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Auditory verbal hallucinations (AVH) are often multiple distressing experiences. Emerging evidence suggests that interventions informed by the principles of cognitive behavioral therapy, such as brief Cognitive Strategy Enhancement (brief-CSE), can reduce the distress related to AVH. The benefits of brief-CSE have been demonstrated for English-speaking patients. This uncontrolled pilot study, conducted in routine clinical practice, evaluated the benefits of brief-CSE within a group of French-speaking AVH hearers. Thirty-two patients were offered the brief-CSE intervention. Self-administered questionnaires were completed pre-post intervention. A significant reduction was observed in AVH distress, with a large effect size, and for more than half of the patients, this reduction was clinically meaningful. AVH severity and anxiety also decreased significantly. This study demonstrates that brief-CSE can be implemented in non-English-speaking routine clinical practice and can reduce several aspects of AVH subjective experience. There is a need to confirm these findings in a larger sample.

Background and objectives Coercion is frequent in psychiatry, with an overall downward trend. Knowledge on the application of seclusion and restraint in open wards remains limited. We aimed to describe the prevalence of coercion in an open inpatient setting and identify risk factors for it. Methods We conducted a retrospective analysis of the use of seclusion and restraint in 2017 in the adult psychiatry division of Geneva University Hospital. To identify risk factors for coercion, we estimated incidence rate ratios using multivariable Poisson regressions. Results Of 865 patients, 142 (16.4%) experienced at least one coercive measure (mostly seclusion). The incidence of coercion was higher in men, single patients, patients with psychotic or bipolar disorders, patients receiving disability benefits, patients with a higher number of previous psychiatric hospitalizations, and patients with higher global scores and higher scores on item 1 (overactive, aggressive or agitated behaviour) on Health of the Nation Outcome Scales (HoNOS) at admission. Age and referrals from the emergency department were not associated with a higher risk of coercion. Conclusion Risk factors for coercion were being male, being single, having psychotic or bipolar disorders, having previous psychiatric hospitalizations, having high HoNOS scores at admission, and being referred from outpatient centres or private physicians. Ratings on the first HoNOS item at admission might be sufficient for a pertinent aggression risk evaluation and thus for the prevention of coercion due to violence. This study is the first to analyse the risks of seclusion in open wards and calls for further research.

Introduction The atypical antipsychotic quetiapine is known to induce weight gain and other metabolic complications. The underlying mechanisms are multifactorial and poorly understood with almost no information on the effect of dosage. Concerns were thus raised with the rise in low-dose quetiapine off-label prescription (i. e., Methods In this study, we evaluated the influence of quetiapine dose for 474 patients included in PsyMetab and PsyClin studies on weight and metabolic parameter evolution. Weight, blood pressure, lipid, and glucose profiles were evaluated during a follow-up period of 3 months after treatment initiation. Results Significant dose-dependent metabolic alterations were observed. The daily dose was found to influence weight gain and increase the risk of undergoing clinically relevant weight gain (≥7% from baseline). It was also associated with a change in plasma levels of cholesterol (total cholesterol, LDL cholesterol, and HDL cholesterol) as well as with increased odds of developing hypertriglyceridemia, as well as total and LDL hypercholesterolemia. No impact of a dose increase on blood pressure and plasma glucose level was observed. Discussion The dose-dependent effect highlighted for weight gain and lipid alterations emphasizes the importance of prescribing the minimal effective dose. However, as the effect size of a dose increase on metabolic worsening is low, the potential harm of low-dose quetiapine should not be dismissed. Prescriptions must be carefully evaluated and regularly questioned in light of side effect onset.

Background and objectives: The present study aims to investigate the effect of the 4-F (Fit, Fun, Feel and Food) group-based program on physical, clinical and biological outcomes in young patients suffering from serious psychiatric disorders.Methods: To prevent weight gain and improve mental and physical health in young patients, we investigated in a naturalistic design, the effect of a group-based intervention through an exploratory study.Results: We observed that out of the 61 outpatients initially included in the program, 71% were overweight or obese. The 24 patients who completed the full program showed no significant decrease in weight or body composition. Our main findings were the significant improvement in muscular endurance as well as coordination from T0 (M=13.65, SD=±1.93) compared to T1 (M=12.49, SD= ±1.81), (t(20) = 3.072 p = Conclusion: Despite the limitations, the findings of this exploratory study demonstrated that this program is feasible and resulted in better physical conditions with enhanced mental well-being in young patients suffering from psychiatric disorders, sedentary behaviour and unhealthy lifestyles. Further research is warranted in controlled and larger population samples to further our understanding of the effect of such interventions.

We aimed to examine the clinical features of psychotic symptoms preceding or concomitant to multiple sclerosis (MS) diagnosis.From the 1st to 10th of January 2020 a systematic review was conducted through an electronic search of different databases. Results were limited to English, French, German, Italian and Spanish language articles.We identified 599 titles, and included 32 cases from case-report and case series. One case report from our department was added. The mean age of first psychiatric symptoms was 25.8 ± 10.2 years, the mean age of MS diagnosis was 31.2 ± 10.7 years and the mean delay until MS diagnosis was 2.7 ± 3 years. Most reported symptoms were delusions (81%), auditory hallucinations (59%) and visual hallucinations (50%). Upon the MS diagnosis, immunosuppressive therapy was significantly more effective for psychotic symptoms than antipsychotics (OR = 9.0; 95%CI: 2.15-37;Poor response or resistance to antipsychotics treatment should alert clinicians on the need to consider a differential diagnosis. Considering the impact of delay in MS diagnosis further research regarding this subject is warranted.KEY POINTSInsight into the occurrence of psychotic symptoms in multiple sclerosis (MS) is mainly limited to case reports and case series.Delay in MS management between initial psychotic symptoms and the MS diagnosis is 2.73 ± 3 years and 0.8 ± 1.2 years for patients presenting a first episode of psychosis.The resistance and poor response to antipsychotics found in most cases (75%) were associated with an excellent improvement (95%) of both psychiatric and neurologic symptoms with corticosteroids.Prospective studies are needed to investigate the spectrum of psychosis in MS.

BACKGROUND Several studies have shown a significant positive impact of intensive short-term ambulatory psychiatric interventions for depression. However, data on outcomes related to factors that are predictive of the efficacy of these interventions in terms of remission or response to treatment remain scarce. The goal of this naturalistic prospective study was to identify factors, including Big Five Inventory personality traits and attachment style, that are predictive of the efficacy of crisis interventions (CIns) in major depressive disorder. METHODS The study included 234 adult outpatients with major depressive disorder who completed all assessments in a study of a short-term intensive ambulatory CIn. In this study, we evaluated sociodemographic factors, and scores on the Global Assessment of Functioning Scale, the Big Five Inventory personality assessment, the Montgomery-Asberg Depression Rating Scale, and the Adult Attachment Scale. RESULTS Mean scores on the Montgomery-Asberg Depression Rating Scale decreased significantly from 26.3 (SD=9.0) at admission to 10.6 (SD=8.1) at the end of the CIn (t=23.9; P

Background The concept of predominant polarity (PP) is defined as presenting more symptoms of one polarity. Previous studies have defined PP as one polarity (either a depression or mania episode) occurring during at least two-thirds of the lifetime. Methods We conducted an observational study with the COPE-BD (Clinical Outcome and Psycho-Education for Bipolar Disorder, Clinical Outcome Measures Section) dataset to identify the diagnostic and treatment differences between bipolar disorder (BD) patients with and without PP. Results The final sample included 210 BD-I (59.0%) and 146 BD-II (41.0%) patients. Of these, 28.9% patients presented predominant polarity (PP): 62 (17.4%) of those patients were depressed polarity predominant (DPP), 41 (11.5%) were manic polarity predominant (MPP), and 253 (71.1%) met criteria for bipolar disorders but did not present with PP. In comparison to this group of BD patients with undetermined polarity, the group of BD patients with PP presented more rapid cycling. Furthermore, in the undetermined polarity group, the onset of illness occurred earlier, and the duration of the illness was longer, with more hypomanic/manic and depressive episodes than patients who met the PP criteria. Limitations This study has a naturalistic and retrospective design and does not allow a specific follow-up of polarity over time. Conclusions These different clinical characteristics underline the importance of considering PP in patients with BD, and justify the need for differential treatment approach which could have an impact on patients' prognosis. Yet, more independent and prospective research is needed to confirm these findings, especially with the new classification of DSM-5 concerning mixed states.

Background and objectives Coercion in psychiatry is legally tolerated as a last resort. The reduction of the use of coercion is a shared goal of hospital administrators, medical and nursing staff and representatives of patients and families but requires the identification of risk factors for coercion. These risk factors in geriatric psychiatric inpatient settings are not well known, especially regarding seclusion. Through examining the prevalence of coercion and patients’ characteristics, this study aims to identify risk factors for coercion in elderly people.Methods The use of coercion in the geriatric psychiatry division of Geneva University Hospital in 2017 was retrospectively analyzed. The incidence rate ratios were estimated with multivariable Poisson regressions to assess risk factors for coercion. Results Eighty-one of 494 patients (16.4%) experienced at least one coercive measure during their stay (mainly seclusion). The risk factors for coercion were younger age, male gender, being divorced or married, cognitive disorders, high item 1 of the Health of the Nation Outcome Scales (HoNOS) score (overactive, aggressive, disruptive or agitated behavior) at admission, previous psychiatric hospitalizations and involuntary referrals from the emergency department. Other disorders and global HoNOS scores were not associated with the use of coercion.Conclusion Higher risks of coercion were outlined in men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. They differed from those observed in younger adults in terms of age, civil status, disorders, global HoNOS scores and referrals. Therefore, geriatric psychiatric populations should be specifically investigated for the development of interventions aiming coercion reduction.

Background and objectives Coercion in psychiatry is legally tolerated as a last resort. The reduction of the use of coercion is a shared goal of hospital administrators, medical and nursing staff and representatives of patients and families but requires the identification of risk factors for coercion. These risk factors in geriatric psychiatric inpatient settings are not well known, especially regarding seclusion. Through examining the prevalence of coercion and patients’ characteristics, this study aims to identify risk factors for coercion in elderly people. Methods The use of coercion in the geriatric psychiatry division of Geneva University Hospital in 2017 was retrospectively analyzed. The incidence rate ratios were estimated with multivariable Poisson regressions to assess risk factors for coercion. Results Eighty-one of 494 patients (16.4%) experienced at least one coercive measure during their stay (mainly seclusion). The risk factors for coercion were younger age, male gender, being divorced or married, cognitive disorders, high item 1 of the Health of the Nation Outcome Scales (HoNOS) score (overactive, aggressive, disruptive or agitated behavior) at admission, previous psychiatric hospitalizations and involuntary referrals from the emergency department. Other disorders and global HoNOS scores were not associated with the use of coercion. Conclusion Higher risks of coercion were outlined in men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. They differed from those observed in younger adults in terms of age, civil status, disorders, global HoNOS scores and referrals. Therefore, geriatric psychiatric populations should be specifically investigated for the development of interventions aiming coercion reduction.

Klinefelter syndrome (KS) 47, XXY is the most frequent chromosomal abnormality causing hypogonadism in humans. This chromosomal abnormality of number in its classical form called homogeneous (supernumerary X) is generally the result of a meiosis accident. Several studies have suggested that individuals with KS are at greater risk of developing various psychiatric disorders, including depression and schizophrenia. The diagnosis is made based on subnormal testosterone with high pituitary gonadotropins and confirmed by determining the karyotype on a blood simple. We did a literature review using an electronic search in three databases: Pubmed/MEDLINE, Google Scholar, and PsychInfo. We found that since 1989, seven case reports with KS and mental disorders with similar and different characteristics of our case illustration of a patient with KS and psychosis were published.

The significant progress of psychiatry in the 20th century provided a sophisticated theoretical framework to analyze the complex relationships between crime and mental illness. Schizophrenia has been traditionally associated with severe cognitive and affective deficits that heavily influence empathy, judgment capacities, but also control of impulsiveness. Although there is an association between psychotic disorders and absence or decrease of legal responsibility, their relationship is also determined by sociodemographic, developmental, and clinical factors. These disorders are associated not only with abolished criminal responsibility but also with diminished responsibility. We conduct a systematic literature review to examine the relation between schizophrenia and criminal responsibility. We have found that this clinical entity is often associated with diminished or abolished criminal liability. We discuss these findings, focusing on the specific deficits found in patients with schizophrenia and examining how this problem affects their behavior and eventually their accountability for their crimes.

Nowadays, new psychotropic treatments might result on rapid onset of weight gain also related to other factors such as individual vulnerability, poor diet and lack of exercise. Many studies have reported that weight gain is only the premise of a series of metabolic disturbances and cardiovascular complications. In this context, we have established since June 2017 in an ambulatory centre in Geneva, a 4F program (Fit, Fun, Feel and Food), to optimize the measures and strategies needed to prevent and reduce weight gain in these patients. This transversal program is naturalistically and systematically centered on physical activity, healthy diet and improved body perception. We will show some preliminary results of 4F program.Nous avons mis en place en juin 2017 un programme de soins centré sur la reprise de l’activité physique, intitulé 4F (Fit, Fun, Feel et Food) qui a comme objectif de limiter la prise de poids et la sédentarité chez des patients souffrants de troubles psychiques modérés à sévères. En effet, la littérature récente dans ce domaine rapporte que certains traitements psychotropes peuvent être obésogènes ainsi que d’autres facteurs tels qu’une vulnérabilité individuelle, un mauvais équilibre nutritionnel et un manque d’exercice physique. Devant ce constat, ce programme de prévention multidisciplinaire de 8 semaines, composé de 4 groupes hebdomadaires, est proposé afin que les patients puissent modifier leur hygiène de vie, leur équilibre nutritionnel et mieux se réapproprier leur corps grâce à une prise en charge adaptée et personnalisée. Cette perturbation pondérale a été notée comme n’étant que la prémisse d’une cascade de perturbations métaboliques et de complications cardiovasculaires.

Introduction The negative symptoms of schizophrenia contribute strongly to functional impairment but are inadequately treated by antipsychotic medication. Several studies have suggested that physical exercise could reduce the negative symptoms. Methods We conducted a systematic review and a meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of physical exercise interventions in improving the negative symptoms of schizophrenia using different databases and trial registries. Results Seventeen RCTs were included in the meta-analysis (n = 954 patients). Overall, the results revealed a significant beneficial effect of physical exercise on negative symptoms. We conducted a subgroup analysis differentiating between aerobic interventions (12 RCTs) and non-aerobic interventions (5 RCTs). Aerobic exercise reduced negative and positive symptoms, while this was not the case for non-aerobic interventions. A sensitivity analysis including only studies with a low risk of bias confirmed the effect on negative but not on positive symptoms. Conclusion Aerobic exercise had a beneficial effect on negative symptoms, albeit with a small effect size. The conclusions are limited by the fact that the included studies did not assess patients for predominant or primary negative symptoms. Given the important role of exercise for physical health, the additional effects on negative symptoms are promising and justify further research to disentangle the effects on primary and secondary negative symptoms.

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Considering how patients recover from mental illness is crucial to offer appropriate therapeutic interventions. This study was designed to determine the psychometric characteristics of the Recovery Style Questionnaire (RSQ) in a sample of outpatients recruited among the referrals to a crisis intervention center presenting with mood or anxiety disorders. Assessments completed at intake and at discharge examined the recovery styles with the RSQ, psychiatric symptoms with the Brief Psychiatric Rating Scale version 4.0, and the Symptom Checklist-Revised; defense mechanisms with the Defense Style Questionnaire 40 items; and global functioning with the Global Assessment Functioning. The RSQ has acceptable reliability, divergent validity, and sensitivity to change after treatment. These findings suggest that the RSQ is a valid and reliable instrument to assess recovery style. They also offer evidence of the usefulness of the RSQ in various clinical settings, such as in crisis intervention centers.

The present study sought to identify factors associated with the onset of a manic or hypomanic episode during the month following a new antidepressant therapy in depressed bipolar patients. Patients receiving mood stabilizers for ≥3 months were screened from 400 French centers and were assessed for a 4-week period following prescription of a first or a new antidepressant. Of the 1242 included participants, 4.8% (n=60) experienced antidepressant-emergent manic switch (AEMS). AEMS was more frequently associated with lifetime manic, depressive, and total mood episodes, and with past AEMS. A higher score at two items of the Montgomery-Åsberg Depression Rating Scale (pessimistic and suicidal thoughts) were significantly associated with AEMS. Logistic regression analysis showed that the number of lifetime manic episodes and past AEMS were the two most factors associated with an AEMS. Having more than four past manic episodes was associated with a 2.84 fold increased risk of AEMS. Cumulative number of past mood episodes seems to be the most important factor for switching to a manic episode following antidepressants in patients with bipolar disorder. Longer-term studies are required to further delineate antidepressant causality from natural disease course.

Meditation-based mind-body therapies (yoga, tai-chi, qi-gong, mindfulness) have been suggested to have a potential therapeutic effect on negative symptoms. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) examining effectiveness of yoga, tai-chi, qi-gong and mindfulness on negative symptoms of schizophrenia, using different databases and trial registries. The primary outcome was effect of mind-body therapies on negative symptoms and the secondary outcome was effect on positive symptoms. Fifteen RCTs were included in the meta-analysis (N = 1081 patients). Overall, we found a beneficial effect of mind-body interventions on negative symptoms at endpoint compared to treatment-as-usual or non-specific control interventions, but the effect was small and moderate to high heterogeneity was present. A subgroup analysis for different types of therapy revealed a significant effect of mindfulness-based and yoga interventions on negative symptoms, but heterogeneity within the yoga subgroup was high. Our results did not show an increase of positive symptoms (N = 1051). Our results suggest a potential for meditation-based mind-body therapies in the treatment of negative symptoms, in particular for mindfulness based approaches and to a lesser extent yoga. Limitations in the available comparisons do not allow concluding on a specific effect of these interventions. Overall, the currently available evidence remains limited and does not yet allow one to recommend mind-body therapies for the reduction of negative symptoms. However, the present findings justify further research on mind-body therapies for the treatment of negative symptoms.

BackgroundThe present study tested the hypothesis of a differential pattern of reward and punishment responsiveness in depression measuring effort mobilization during anticipation and facial expressions during consumption.MethodsTwenty patients with major depressive disorder (MDD) and 20 control participants worked on a memory task under neutral, reward, and punishment instructions. Effort mobilization was operationalized as cardiovascular reactivity, while facial expressions were measured by facial electromyographic reactivity. Self-report measures for each phase complemented this multi-method approach.ResultsDuring anticipation, MDD patients showed weaker cardiac pre-ejection period (PEP) reactivity to reward and blunted self-reported wanting, but weaker PEP reactivity to punishment and unchanged self-reported avoidance motivation. During consumption, MDD patients showed reduced zygomaticus major muscle reactivity to reward and blunted self-reported liking, but unchanged corrugator supercilii muscle reactivity to punishment and unchanged self-reported disliking.ConclusionsThese findings demonstrate reduced effort mobilization during reward and punishment anticipation in depression. Moreover, they show reduced facial expressions during reward consumption and unchanged facial expressions during punishment consumption in depression.

L’evaluation de la satisfaction des patients envers les services medicaux est une mesure qui s’est developpee depuis une trentaine d’annees; elle s’est rapidement focalisee sur les patients hospitalises dans des cliniques psychiatriques. Cette publication traite de la satisfaction des patients beneficiant d’un suivi psychiatrique en ambulatoire.

Background Schizophrenia is a chronic psychiatric disorder that generally begins in late adolescence or early adulthood. This early onset is often linked with a devastating lifelong impact on both the social network and work capacities of the affected subjects. Beginning in the mid-1990s, several sets of diagnostic criteria aiming to identify "high-risk" patients were developed and applied in clinical studies. Short-term rates of onset of psychosis in this subgroup of subjects ranged from 20% to 40%. However, 20 years later, the proposal to introduce "psychosis risk syndrome" as a coded diagnostic category in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders remained controversial and was finally rejected. Instead, "attenuated psychosis syndrome" was included in section III of the newly published manual as a condition for further studies. Objective The goal of this article is to review the extant literature concerning the advantages and risks of early assessment of psychotic symptoms ("prodrome" and "psychosis-risk syndrome") and concerning available therapeutic options, both psychosocial and pharmacological. Conclusions "Attenuated psychosis syndrome" is a clinically useful concept. It identifies help-seeking individuals with mental health problems who need an intervention and who, if no treatment strategy is proposed, present a higher likelihood of developing a psychosis spectrum disorder in the years following their first contact with a mental health facility. In parallel with the clinical utility of this concept, additional research focused on this group of patients is warranted to further understand the emerging phase of psychotic disorders and to develop effective and efficient evidence-based prevention strategies.

The aim of the present exploratory study was to examine the clinical differences of Auditory Verbal Hallucinations (AVHs) according to their spatial localization. Sixty-six outpatients were divided into three separate groups: inner, external and dual AVHs. The three groups were compared on sociodemographic variables (age, gender, education, marital status, living situation, employment, social disability), on clinical psychiatric characteristics (diagnosis, medication, comorbidities, illness onset, illness duration and hospitalizations) and on the measure yielded by the clinical assessments (Brief Psychiatric Rating Scale-Expanded, version 4.0; Maastricht Voices Interview for Adults; Belief About Voices Questionnaire Revised, the Clinical Global Impression, the Global Assessment Functioning Self-Esteem Rating Short Form, the World Health Organisation Quality of Life-Bref). Gender, living situation, social quality of life and some items regarding beliefs about AVHs raised significant difference, however most of the other comparisons failed to reach significance. Taken together, our findings suggest that all AVHs subtypes have equal clinical significance in patients presenting a chronic mental illness. However, the power of the study limits the generalization of the findings. Clinical implications of the findings are proposed.

Background A limited number of studies have investigated the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of resistant depression in an outpatient private practice setting. We hypothesized that rTMS would be safe and effective in the treatment of resistant depression in a nonresearch population. Methods We treated 22 outpatients with unipolar or bipolar depression who were experiencing a moderate to severe treatment-resistant major depressive episode (MDE). Treatment was based on a flexible dose schedule of either 5 Hz or 10 Hz rTMS applied over the left dorsolateral prefrontal cortex with modified parameters. Assessments were performed at baseline, then on a weekly basis. The patients had received at least 2 trials of antidepressant medication of an adequate dose and duration without satisfactory improvement in the index MDE. Results There was a significant change in Montgomery-Asberg Depression Rating Scale scores from baseline (29.14±5.85) to the end of week 4 (16.27±11.20); 50.00% (11/22) were responders and 40.9% (9/22) achieved remission. No major side effects were observed aside from mild headache in some patients. Conclusions rTMS applied to the left dorsolateral prefrontal cortex was safe and effective in an important subset of outpatients with a moderate to severe MDE in a naturalistic setting. Outcomes demonstrated response rates similar to research populations. Further larger studies are needed to confirm the safety and effectiveness of rTMS in naturalistic conditions.

The treatment of bipolar disorder (BD) usually requires combination therapies, with the critical issue of the emergence of adverse drug reactions (ADRs) and the possibility of low treatment adherence. Genetic polymorphisms are hypothesized to modulate the pharmacodynamics of psychotropic drugs, representing potential biological markers of ADRs. This study investigated genes involved in the regulation of neuroplasticity (BDNF, ST8SIA2), second messenger cascades (GSK3B, MAPK1, and CREB1), circadian rhythms (RORA), transcription (SP4, ZNF804A), and monoaminergic system (HTR2A and COMT) in the risk of neurological, psychic, autonomic, and other ADRs. Two independent samples of BD patients naturalistically treated were included (COPE-BD n = 147; STEP-BD n = 659). In the COPE-BD 34 SNPs were genotyped, while in the STEP-BD polymorphisms in the selected genes were extracted from the genome-wide dataset. Each ADRs group was categorized as absent-mild or moderate-severe and logistic regression with appropriate covariates was applied to identify possible risk genotypes/alleles. 58.5 and 93.5 % of patients were treated with mood stabilizers, 44.2 and 50.7 % were treated with antipsychotics, and 69.4 and 46.1 % were treated with antidepressants in the COPE-BD and STEP-BD, respectively. Our findings suggested that ST8SIA2 may be associated with psychic ADRs, as shown in the COPE-BD (rs4777989 p = 0.0017) and STEP-BD (rs56027313, rs13379489 and rs10852173). A cluster of RORA SNPs around rs2083074 showed an effect on psychic ADRs in the STEP-BD. Trends supporting the association between HTR2A and autonomic ADRs were found in both samples. Confirmations are needed particularly for ST8SIA2 and RORA since the few available data regarding their role in relation to psychotropic ADRs.

Dissociative disorders are a set of disorders defined by a disturbance affecting functions that are normally integrated with a prevalence of 2.4 percent in industrialised countries. These disorders are often poorly diagnosed or misdiagnosed because of sharing common clinical features with psychotic disorders, but requiring a very different trajectory of care. Repeated clinical situations in a crisis centre in Geneva provided us with a critical overview of current evidence of knowledge in clinical and etiopathological field about dissociative disorders. Because of their multiple expressions and the overlap with psychotic disorders, we focused on the clinical aspects using three different situations to better understand their specificity and to extend our thinking to the relevance of terms “neurosis” and “psychosis.” Finally, we hope that this work might help physicians and psychiatrists to become more aware of this complex set of disorders while making a diagnosis.

Background: Social adjustment is impaired in depressed patients. The difficulty to adjust to social circumstances has been hypothesized to be one of the causes of depression, as well as a consequence of the disorder. Genetic variation in the serotonin transporter gene has been previously associated with social adjustment levels in patients with mood disorders. Methods: We investigated whether variations on the HTR1A (rs6295) and HTR2A (rs7997012) genes were associated with levels of social adjustment using the Social Adjustment Scale in two samples of depressed patients (total n=156). Results: Patients carrying the GG genotype of the HTR2A-rs7997012 showed better social adjustment in areas of work and family unit bonding. Limitations: These findings did not survive correction for multiple testing and should be interpreted with caution. Conclusion: Our finding is in line with previous observations that have associated the G allele of the HTR2A-rs7997012 with higher rate of antidepressant response. The HTR2A-rs7997012 is worthy of further investigation in studies examining factors that are related to depression course and outcome. (C) 2013 Elsevier B.V. All rights reserved

Summary Brief therapy centres in Geneva: a crisis in the crisis centres? Created at Geneva in 1980, brief therapy centres are outpatient units providing psychiatric care based on a psychodynamic crisis intervention model. Their initial purpose was to offer an alternative to hospitalisation to patients who habitually are not major consumers of hospital care. In 2001 they were assigned a new institutional role: to widen their care offering and lighten the burden on hospitals by taking in, among others, patients with much more severe psychopathologies. We conducted a retrospective pilot study including the 449 patients treated at the Servette sector 3 brief therapy centre during 2006, to improve our understanding of how practice had really evolved at these centres in response to the changes institutional therapy had undergone in the last two decades. In general we noted among these patients a high rate of psychiatric antecedents with a time to admission seldomly below 24 h. We found a high rate of referrals by psychiatric emergency departments at the expense of indications from general practitioners and psychiatrists, while the diagnosis of mood disorder (76% with 72.4% depressive disorders) was significantly represented. We also observed several significant differences between the patient group receiving crisis-type care and the group receiving only nights of support. The retrospective study we conducted showed us that the new institutional role is only partly fulfilled and raises the question of a gap between theory and practice that is widening with the passage of time.

Patients with bipolar disorders (BPD) display high rates of comorbidities, especially substance abuse (20-40%) and attention deficit/hyperactivity disorder (ADHD) (6%-20%). However, there are virtually no data evaluating the role of current ADHD on the global functioning of patients with BPD. The recent literature suggests that impairments in quality of life are a key prognostic feature for predicting the long course of BPD. The aim of this study was to investigate the intrinsic impact of adult ADHD and substance abuse in patients with BPD on levels of social adaptation, functioning and vitality. Seventy-three outpatients with BPD I or II, all euthymic and being treated with mood stabilizers, were evaluated using the following measures: 1) the Diagnostic Interview of Genetics Study for DSM-IV criteria; 2) the ADHD Self-Report Scale (ASRS) (screening of adult ADHD); 3) measures of quality of life: social adaptation (Social Adjustment Scale Self-Report (SAS-SR)), well-being (Short Form 36 (SF-36) Health Survey), and the Brief Psychiatric Rating Scale. In this clinical sample, 30% met the ADHD criteria and 22% were substance abusers. The results showed that the presence of ADHD in BPD patients significantly predicted a low social functioning and adaptation by comparison with BPD patients without ADHD. By contrast, we failed to detect a significant impact of substance abuse on those functional outcomes. This is the first step towards improved screening for comorbidities and an understanding of their crucial role in the prognosis of the disorder, as well as in defining new multilevel therapeutic strategies.

Energy homeostasis is achieved by the integration of peripheral metabolic signals by the neural circuits involving specific hypothalamic nuclei and brain stem regions. These neural circuits mediate many of the effects of the adipocyte-derived hormone leptin and gut-derived hormone ghrelin. The former is strongly anorexigenic while the latter is the only orexigenic agent active when administered by a peripheral route. Abnormal regulation of these 2 antagonistic regulatory peptides in patients with schizophrenia could play a role in the impairment in the regulation of food intake and energy balance. This bibliographical analysis aims to compare 27 prospective and cross-sectional studies published on circulating leptin and ghrelin levels during acute and chronic administration of antipsychotics treatment, especially atypical ones. Fasting morning leptin levels of schizophrenic patients increase rapidly in the first 2 weeks after atypical antipsychotic (AAP) treatment (mostly olanzapine and clozapine) and remain somehow elevated after that period up to several months. On the contrary, conventional antipsychotics (such as haloperidol) do not interfere with leptin levels. In contrast to leptin, fasting morning ghrelin levels decrease during the first few weeks after the beginning of AAPs treatment while they increase in the longer run. Surprisingly, body weight gain and correlations between the variation of these 2 peptides and adiposity and metabolism-related parameters such as the body mass index and abdominal perimeter were not systematically considered. Finally, an objective evaluation of feeding behavior during antipsychotic treatment remains to be determined.

Objectives. Only few studies investigated treatment strategies for treatment resistant depression (TRD). The objective of this multicentre study was to evaluate TRD patients who did not respond to at least two antidepressants. Methods. A total of 417 patients, who failed to respond to a previous retrospectively assessed antidepressant (AD1), were firstly included in a 6-week venlafaxine treatment (AD2); secondly, those who failed to respond were treated for further 6 weeks with escitalopram (AD3). Results. Out of 417 patients who had failed to respond to previous treatment (AD1), 334 completed treatment with venlafaxine to prospectively define TRD. In the intent to treat (ITT) population in the first phase of the trial (AD2), responders to venlafaxine were 151 (36.21%) out of which remitters were 83 (19.90%). After phase one, 170 non-responders, defined as TRD, were included in the second phase and 157 completed the course. Of the 170 ITT entering the second phase (AD3), responders to escitalopram were 71 (41.76%) out of which remitters were 39 (22.94%). After the third treatment, patients showed a dropout rate of 7.65% and a rate of presence of at least one serious adverse event of 19.18%. Conclusions. Relevant rates of response and remission may be observed after a third line treatment in patients resistant to two previous treatments. A relevant limitation of this study was represented by the design: naturalistic, non-randomized, open-label, without a control sample and with unblinded raters. Objectives. Only few studies investigated treatment strategies for treatment resistant depression (TRD). The objective of this multicentre study was to evaluate TRD patients who did not respond to at least two antidepressants. Methods. A total of 417 patients, who failed to respond to a previous retrospectively assessed antidepressant (AD1), were firstly included in a 6-week venlafaxine treatment (AD2); secondly, those who failed to respond were treated for further 6 weeks with escitalopram (AD3). Results. Out of 417 patients who had failed to respond to previous treatment (AD1), 334 completed treatment with venlafaxine to prospectively define TRD. In the intent to treat (ITT) population in the first phase of the trial (AD2), responders to venlafaxine were 151 (36.21%) out of which remitters were 83 (19.90%). After phase one, 170 non-responders, defined as TRD, were included in the second phase and 157 completed the course. Of the 170 ITT entering the second phase (AD3), responders to escitalopram were 71 (41.76%) out of which remitters were 39 (22.94%). After the third treatment, patients showed a dropout rate of 7.65% and a rate of presence of at least one serious adverse event of 19.18%. Conclusions. Relevant rates of response and remission may be observed after a third line treatment in patients resistant to two previous treatments. A relevant limitation of this study was represented by the design: naturalistic, non-randomized, open-label, without a control sample and with unblinded raters.

Scientific evidence that fluoxetine is one of the effective treatment of depression exists. Since 2000, a debate has been launched concerning the possibility of antidepressant drugs, especially, selective serotonin reuptake inhibitor to induce suicidality in some depressive patients. Suicidal attempts of 3 of the outpatients taken into care in a crisis center in Geneva, following the introduction of fluoxetine in the usual dose of 20 mg per day, led us to investigate and to carry out a non-exhaustive comprehensive literature review of available randomized trials, meta-analyses and epidemiological studies. This work enabled us to highlight some points of interest, including medical attitudes and therapeutic guidelines that sometimes seem to be contradictory, especially regarding the use of antidepressants in children and adolescents.

Background: Brief therapy centers (BTCs) are outpatient mental health units based initially on a psychodynamic model of crisis intervention, and evolving later into a global care approach. The main objective of BTC is to provide mentally ill patients with a viable alternative to hospitalization. Methods: We undertook a retrospective study of 323 patients admitted to a BTC in Geneva in order to understand the evolution of our patients care over the changes in psychiatry over the last 2 decades. To this end, we considered predictive factors of relapse for 160 individuals with repeated “revolving door” admissions compared to 163 patients with a single admission to the BTC. To analyze data, we mainly use analysis of variance and logistic regression with SPSS software. Results: Living alone, lower socio-educational levels, unstable working conditions, crisis factor of professional trouble, and preexisting psychiatric conditions, such as depression, bipolar disorders, psychotic disorders or borderline personality disorder, that required multiple social and systemic interventions, and medical treatments (such as antipsychotics and mood stabilizers) increase probability that patients relapse and require multiple BTC admissions. Conclusions: The results of the present study that are considered as preliminary, support the development of ambulatory mental health units that attempt to adapt their intervention practices to different populations in order to prevent the revolving door phenomenon and therefore contribute to improve the global system of mental health.