the study is to explore this construct referring to ageing. The characteristics of resilience were assessed in older adults, the additional endpoint is to focus on the role of institutionalization in nursing home and on the influence of chronic psychiatric illness. Method: 197 patients (aged 65 and over) have been enrolled in the observational crosssectional study. The sample was composed by 91 subjects who lived at home (Communitydwelling, group I), 56 subjects who lived in a nursing home (Nursing-home, group II) and 50 subjects who lived in a nursing home, suffering from psychiatric disorders (Psychogeriatric division, group III). The resilience was evaluated through the Resilience Scale (RS) and the Connor-Davidson Resilience Scale (CD-RISC). Results: The mean total score of RS decreased from the group I to the group III (55.4, 49.8 and 46.6, respectively). Moreover, using pairwise comparison among groups, significant differences between the group I and the group II (5.6, p˂0.0001) and between the group I and the group III (8.8, p˂0.0001) were found. In the CD-RISC total score, significant differences among the three groups (p˂0.0001) were observed, with a decrease of the mean values from the group I to the group III (66.2, 62.4 and 56.4, respectively). The pairwise comparison showed significant differences between the group III and the group I (p˂0.0001) and between the group III and the group II (p=0.03). Conclusion: The first aim of the study to explore the construct of resilience in reference to ageing both as a dispositional resource and as an environment adjusted strategy of adaptation has been reached: the characteristics of resilience were assessed in older adults. Moreover, the second endpoint has been achieved too as the data showed that resilience skills of older adults are compromised both by institutionalization and by concurrent diagnosis of psychiatric disorder.

The article presents four clinical cases of patients with the common history of recurrent surgery. These conditions are interesting first of all for general medicine and surgery, apart from psychiatry. Indeed, patients with these characteristics are almost invariably subjected to psychiatric evaluation by internal doctors and surgeons and this is evident in our case reports, despite the rarity of the phenomenon in latest decades aside from plastic surgery. The first aim of the study is to compare diagnostic classifications between DSM-IV-TR and DSM-5 in reference to the case reports of recurrent surgery in order to observe the changes occurring in the diagnostic criteria and classification and the different attitude of the two manuals towards these disorders. The second endpoint is to describe the common features and the differences between the cases that could motivate a different prognostic evolution to raise a hypothesis that could be a starting point for further research. According to previous classification of mental disorders in the DSM IV-TR, patients addicted to recurrent surgery are included in the diagnostic category of “Factitious Disorder with Predominantly Physical Signs and Symptoms”. In the DSM-5 typical clinical manifestations of recurrent surgery are excluded from diagnostic criterions of “Factitious Disorder”. The new manual moves away from the classic nosography tradition and highlights a bigger importance of an objective clinical observation of patients in comparison with the sole clinical history: the most suitable diagnosis is the “Somatic Symptom Disorder”.

In psychiatric rehabilitation the individual treatment plan can be formulated from tools that provide a multidimensional assessment of the patient. This study aims to analyze the relationship between distress and recovery style (integration and sealing over) from the psychosis. Assuming that this relationship affects the burden management, the study has the additional target of gaining more elements to direct the formulation of more effective therapeutic / rehabilitation programs.The study was carried out in a psychiatric day center, semi-residential structure of mental health services of the National Health System in Italy. 45 patients enrolled have been evaluated by the Neuropsychiatric Inventory (NPI - Italian version) and Integration / Sealing Over Scale (ISOS - Italian version), within three months (March-June 2014).In the sample, the symptoms which cause a greater distress in the health workers, in an absolute sense, are uninhibition, irritability and apathy. Moreover, the results indicate that depression and anxiety cause a greater degree of distress in sealer patients.Uninhibition, irritability and apathy were more burdensome for mental health workers, because they require a greater engagement in the therapeutic relationship. Anxious and depressive symptoms cause a greater degree of distress in the sealers patients, reporting lower endurance of the denial of psychosis. The data seem to prove that knowing, differentiating and deepening the different aspects of the recovery style of each patient enable us to estimate the burden management, starting from the taking in charge, and to reduce the distress and the risk of burn out of the mental health workers.

Marta Ielmini,1 Nicola Poloni,1 Ivano Caselli,1 Jordi Espadaler,2 Miquel Tuson,2 Alessandro Grecchi,3 Camilla Callegari1 1Department of Medicine and Surgery, Division of Psychiatry, University of Insubria, Varese, Italy; 2AB-BIOTICS S.A, R&D Unit, Sant Cugat del Valles, Barcelona, Spain; 3ASST Santi Paolo e Carlo Borromeo, Division of Psychiatry, Milan, Italy Background: Bipolar disorder (BD) is a frequent cause of disability, health care costs, and risk of suicide. Pharmacogenetic tests (PGTs) could help clinicians to identify those patients predisposed to the occurrence of adverse events (AEs) improving the understanding of the correlation between genetic variants and drug response.Materials and methods: The study evaluated 30 patients affected by BD type I or II (according to Diagnostic and Statistical Manual of Mental Disorders, version 5) who underwent the PGT Neurofarmagen® (AB-BIOTICS SA, Barcelona, Spain) between March 2016 and March 2017. The primary aim of this study was to identify if the treatment prescribed by the psychiatrists was consistent with the treatment suggested by the PGT at T0 (corresponding to the test report communication). As a secondary aim, we wanted to assess if clinicians had changed the treatment (in case of discordance) at T1 (3-month follow-up visit) according to the results of the PGT.Results: At T0, only 4 patients (13%) had an optimal therapy in line with the PGT suggestions. At 3-month follow-up, 13 patients (40%) had received a change of therapy consistent to the test, showing a significant statistical improvement in the Clinical Global Impression item Severity (CGI-S) score over time compared to those not having changes consistent with the test. Regarding AEs, at baseline 9 out of 10 (90%) of the patients who received a therapy modification according to the test presented AEs, and a significant within-group reduction was observed after 3 months (p = 0.031).Conclusion: Despite the small sample size, the study shows promising data about the usefulness of PGT to support clinicians in reaching a more effective and tolerated treatment in the routine approach of BD. Keywords: pharmacogenetics testing, bipolar disorder, personalized medicine, pharmacogenetics, adverse events, tolerability, mood disorder