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Early maladaptive schemas (EMS), illness representations, and coping are associated with clinical outcomes of patients with major depressive disorder (MDD). However, the pathways that link these factors are largely unknown. The present prospective study aimed at investigating the possible mediating role of illness representations and coping in the associations among schema domains, symptom severity, and suicide risk in MDD. Participants were 135 patients diagnosed with MDD, aged 48.13 ± 14.12 (84.4% females). The Young Schema Questionnaire-Short Form 3 was used to measure schema domains at baseline. Illness representations and coping were measured at approximately five months later (mean = 5.04 ± 1.16 months) with the Illness Perception Questionnaire-Mental Health and the Brief COPE Inventory, respectively. MDD outcomes were measured about 10 months after the baseline assessment (mean = 9.44 ± 2.36 months) with the Beck Depression Inventory and the Risk Assessment Suicidality Scale. SPSS AMOS 27 was used to conduct path analysis. Serial mediation Structural Equation Modelling, controlling for age, education, marital status, working status, MDD duration, pharmacotherapy, and psychotherapy, revealed that Impaired Autonomy and Performance was positively linked to suicide risk. Negative MDD impact representations and symptom severity serially mediated the aforementioned association. Finally, problem-focused coping was negatively related to symptom severity and suicide risk. This study’s main limitation was modest sample size. Representations regarding the impact and severity of MDD mediate the effects of Impaired Autonomy and Performance on future suicide risk in MDD. Healing Impaired Autonomy and Performance domain of EMS, restructuring patients’ representations of high MDD impact, and enhancing problem-focused coping could significantly reduce symptom severity and suicide risk in Schema Therapy with MDD individuals.

The present study aims to explore the association of maternal sleep disturbances during late pregnancy on child neuropsychological and behavioral development in preschool years. The study included 638 mother-child pairs from the prospective Rhea mother-child cohort in Crete, Greece. Information on antenatal sleep disturbances was collected through a computer-assisted interview. Children's neuropsychological and behavioral development was assessed using the McCarthy Scales of Children's Abilities (MSCA), the Attention-Deficit Hyperactivity Disorder Test (ADHDT), and the Strengths and Difficulties Questionnaire (SDQ). Multivariate analysis showed that maternal sleep duration less than 8 h was associated with reduced scores in the general cognitive scale (β = -2.28, 95% CI -4.54, -0.02, R

The transitional period of emerging adulthood can cause a lot of stress to the individuals due to the multiple life changes and the social pressure. Efficient emotion regulation and resilience can be proven important qualities in the face of stressors during this period. The aim of the present study was to test a path analytic model accounting for emerging adults’ resilience that takes into account emotion regulation strategies (e.g., cognitive reappraisal and expressive suppression) and self-esteem. Also, two alternative models with reverse ordering of the variables to examine the theoretical possibility of reverse causation were formulated and tested. The sample consisted of 390 university students (70.8% females and 29.2% males) with mean age 20.64 years (± 1.83). The Emotion Regulation Questionnaire (ERQ), the Rosenberg Self-Esteem Scale (RSES), and the Connor-Davidson Resilience Scale (CD-RISC) were used to assess emotion regulation, self-esteem, and resilience, respectively. The results indicated that resilience was correlated positively with cognitive reappraisal and negatively with expressive suppression. Self-esteem partially mediated the relationship between cognitive reappraisal and resilience, and fully mediated the association of expressive suppression with resilience. Thus, cognitive reappraisal had a positive direct and indirect effect on resilience through the mechanism of self-esteem, while expressive suppression had a negative indirect effect on resilience through the mechanism of self-esteem. Alternative directions of causality with reverse ordering of the variables were not supported. These findings suggest that efficient regulation of emotions can boost self-esteem, which in turn makes individuals capable of responding adaptively to stress. Implications for enhancing self-esteem among individuals experiencing multiple stressors during emerging adulthood are discussed.

Background Social media use has vastly increased during the past few years, especially among young adults. Studies examining the relationship of social media use with mental health have yielded mixed findings. Additionally, such studies are extremely limited in Greece. The present study aimed to investigate the association between social media use, depressive symptoms and self-esteem among Greek young adults. Method A total of 654 individuals (50.5% male) aged 18-30 years (Μ = 23.62, SD = 2.71) completed self-reported questionnaires regarding social media use, depressive symptoms and self-esteem. Results Increased daily use of YouTube (more than five hours) showed a significant association with higher depressive symptomatology, b = 2.99, 95% CI [.78, 5.20], p = .008, while daily use of Facebook between two and five hours was related to significantly higher self-esteem, b = 1.61, 95% CI [.78, 2.44], p < .001, after adjusting for participants’ gender, age, educational level and employment status. The association of increased daily use of YouTube with depressive symptoms was more pronounced in males than in females. Moreover, self-reported active use of Facebook and Instagram were linked with significantly lower depressive symptoms and higher self-esteem compared to passive involvement. Conclusion The results suggest that social media use is closely related to self-esteem and depressive symptomatology in young adults. These findings may contribute to a deeper clinical understanding of the association between electronic social networking and mental health.

Background: The way postpartum parents’ COVID-19-related concerns are associated with the family environment, support resources and depressive symptoms areunder-investigated. Methods: Two hundred and forty-three new parents (132 mothers, 111 fathers) completed self-report questionnaires within an 8-week period after birth. Parental concerns for COVID-19-related life changes were assessed with the COVID-19 Questionnaire, perceived social support with the Multidimensional Scale of Perceived Social Support, perceived family functioning with the Family Adaptability and Cohesion Evaluation Scales IV Package, dyadic coping behaviors with the Dyadic Coping Inventory and maternal/paternal postnatal depression with the Edinburgh Postnatal Depression Scale. Results: (a) Higher levels of COVID-19-related concerns about daily life were associated with lower levels of family communication, satisfaction and increased depressive symptomatology in both parents, and with lower levels of family functioning in mothers; (b) Maternal health care COVID-19-related concerns were linked with lower levels of family communication, lower perceived social support and with an increase in maternal depressive symptoms; and (c) COVID-19-related concerns about neonate hospitalization were associated with increased maternal depressive symptoms. Conclusion: Τhese findings suggest that COVID-19-related concerns had a common negative effect on both postpartum mothers’ and fathers’ mental health and on certain aspects of family functioning.

Background Prior studies have shown that young people “not in education, employment or training” (“NEET”) are at higher risk for psychopathology and substance abuse. Similar studies are lacking in Southern European populations. We aimed to examine the associations of anxiety and depressive symptoms, and substance use with NEET status in a large, randomized population-based sample in Greece. Methods A telephone structured questionnaire was conducted in a representative sample of 2771 young Greeks aged 15–24 years. Anxiety and depressive symptoms were assessed with GAD-7 and PHQ-9 scales, respectively. Substances use and several sociodemographic parameters were also examined. Results In our sample 16.4% were NEETs. In multivariate analyses, NEETs compared to non-NEETs were older, with lower family income, without insurance and more likely to be married and smoke. Furthermore, NEET status was associated with a higher GAD-7 score among older NEETs and long-term NEETs (NEETs unemployed for more than a year). Moreover, being NEET among older participants was associated with severe symptoms of anxiety and moderate/severe symptoms of depression. Limitations This was a telephone survey and a clinical evaluation of the patients was not performed. Furthermore, the structured interview was not designed to detect the level of substance use or the reasons for being NEET. Conclusions NEET status is frequent among young Greeks. Older, and long-term NEETs appear to be at higher risk for presenting anxiety/depression symptoms. Whether NEET status is associated with adverse outcomes later in life requires longitudinal studies.

There is growing evidence associating inflammatory markers in complex, higher order neurological functions, such as cognition and memory. We examined whether high levels of various inflammatory markers are associated with cognitive outcomes at 4 years of age in a mother-child cohort in Crete, Greece (Rhea study). We included 642 children in this cross-sectional study. Levels of several inflammatory markers (IFN-γ, IL-1β, IL-6, IL-8, IL-17α, IL-10, MIP-1α, TNF-α and the ratios of IL-6 to IL-10 and TNF-α to IL-10) were determined in child serum via immunoassay. Neurodevelopment at 4 years was assessed by means of the McCarthy Scales of Children’s Abilities. Multivariate linear regression analyses were used to estimate the associations between the exposures and outcomes of interest after adjustment for various confounders. Our results indicate that children with high TNF-α concentrations (≥90th percentile) in serum demonstrated decreased scores in memory (adjusted β = −4.0; 95% CI: −7.7, −0.2), working memory (adjusted β = −4.0; 95% CI: −8.0, −0.1) as well as in memory span scale (adjusted β = −4.0; 95% CI: −7.9, −0.1). We also found that children with high IFN-γ serum levels showed lower scores in memory span scale (adjusted β = −3.4; 95% CI: −7.3, −0.4). Children with elevated TNF-α/IL-10 ratio demonstrated decreased quantitative (adjusted β = −4.3; 95% CI: −8.2, −0.4), motor (adjusted β = −3.5; 95% CI: −7.5, −0.5), executive function (adjusted β = −4.8; 95% CI: −8.5, −1.1), general cognitive (adjusted β = −3.6; 95% CI: −7.3, −0.1), memory (adjusted β = −3.8; 95% CI: −7.6, −0), working memory (adjusted β = −3.5; 95% CI: −7.5, −0.5) and memory span scores (adjusted β = −5.3; 95% CI: −9.1, −1.4) The findings suggest that high levels of TNF-α may contribute to reduced memory performance at preschool age.

Purpose Illness representations are key determinants of depressive symptoms in patients with mental and physical disorders. Leventhal's Common Sense Model (CSM) - the leading psychological model of self-regulation - is used to understand people's responses to illness. The CSM proposes a dynamic interaction between illness representations, self-management, and health outcomes. This systematic review is the first to examine the associations of the CSM's illness representations with clinical and treatment-related outcomes in patients with depression and to identify factors that mediate or moderate the aforementioned associations. Methods We carried out a comprehensive literature search on PubMed, ScienceDirect, PsycINFO, Scopus, Google Scholar, and Web of Science databases. Eleven studies investigating the association between illness representations and depression outcomes were identified. Results Negative representations of identity, control, consequences, coherence, and chronic timeline were associated with poorer depression outcomes, including higher severity of depression, higher anxiety level, poorer patient psychosocial functioning, and longer treatment duration. Furthermore, various beliefs about the causes of depression were differentially associated with outcome variables. Limitations The search was limited to English language and grey literature was not examined. Conclusion Having a thorough understanding of depression and appraising it as an acute and controllable illness, with a limited number of symptoms and consequences is associated with better outcomes, and an overall better illness experience. The findings of this review have the potential to inform clinical interventions in depression based on illness representations. Further research is required to establish causal relations between illness representations and depression outcomes.

The present study examines whether attitudes of mental health professionals (MHPs) towards severe mental illness are associated with professional quality of life. The Attitudes towards Severe Mental Illness (ASMI), the Maslach Burnout Inventory (MBI), and the Professional Quality of Life Scale-5 (ProQOL-5) were completed by 287 MHPs in Greece (25.4% males, 74.6% females). The results indicate that MHPs hold predominantly positive attitudes towards people with severe mental illness. Nonetheless, MHPs' attitudes are deemed to be stereotypical according to ASMI concerning treatment duration, prospects of recovery, and whether patients are similar to other people. Higher scores in emotional exhaustion, depersonalization, compassion fatigue and ProQOL-5 burn out dimension were significantly associated with MHPs' unfavorable attitudes, whereas higher scores in compassion satisfaction and personal accomplishment were associated with MHPs' positive attitudes. Assessing compassion fatigue, compassion satisfaction and burnout levels could help identify the processes involved in the development or maintenance of MHPs' stigmatizing attitudes.

BACKGROUND There is limited knowledge on the physiological and behavioral pathways that may affect the developmental outcomes of preterm infants and particularly on the link between autonomic nervous system maturation and early social human behavior. Thus, this study attempts to investigate the way heart rate variability (HRV) parameters are related to emotional coordination in interactions of preterm and full-term infants with their parents in the first year of life and the possible correlation with the developmental outcomes of infants at 18 months. OBJECTIVE The first objective is to investigate the relationship between emotional coordination and HRV in dyadic full-term infant–parent (group 1) and preterm infant–parent (group 2) interactions during the first postpartum year. The second objective is to examine the relationship of emotional coordination and HRV in groups 1 and 2 in the first postpartum year with the developmental outcomes of infants at 18 months. The third objective is to investigate the effect of maternal and paternal postnatal depression on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. The fourth objective is to examine the effect of family cohesion and coping on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. METHODS This is an observational, naturalistic, and longitudinal study applying a mixed method design that includes the following: (1) video recordings of mother-infant and father-infant interactions at the hospital, in the neonatal period, and at home at 2, 4, 6, 9, and 12 months of the infants’ life; (2) self-report questionnaires of parents on depressive symptoms, family cohesion, and dyadic coping of stress; (3) infants’ HRV parameters in the neonatal period and at each of the above age points during and after infant-parent video recordings; and (4) assessment of toddlers’ social and cognitive development at 18 months through an observational instrument. RESULTS The study protocol has been approved by the Research Ethics Committee of the University of Crete (number/date: 170/September 18, 2020). This work is supported by the Special Account for Research Funds of the University of Crete (grant number: 10792-668/08.02.2021). All mothers (with their partners) of full-term and preterm infants who give birth between March 2021 and January 2022 at the General University Hospital of Crete (northern Crete, Greece) will be invited to participate. The researcher will invite the parents of infants to participate in the study 1 to 2 days after birth. Data collection is expected to be completed by March 2023, and the first results will be published by the end of 2023. CONCLUSIONS Investigating the regulatory role of HRV and social reciprocity in preterm infants may have implications for both medicine and psychology. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/28089

Background There is limited knowledge on the physiological and behavioral pathways that may affect the developmental outcomes of preterm infants and particularly on the link between autonomic nervous system maturation and early social human behavior. Thus, this study attempts to investigate the way heart rate variability (HRV) parameters are related to emotional coordination in interactions of preterm and full-term infants with their parents in the first year of life and the possible correlation with the developmental outcomes of infants at 18 months. Objective The first objective is to investigate the relationship between emotional coordination and HRV in dyadic full-term infant–parent (group 1) and preterm infant–parent (group 2) interactions during the first postpartum year. The second objective is to examine the relationship of emotional coordination and HRV in groups 1 and 2 in the first postpartum year with the developmental outcomes of infants at 18 months. The third objective is to investigate the effect of maternal and paternal postnatal depression on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. The fourth objective is to examine the effect of family cohesion and coping on the relation between emotional coordination and HRV in the two groups and on developmental outcomes at 18 months. Methods This is an observational, naturalistic, and longitudinal study applying a mixed method design that includes the following: (1) video recordings of mother-infant and father-infant interactions at the hospital, in the neonatal period, and at home at 2, 4, 6, 9, and 12 months of the infants’ life; (2) self-report questionnaires of parents on depressive symptoms, family cohesion, and dyadic coping of stress; (3) infants’ HRV parameters in the neonatal period and at each of the above age points during and after infant-parent video recordings; and (4) assessment of toddlers’ social and cognitive development at 18 months through an observational instrument. Results The study protocol has been approved by the Research Ethics Committee of the University of Crete (number/date: 170/September 18, 2020). This work is supported by the Special Account for Research Funds of the University of Crete (grant number: 10792-668/08.02.2021). All mothers (with their partners) of full-term and preterm infants who give birth between March 2021 and January 2022 at the General University Hospital of Crete (northern Crete, Greece) will be invited to participate. The researcher will invite the parents of infants to participate in the study 1 to 2 days after birth. Data collection is expected to be completed by March 2023, and the first results will be published by the end of 2023. Conclusions Investigating the regulatory role of HRV and social reciprocity in preterm infants may have implications for both medicine and psychology. International Registered Report Identifier (IRRID) PRR1-10.2196/28089

BackgroundMaternal thyroid hormones’ supply is crucial for fetal neurodevelopment; however, the role of maternal mild thyroid dysfunction is not clear. We aimed to assess the association of maternal mild thyroid dysfunction with child neuropsychological development from infancy to early childhood.MethodsWe included 757 mother–child pairs from the prospective ‘Rhea’ cohort on Crete, Greece. Maternal thyroid functioning was assessed by quantitative analysis of serum thyroid-stimulating hormone, free thyroxine, thyroid peroxidase antibodies and thyroglobulin antibodies at early gestation (mean=14 weeks). Neuropsychological assessment was based on Bayley Scales of Infant Development (18 months of age), McCarthy Scales of Children’s Abilities (4 years of age), Raven’s Coloured Progressive Matrices, Trail Making Test and Finger Tapping Test (6 years of age).ResultsIn multivariate adjusted linear regression analyses, maternal hypothyroxinemia was associated with decreased verbal scores at 4 years and reduced motor speed at 6 years of age. Maternal thyroid autoimmunity was associated with decreased child perceptual and motor ability at 4 years of age. Four trajectories of longitudinal non-verbal cognitive development were identified and children exposed to maternal thyroid autoimmunity had increased risk for belonging to an adverse trajectory (‘low’: adjusted relative risk ratio (RRR) = 2.7 95% CI: (1.4, 5.2), ‘high-decreasing’: adjusted RRR = 2.2 95% CI: (1.2, 4.0), ‘low-increasing’: adjusted RRR = 1.8 95% CI: (1.0, 3.2)).ConclusionMaternal hypothyroxinemia is associated with reduced offspring verbal and motor ability. Maternal thyroid autoimmunity is associated with decreased offspring perceptual performance and motor ability and increased risk for adverse non-verbal cognitive development from infancy to childhood.

BACKGROUND/AIM: Inflammation provides a substrate for mechanisms that underlie the association of maternal diet during pregnancy with Attention Deficit-Hyperactivity Disorder (ADHD) symptoms in childhood. However, no previous study has quantified the proinflammatory potential of maternal diet as a risk factor for ADHD. Thus, we evaluated the association of maternal dietary inflammatory index (DII(®)) scores during pregnancy with ADHD symptoms in 4 year-old children born in two Mediterranean regions. METHODS: We analyzed data from two population-based birth cohort studies – INMA (Environment and Childhood) four subcohorts in Spain (N=2,097), and RHEA study in Crete (Greece) (N=444). The DII score of maternal diet was calculated based on validated food frequency questionnaires completed during pregnancy (12(th) and/or 32(nd) week of gestation). ADHD symptoms were assessed by ADHD-DSM-IV in INMA cohort and by ADHDT test in RHEA cohort, with questionnaires filled-out by teachers and parents, respectively. The associations between maternal DII and ADHD symptoms were analysed using multivariable-adjusted zero-inflated negative binomial regression models in each cohort study separately. Meta-analysis was conducted to combine data across the cohorts for fitting within one model. RESULTS: The DII was significantly higher in RHEA (RHEA=2.09 [1.94, 2.24]) in comparison to INMA subcohorts (Asturias=−1.52 [−1.67,−1.38]; Gipuzkoa=−1.48 [−1.64,−1.33]; Sabadell=−0.95 [−1.07,−0.83]; Valencia= −0.76 [−0.90,−0.62]). Statistically significant reduced risk of inattention symptomatology (OR = 0.86; CI 95% = 0.77–0.96), hyperactivity symptomatology (OR = 0.82; CI 95% = 0.72–0.92) and total ADHD symptomatology (OR = 0.82; CI 95%= −0.72–0.93) were observed with increased maternal DII in boys. No statistically significant associations were observed in girls between maternal DII and inattention, hyperactivity and total ADHD symptomatology. CONCLUSIONS: We found reduced risk of ADHD symptomatology with increased DII only in boys. This relationship requires further exploration in other settings.

The COVID-19 pandemic raised many challenges for university staff and students, including the need to work from home, which resulted in a greater reliance on technology. We collected questionnaire data from university students (N = 894) in three European countries: Greece, Italy, and the United Kingdom. Data were collected between 7th April 2020 and 19th June 2020, representing a period covering the first lockdown and university closures in these countries and across Europe generally. We tested the hypotheses that technology-related stressors (techno-overload, work-home conflict, techno-ease, techno-reliability, techno-sociality, and pace of change) would be associated with anxiety and depressive symptoms, and that coping styles (problem-focused, emotion-focused, and avoidance) would mediate these relationships. Results showed significant positive associations between techno-overload, work-home conflict and anxiety and depressive symptoms, and significant negative associations between techno-reliability, techno-ease and anxiety and depressive symptoms. A significant negative association was found between techno-sociality and depressive symptoms but not anxiety symptoms. No evidence was found for an association between pace of change and anxiety or depressive symptoms. Multiple mediation analyses revealed significant direct effects of techno-overload, work-home conflict and techno-ease on anxiety symptoms, and of work-home conflict and techno-ease on depressive symptoms. Work-home conflict had significant indirect effects on anxiety and depressive symptoms through avoidance coping. Techno-overload and techno-ease both had significant indirect effects on anxiety symptoms through problem- and emotion-focused coping. Techno-ease also had a significant indirect effect on depressive symptoms through problem-focused coping. The findings add to the body of evidence on technostress amongst university students and provide knowledge on how technostress translates through coping strategies into anxious and depressive symptoms during the disruption caused by the outbreak of a pandemic disease.

Animal studies suggest that prenatal vitamin D status may affect fetal brain growth. However, human studies are scarce with conflicting results. We aimed to investigate the association of maternal 25-hydroxyvitamin D [25(OH) D] levels with multiple neurodevelopmental outcomes at 4 years of age. We included 487 mother–child pairs from the prospective pregnancy cohort, “Rhea” in Crete, Greece. Maternal serum 25(OH) D concentrations were measured at the first prenatal visit (13 ± 2.4 weeks). Cognitive functions at 4 years were assessed by means of the McCarthy Scales of Children’s Abilities. Behavioral difficulties were assessed by means of Strengths and Difficulties Questionnaire and Attention Deficit Hyperactivity Disorder Test. Children of women in the high 25(OH) D tertile (>50.7 nmol/l) had 37% decreased number of hyperactivity–impulsivity symptoms (IRR 0.63, 95% CI 0.39, 0.99, p trend = 0.05) and 40% decreased number of total ADHD-like symptoms (IRR 0.60, 95% CI 0.37, 0.95, p trend = 0.03) at 4 years of age, compared to children of women in the low 25(OH) D tertile (

Early-life exposures are critical for later child cognitive development. McCarthy Scales of Children's Abilities (MSCA) were used to assess cognitive development of 700 preschoolers (Mage = 4.2 years), derived from the "Rhea" birth cohort, in Greece. Principal component analysis (PCA) was applied on prospectively collected exposure data. Six components were extracted; five of them were associated with child cognition. Higher parental social status, preschool attendance and less TV watching, nonsmoking during pregnancy and breastfeeding, and parental involvement in child life were protective factors of child cognition at 4 years. Increased child birth order was negatively associated with child cognition. Offspring's size at birth was not associated with any cognitive outcome. These findings reveal the importance of early-life exposures to child cognitive development.

Objective Leptin is critical for central nervous system development and maturation. This study aimed to evaluate the potential regulatory role of cord leptin in the neuropsychomotor development of children ages 18 months to 6 years. Methods This study included 424 children from a prospective mother-child cohort (Rhea Study; Crete, Greece) with available cord leptin levels and data on neurodevelopmental outcomes at 18 months (Bayley Scales of Infant and Toddler Development, Third Edition), 4 years (McCarthy Scales of Children's Abilities), and 6 years (Raven's Coloured Progressive Matrices and Trail Making Test). Multivariable linear regression models were used to explore the associations. Results Each 10-ng/mL increase in the cord leptin level was associated with increased scores on the gross motor scale at 18 months (β coefficient: 3.8; 95% CI: 0.0-7.5), with decreased scores in the general cognitive performance (β coefficient: -3.0; 95% CI: -5.5 to -0.4), perceptual performance (β coefficient: -3.4; 95% CI: -6.0 to -9.9), working memory (β coefficient: -3.1; 95% CI: -5.7 to -0.4), executive function (β coefficient -3.1; 95% CI: -5.7 to -0.5), and functions of the posterior cortex (β coefficient: -2.7; 95% CI: -5.2 to -0.1) scales at 4 years, and with a 3.7-unit decrease in the Raven's Coloured Progressive Matrices score at 6 years (β coefficient: -3.7; 95% CI: -6.9 to -0.5). Conclusions Increased cord leptin levels are associated with enhanced gross motor development at 18 months but decreased cognitive performance in early and middle childhood.

Background: Persistent Organic Pollutants (POPs) are highly-resistant compounds to environmental degradation and due to fat solubility they bioaccumulate through the food chain. As they cross the placenta, in utero exposure to POPs could disrupt child neurodevelopment as they are considered to be neurotoxic. Aims: We examined whether in utero exposure to levels of different POPs is associated with offspring cognitive and behavioral outcomes at 4 years of age in a mother-child cohort in Crete, Greece (Rhea study). Methods: We included 689 mother-child pairs. Concentrations of several polychlorinated biphenyls (PCBs) and other organochlorine compounds (dichlorodiphenyl dichloroethene [DDE], hexachlorobenzene [HCB]) were determined in maternal serum collected in the first trimester of pregnancy by triple quadrupole mass spectrometry. Neurodevelopment at 4 years was assessed by means of the McCarthy Scales of Children's Abilities. Behavioral difficulties were assessed by Strengths and Difficulties Questionnaire and Attention Deficit Hyperactivity Disorder Test. Linear regression analyses were used to estimate the associations between the exposures and outcomes of interest after adjustment for potential confounders. Results: Children with “high” HCB concentrations (≥90th percentile) in maternal serum, demonstrated decreased scores in perceptual performance (adjusted β = −6.07; 95% CI: −10.17, −1.97), general cognitive (adjusted β = −4.97; 95% CI: −8.99, −0.96), executive function (adjusted β = −6.24; 95% CI: −10.36, −2.11) and working memory (adjusted β = −4.71; 95% CI: −9.05, −0.36) scales at 4 years of age. High exposure to PCBs (≥90th percentile) during pregnancy was associated with a 4.62 points reduction in working memory score at 4 years of age (95% CI: −9.10, −0.14). Prenatal exposure to DDE, HCB and PCBs was not associated with child behavioral difficulties. Conclusions: The findings suggest that prenatal exposure to HCB and PCBs may contribute to reduced cognitive development at preschool age. Our results raise the possibility that exposure to HCB may play a more important role in child cognition than previously considered. Keywords: Persistent organic pollutants, PCBs, HCB, Neuropsychological development, Cognition, McCarthy Scales for Children’s Abilities

Background Viral infections of the central nervous system may have detrimental effects for the developing brain, but the effects of less virulent common infections are unclear. We aim to investigate the impact of common viral infections of early childhood on neuropsychological performance of children at age four. Methods We used cross-sectional data on 674 children participating at the 4 years of age follow-up of the Rhea birth cohort in Crete, Greece. Blood levels of IgG antibodies to 10 polyomaviruses (BKPyV, JCPyV, KIPyV, WUPyV, HPyV6, HPyV7, TSPyV, MCPyV, HPyV9, and HPyV10) and four herpesviruses [Epstein–Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus-1 (HSV-1), and herpes simplex virus-2 (HSV-2)] were measured using multiplex serology. Child's neuropsychological development at age four was assessed using the McCarthy Scales of Children's Abilities, the Attention-Deficit Hyperactivity Disorder Test (ADHDT), and the Strengths and Difficulties Questionnaire (SDQ). Multiple linear regression models were used to explore the associations. Results Seroprevalence to polyomaviruses ranged from 21% for HPyV9 to 82% for HPyV10. Seroprevalence for EBV was 53%, for CMV 26%, for HSV-1 3.6%, and for HSV-2 1.5%. Children seropositive to ≥8 polyomaviruses had lower score in ADHDT inattention subscale [β = −1.28 (95% CI: −2.56, −0.001)] and lower score in SDQ hyperactivity–inattention subscale [β = −.99 (95% CI: −1.60, −0.37)] versus children seropositive to ≤3 polyomaviruses. Seropositivity to BKPyV, a potential neurotropic virus, was associated with higher score in ADHDT inattention subscale [β = .87 (95% CI: 0.03, 1.71)]. Conclusions These findings suggest that acquisition of polyomaviruses during development may influence behavioral outcomes in early childhood.

The evidence regarding a potential link of low-to-moderate iodine deficiency, selenium status, and cadmium exposure during pregnancy with neurodevelopment is either contradicting or limited. We aimed to assess the prenatal impact of cadmium, selenium, and iodine on children's neurodevelopment at 4 years of age. The study included 575 mother-child pairs from the prospective "Rhea" cohort on Crete, Greece. Exposure to cadmium, selenium and iodine was assessed by concentrations in the mother's urine during pregnancy (median 13 weeks), measured by ICPMS. The McCarthy Scales of Children's Abilities was used to assess children's general cognitive score and seven different sub-scales. In multivariable-adjusted regression analysis, elevated urinary cadmium concentrations (≥0.8 µg/L) were inversely associated with children's general cognitive score [mean change: -6.1 points (95 % CI -12; -0.33) per doubling of urinary cadmium; corresponding to ~0.4 SD]. Stratifying by smoking status (p for interaction 0.014), the association was restricted to smokers. Urinary selenium was positively associated with children's general cognitive score [mean change: 2.2 points (95 % CI -0.38; 4.8) per doubling of urinary selenium; ~0.1 SD], although the association was not statistically significant. Urinary iodine (median 172 µg/L) was not associated with children's general cognitive score. In conclusion, elevated cadmium exposure in pregnancy of smoking women was inversely associated with the children's cognitive function at pre-school age. The results indicate that cadmium may adversely affect neurodevelopment at doses commonly found in smokers, or that there is an interaction with other toxicants in tobacco smoke. Additionally, possible residual confounding cannot be ruled out. The “Rhea” project was financially supported by European projects (EU FP6-2003-Food-3-NewGeneris, EU FP6. STREP Hiwate, EU FP7 ENV.2007.1.2.2.2. Project No 211250 Escape, EU FP7-2008-ENV-1.2.1.4 Envirogenomarkers, EU FP7-HEALTH-2009-single stage CHICOS, EU FP7 ENV.2008.1.2.1.6. Proposal No 226285 ENRIECO, EU-FP7-HEALTH-2012 Proposal No 308333 HELIX) and the Greek Ministry of Health (Program of Prevention of obesity and neurodevelopmental disorders in preschool children, in Heraklion district, Crete, Greece: 2011–2014; “Rhea Plus”: Primary Prevention Program of Environmental Risk Factors for Reproductive Health, and Child Health: 2012–2015). The present study was also funded by Karolinska Institutet, the Swedish Research Council Formas (Project No. 210-2013-751), and Swedish Research Council

Background Recently, suicides in Greece have drawn national and international interest due to the current economic crisis. According to published reports, suicides in Greece have increased up to 40% and Crete has been highlighted as an area with the sharpest increase. Aim To investigate the suicide mortality rates in Crete between 1999 and 2013 and their association with the economic crisis. Methods Data on suicides were selected from the Department of Forensic Medicine files of the University of Crete. Results Our analysis showed that (1) Crete, has the highest suicide mortality rate in Greece, however no significant increase was observed between 1999 and 2013, (2) there were opposing trends between men and women, with women showing a decrease whereas men showed an increase in that period, (3) there was a significant increase of suicides in middle-aged men (40–64 yrs) and elderly, although the highest unemployment rates were observed in young men and women, and (4) finally, there was a regional shift of suicides with a significant decrease in Western Crete and a significant increase in Eastern Crete. Conclusions Although, Crete has the highest suicide mortality rates in Greece, we did not observe an overall increase during the last 15 years, including the period of economic crisis. Furthermore, there was an increase in middle-aged and elderly men, whereas young men and women showed oppositional trends during the years of austerity. This may be related to the culturally different expectations for the two genders, as well as that younger individuals may find refuge to either strong family ties or by immigrating abroad. Finally, the relative increase of suicides in Eastern Crete may be explained by factors, such as the lack of community mental health services in that area.

The aim of the present study was to assess the relationship between illness-related characteristics, such as symptom severity and psychosocial functioning, and specific aspects of family functioning both in patients experiencing their first episode of psychosis (FEP) and chronically ill patients. A total of 50 FEP and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) and their family caregivers participated in the study. Family functioning was evaluated in terms of cohesion and flexibility (FACES IV Package), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Patients' symptom severity (BPRS) and psychosocial functioning (GAS) were assessed by their treating psychiatrist within 2 weeks from the caregivers' assessment. Increased symptom severity was associated with greater dysfunction in terms of family cohesion and flexibility (β coefficient -0.13; 95 % CI -0.23, -0.03), increased caregivers' EE levels on the form of emotional overinvolvement (β coefficient 1.03; 95 % CI 0.02, 2.03), and psychological distress (β coefficient 3.37; 95 % CI 1.29, 5.45). Family burden was found to be significantly related to both symptom severity (β coefficient 3.01; 95 % CI 1.50, 4.51) and patient's functioning (β coefficient -2.04; 95 % CI -3.55, -0.53). No significant interaction effect of chronicity was observed in the afore-mentioned associations. These findings indicate that severe psychopathology and patient's low psychosocial functioning are associated with poor family functioning. It appears that the effect for family function is significant from the early stages of the illness. Thus, early psychoeducational interventions should focus on patients with severe symptomatology and impaired functioning and their families.

BACKGROUND Limited evidence exists on the association between exposure to Helicobacter pylori infection early in life, including fetal life, and neurodevelopment in childhood. METHODS We used prospective data on 352 mother-child pairs and cross-sectional data on 674 children to assess the association of maternal and child's H. pylori seropositivity correspondingly on child's neurodevelopment at age four in the Rhea birth cohort in Crete, Greece. Blood levels of immunoglobulin G antibodies to 12 H. pylori proteins were measured using multiplex serology. Child's neurodevelopment at age four was assessed using the McCarthy Scales of Children's Abilities. Linear regression models were used to explore the associations after adjusting for potential confounders. RESULTS Helicobacter pylori seroprevalence (95% CI) in cord blood, representing maternal status, was 41.5% (36.3%, 46.8%) and in 4 years old children was 6.5% (95% CI 4.8%, 8.7%). Children of H. pylori seropositive mothers had lower score in the general cognitive (-3.87, 95% CI -7.02, -0.72), verbal (-2.96, 95% CI -6.08, 0.15), perceptual performance (-3.37, 95% CI -6.60, -0.15), quantitative (-2.85, 95% CI -6.28, 0.58), and memory scale (-3.37, 95% CI -6.67, -0.07) compared to those of seronegative mothers. Seropositivity in cord blood specifically to GroEl and NapA - two of the 12 H. pylori proteins investigated - was associated with lower scores in almost all scales. At age four, H. pylori seropositive children performed worst in neurodevelopment assessment compared to their seronegative counterparts although no association reached statistically significant level. CONCLUSIONS Helicobacter pylori infection in early life may be an important but preventable risk factor for poor neurodevelopment.

Antenatal maternal mental health has been identified as an important determinant of postpartum depression (PPD). We investigated the occurrence of depression both antenatally and postnatally and examined whether maternal trait anxiety and depression during pregnancy were associated with PPD at 8 weeks postpartum in a prospective mother–child cohort (Rhea Study) in Crete, Greece. 438 women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Trait subscale of the State-Trait Anxiety Inventory (STAI-Trait) questionnaires assessing antenatal depression and anxiety, respectively, during the third trimester of pregnancy as well as the EPDS at 8 weeks postpartum. The prevalence of women with probable depression (EPDS score ≥13) was 16.7 % at 28–32 weeks of pregnancy and 13.0 % at 8 weeks postpartum. A per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 70 % (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in EPDS during pregnancy increased the odds for PPD by 27 % (OR = 1.27, 95 % CI 1.19, 1.36). Our findings suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for postpartum depression.

Aims.Few epidemiological studies evaluated associations between perinatal complications and maternal mood at the early postpartum period and the findings are inconsistent. We aimed at investigating a wide range of complications during pregnancy, at delivery, and at the early postpartum period as determinants of postpartum depression (PPD) at 8 weeks postpartum.Methods.A total of 1037 women who enrolled in the Rhea mother–child cohort in Crete, Greece participated in the present study. Information on pregnancy, perinatal and postpartum complications was obtained from clinical records or by questionnaires. Postpartum depressive symptoms were assessed at 8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multivariable linear and logistic regression models were fit to estimate the association between pregnancy, perinatal and postpartum complications and maternal depressive symptoms, adjusting also for potential confounders.Results.The prevalence of women with probable depression (EPDS score ≥ 13) was 13.6% at 8 weeks postpartum. Gestational hypertension and/or preeclampsia (β coefficient 1.86, 95% CI: 0.32, 3.41) and breastfeeding difficulties (β coefficient 0.77, 95% CI: 0.02, 1.53) were significantly associated with higher PPD symptoms. Sleep patterns during pregnancy, such as sleep deprivation (OR = 3.57, 95% CI: 1.91, 6.67) and snoring (OR = 1.81, 95% CI: 1.11, 2.93), and breastfeeding duration less than 2 months (OR = 1.77, 95% CI: 1.19, 2.64) were significantly associated with increase in the odds for PPD. Some other complications, such as unplanned pregnancy and hospitalisation during pregnancy were also associated with EPDS score, but these associations were explained by socio-demographic characteristics of the mother.Conclusions.We found that several pregnancy, perinatal and postpartum complications may have an adverse effect on maternal mood at the early postpartum period. These findings have considerable implications for developing effective prevention and early psychoeducational intervention strategies for women at risk of developing PPD.

Background Poor perinatal maternal mental health has been linked with negative outcomes on early child development; however, the importance of maternal personality has been neglected thus far. We aimed to examine the effects of antenatal and postnatal maternal mental health, including assessment of maternal personality characteristics, on child neuropsychological and behavioral development at preschool years in a population based mother-child cohort (Rhea Study) in Crete, Greece. Method Self-reported measures of maternal depression (EPDS), trait anxiety (STAI-Trait) and personality traits (EPQ-R) were assessed in a sample of 288 women at 28–32 weeks of gestation. A larger sample of 642 mothers completed the EPDS scale at 8 weeks postpartum. Children's neuropsychological (MSCA) and behavioral (ADHDT and SDQ) development were assessed at 4 years of age. Linear regression analyses were used to estimate the associations between the exposures and outcomes of interest after adjustment for potential confounders. Results Regarding child neuropsychological development, increased postnatal depressive symptoms were associated with child's perceptual performance, whereas increased maternal psychoticism was linked with child's motor ability at 4 years of age. Furthermore, elevated levels of maternal depression during pregnancy and postpartum, and the predisposing personality characteristics of trait anxiety and neuroticism, were associated with children's behavioral difficulties. Limitations A clinical diagnostic instrument for maternal mental health was not used and assessment of children's behavior was based on maternal report. Conclusion These findings suggest that poor perinatal maternal mental health and an adverse personality profile may be associated with impaired child neuropsychological and behavioral development at preschool years.

Studies have suggested an association between maternal obesity pre-pregnancy and gestational diabetes (GDM) with impaired offspring neurodevelopment, but it is not clear if these associations are explained by shared familiar characteristics. We aimed to assess the associations of maternal and paternal obesity, maternal glucose intolerance in early pregnancy and GDM, with offspring neurodevelopment at 4 years of age. We included 772 mother–child pairs from the “Rhea” Mother–Child cohort in Crete, Greece. Data on maternal/paternal body mass index (BMI) and maternal fasting serum samples for glucose and insulin measurements were collected at 12 weeks of gestation. GDM screening was performed at 24–28 weeks. Neurodevelopment at 4 years was assessed using the McCarthy Scales of Children’s Abilities. Behavioral difficulties were assessed by Strengths and Difficulties Questionnaire and Attention Deficit Hyperactivity Disorder Test. Multivariate linear regression analyses showed that maternal obesity was associated with a significant score reduction in general cognitive ability (β-coeff −4.03, 95% CI: −7.08, −0.97), perceptual performance (β-coeff −4.60, 95% CI: −7.74, −1.47), quantitative ability (β-coeff −4.43, 95% CI: −7.68, −1.18), and executive functions (β-coeff −4.92, 95% CI: −8.06, −1.78) at 4 years of age, after adjustment for several confounders and paternal BMI. Maternal obesity was also associated with increased behavioral difficulties (β-coeff 1.22, 95% CI: 0.09, 2.34) and ADHD symptoms (β-coeff 4.28, 95% CI: 1.20, 7.36) at preschool age. Paternal obesity maternal glucose intolerance in early pregnancy and GDM was not associated with child neurodevelopment. These findings suggest that maternal obesity may impair optimal child neurodevelopment at preschool age independently of family shared characteristics.

The aim of the present study was to examine the psychometric properties of the Greek version of Family Adaptability and Cohesion Evaluation Scales IV (FACES IV) Package. The original FACES IV displays a six-factor structure with two balanced scales—Balanced Cohesion and Balanced Flexibility—and four unbalanced scales—Disengaged, Enmeshed, Rigid, and Chaotic—and has been shown to have satisfactory internal and test–retest reliability. A total of 584 family members agreed to participate in the study. The findings indicated that the Greek version displays similar factor structure to the original version. Cronbach’s α coefficients for the six scales ranged from .59 to .79. The test–retest correlation coefficients ranged between .94 and .97. The Family Communication Scale and the Family Satisfaction Scale demonstrated high internal consistency and test–retest reliability. Thus, the Greek version of the FACES IV Package appears to be a valid and reliable instrument to be used in both research and clinical assessment of family functioning.

Background/AimsMaternal personality may increase vulnerability to stress, which could lead to an unfavourable intrauterine environment to the fetus. We sought to investigate the impact of maternal personality traits on adverse birth outcomes such as preterm birth, and fetal growth restriction in the mother-child cohort study (RHEA Study) in Crete, Greece 2007–2009.MethodsFive hundred and eighty pregnant women participating in “Rhea” cohort study completed the Eysenck Personality Questionnaire-Revised (EPQ-R) at 28–32 weeks of gestation. Information on anthropometric measures at birth was obtained from the hospital delivery logs and medical records. Fetal growth restriction was based on a customized model, and multivariate logistic regression models were used adjusting for confounders.ResultsA per unit increase in the EPQ Neuroticism scale increased the risk for fetal weight growth restriction by 9% [Odds Ratio (OR) = 1.09, 95 percent CI: 1.01, 1.19)], and for fetal head circumference growth restriction by 6% [OR = 1.06, 95 percent CI: 1.01, 1.18] after adjusting for maternal age, education, origin, marital status, working status, pre-pregnancy BMI, delivery type, parity, smoking, and alcohol intake during pregnancy.ConclusionsMaternal neuroticism, which predisposes to negative mood, may be a risk factor for fetal growth restriction.

ObjectiveTo investigate whether high doses of folic acid supplementation in early pregnancy are associated with child neurodevelopment at 18 months of age.DesignThe study uses data from the prospective mother–child cohort ‘Rhea’ study. Pregnant women completed an interviewer-administered questionnaire on folic acid supplementation at 14–18 weeks of gestation. Neurodevelopment at 18 months was assessed with the use of the Bayley Scales of Infant and Toddler Development (3rd edition). Red-blood-cell folate concentrations in cord blood were measured in a sub-sample of the study population (n 58).SettingHeraklion, Crete, Greece, 2007–2010.SubjectsFive hundred and fifty-three mother–child pairs participating in the ‘Rhea’ cohort.ResultsSixty-eight per cent of the study participants reported high doses of supplemental folic acid use (5 mg/d), while 24 % reported excessive doses of folic acid (>5 mg/d) in early pregnancy. Compared with non-users, daily intake of 5 mg supplemental folic acid was associated with a 5-unit increase on the scale of receptive communication and a 3·5-unit increase on the scale of expressive communication. Doses of folic acid supplementation higher than 5 mg/d were not associated with additional increase in the neurodevelopmental scales.ConclusionsThis is the first prospective study showing that high doses of supplementary folic acid in early pregnancy may be associated with enhanced vocabulary development, communicational skills and verbal comprehension at 18 months of age. Additional longitudinal studies and trials are needed to confirm these results.

Studies on determinants affecting child development are still limited in Greece. The aim of the present study was to describe the socio-demographic characteristics associated with neurodevelopment in infants aged 18 months in the Mother-Child Cohort (Rhea Study) in Crete, Greece. A total of 599 (72.9%) mothers agreed to participate in the neurodevelopment protocol and 612 infants (586 singletons and 26 twins) were assessed by means of the Bayley Scales of Infant and Toddler Development (3rd edition). The present analysis includes 605 infants. Multivariable linear regression models were implemented to examine the associations between the Bayley-III standardised scores and different parental and infant characteristics, also adjusting for quality of assessment. Girls were found to have better neurodevelopmental outcomes in cognitive, receptive and expressive communication, fine motor and social-emotional development. Maternal higher education was positively associated to almost all aspects of infant neurodevelopment assessed. Increasing number of older siblings was negatively associated with cognitive development, communication skills and gross motor development. Our results, also, suggest a positive effect of maternal employment on infants' receptive and expressive communication, and gross motor scores. The results of the present study suggest that in the population on Crete social and environmental factors contributed more to infants' neurodevelopment at 18 months than biological factors.

The present study aimed to evaluate a path analytic model accounting for caregivers' psychological distress that takes into account perceived family cohesion and flexibility, expressed emotion and caregiver's burden associated with the presence of mental illness in the family. 50 first-episode and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) recruited from the Inpatient Psychiatric Unit of the University Hospital of Heraklion, Crete, Greece, and their family caregivers participated in the study. Family functioning was assessed in terms of cohesion and flexibility (FACES-IV), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Structural equation modelling was used to evaluate the direct and indirect effects of family dynamics on caregivers' psychological distress. The results showed that neither family cohesion nor family flexibility exerted significant direct effects on caregivers' psychological distress. Instead, the effect of flexibility was mediated by caregivers' criticism and family burden indicating an indirect effect on caregivers' psychological distress. These results apply equally to caregivers of first episode and chronic patients. Family interventions aiming to improve dysfunctional family interactions by promoting awareness of family dynamics could reduce the burden and improve the emotional well-being of family caregivers.