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Type 2 diabetes mellitus (T2DM) is a common metabolic disorder with various medical and psychological adverse effects. Well-being in patients with T2DM is often compromised. The aim of the present study was to investigate clinicodemographic predictors of well-being in patients with T2DM with no known psychiatric history and explore the mediatory role of undiagnosed anxiety and depression. We recruited 175 outpatients with T2DM (54.3% males, aged 34-79 (mean 59.9) years) followed-up at the Diabetes Center of the General Hospital of Nikaia-Peiraeus in Athens. Patients included had no severe diabetes-related complications or known psychiatric history. Well-being was measured with the Mental Health Continuum Short-Form (MHC-SF), a novel 14-item tool measuring the emotional (EWB), social (SWB) and psychological (PWB) dimensions of well-being, as well as a total score of well-being (WBT). Hospital Anxiety and Depression Scale (HADS) was used for screening for undiagnosed anxiety (HADS-A) and depression (HADS-D). Patients' demographics, Body Mass Index (BMI), glycemic control (HbA1c), T2DM duration, comorbid hypertension or dyslipidemia and type of antidiabetic medication were investigated as predictors of well-being or its dimensions in stepwise linear regression models, also including or excluding HADS-A and HADS-D. Mediational effects of HADS-A and HADS-D were explored in structural equation models through path analyses. Results showed that 21.1% of participants had comorbid depression (HADS-D≥11) and 5.1% comorbid anxiety disorder (HADS-A≥11). In the models without HADS, higher WBT as well as EWB and PWB were significantly predicted by lower HbA1c (all p=0.001) and lower BMI (p=0.015, 0.019 and 0.030, respectively). After being included in the model, HADS-A and HADS-D significantly predicted WBT and every dimension of well-being, but the effects of HbA1c and BMI were no longer statistically significant. In path analyses, the indirect effects of HbA1c and BMI on well-being via HADS-D were statistically significant, while the direct and indirect effects via HADS-A were not. Therefore, the effects of HbA1c and BMI on EWB, PWB and WBT were completely mediated by HADS-D. Concludingly, this is the first study using MHC-SF to measure well-being in patients with T2DM. High levels of undiagnosed depression were recorded, in agreement with other studies. Depression was predicted by HbA1c and BMI and finally predicted well-being. Undiagnosed depression fully explained the effects of HbA1c and BMI on well-being. The interplay of glycemic control and positive mental health should be further investigated.

The impact of COVID-19 pandemic on quality of life is widely underscored. This study aimed to investigate the role of cognitive, affective, and behavioral factors on quality of life, as well as their mediating effect in the relationship of perceived risk of infection and control beliefs with quality of life. The sample consisted of 1730 adults. A battery of established and self-devised scales was administered online. It was found that higher levels of perceived risk of infection and negative emotionality predicted worse quality of life, while reflective functioning independently contributed to better well-being. Furthermore, a greater sense of personal control predicted better quality of life, but this effect was partially mediated by positive reappraisal, wishful thinking, avoidance, and trust. Specifically, higher level of control beliefs predicted better quality of life through higher levels of positive reappraisal and trust along with less use of wishful thinking and avoidance. Adherence to preventive measures was unrelated to quality of life. It is concluded that psychological factors and adaptive coping strategies should be prioritized in designing interventions and policies against COVID-19 pandemic.

Panic disorder (PD) is a common anxiety disorder with severe social and health consequences in the lives of individuals who suffer from it. General population studies that attempt to measure the prevalence of this disorder across the world suggest that a 1.7% to 4.7 % of adults and adolescents suffer from Panic Disorder. In Greece, research analyzing the abovementioned matters is limited, and previous studies were put forward in small samples. The aim of the present study was to describe the prevalence and sociodemographic associations of panic disorder (PD) and related subthreshold panic symptoms in the general population of Greece and to appraise the comorbidity, use of services and impact on quality of life of these syndromes. This was a secondary analysis of the 2009-2010 psychiatric morbidity survey carried out in a representative sample of the Greek general population (4894 participants living in private households, 18-70 years, response rate 54%). Psychiatric disorders were assessed with the computerized version of the revised Clinical Interview Schedule (CIS-R). Quality of life was assessed with the EuroQoL EQ-5D generic instrument. The utilization of health services was examined by making relevant questions. Finally, direct questions were used to assess sociodemographic and socioeconomic factors According to our findings, 1.87% of the participants (95% confidence interval [CI]: 1.50-2.26%) met criteria for PD and 1.61% met criteria for subclinical PD (95% CI: 1.26-1.96%). There was a clear female preponderance for both PD (p=0.001) and Sub-PD (p=0.01). In addition, 3.48% of the participants reported having experienced panic attacks during the past week (95% confidence interval [CI]: 2.98-4.01%). PD or subclinical PD was independently associated with a limited number of sociodemographic and socioeconomic variables especially after the adjusted analysis. Both panic related conditions involved significant reductions in quality of life and elevated utilization of health services for both medical and psychological reasons in comparison to healthy participants. In conclusion, PD and subclinical panic symptoms were common in the general Greek population with substantial comorbidity and impaired quality of life. The observed use of the general and psychological health services among adults with panic symptoms and its temporal and economic consequences calls for more efficient diagnostic and treatment policies.

The ability to mentalize, namely to understand, interpret and effectively communicate the mental state of self and others is considered important in self-organisation and affect regulation. The aim of the present study was to provide data on the validation process of Reflective Functioning Questionnaire (RFQ), a recently developed measure of mentalizing, in order to evaluate its use in research and in clinical practice for Greek populations. A total of 219 participants (102 people with type 1 diabetes and 117 healthy individuals) completed the RFQ. A principal component analysis supported the 2-factor model (RF certainty for mental states and RF uncertainty for mental states) in both samples. Internal consistencies of both subscales were satisfactory (α=0.80 for RF certainty and α=0.79 for RF uncertainty). Relationships with validity measures of psychological distress, empathy and emotional intelligence provided further support for the psychometric properties of the scale. As expected, there were positive associations between the degree of certainty concerning mental states and emotional intelligence (r=0.390, p0.01), as well as empathy (r=0.292, p0.01) in general population. Conversely, negative associations were found between the degree of certainty about mental states and psychological distress in the diabetes group (r=-0.470, p0.01) and in general population (r=0.320, p0.01). A reverse pattern of associations was observed between the degree of uncertainty about mental states and emotional intelligence (r=-0.265, p0.01) in general population, as well as psychological distress in both the diabetes group (r=0.590, p0.01) and in general population (r=0.330, p0.01). Also, as expected, there were differences across age groups, with older participants reporting a more balanced reflective functioning - with higher certainty levels in the diabetes group (t=-2.133, p0.05) and the healthy participants (t=-2.738, p0.05) and lower uncertainty levels in the diabetes group (t=-2.480, p0.05) and the healthy participants (t=-2.779, p0.05). The data collected so far support the reliability and validity of the measure that can be used in research to address mentalizing impairments. However, further research is needed to evaluate its consistency thought time with a test-retest analysis, and to evidence its factorial structure with a confirmatory factor analysis. In addition, it is of primary importance to extend the validity testing of RFQ in clinical populations to further support its use in clinical practice.

More than a year has passed since World Health Organization (WHO) declared COVID-19 as a pandemic, and during this period over 237 million cases and more than 4.8 million deaths have occurred worldwide due to COVID-19.1 This unprecedented pandemic not only has burdened health systems but it also constitutes a major stressful event both due to the threat of illness and death that it poses, and to the drastic impact on human relations, financial activity, access to health services, etc. Additional factors that may contribute to stress include the protection measures against COVID-19, social distancing, and mobility restrictions. The impact of the pandemic on suicidal behavior, especially on the Greek population, is of critical importance, due to the increase in suicidality during the recent financial crisis in the country.2 The impressive decline in the GDP during the first months of the COVID-19 pandemic (-9% of GDP),3 unemployment, isolation, reduced social contacts, problems in accessing mental health services, and also the limitations in terms of psychological support may increase the risk of suicidal behavior.4 With a view to investigating the psychosocial effects of the COVID-19 pandemic, an online questionnaire was developed in March 2020 by the Second Department of Psychiatry of the National and Kapodistrian University of Athens (NKUA) and the Postgraduate Program "Liaison Psychiatry: Integrated Care of Physical and Mental Health" of NKUA. This questionnaire included items regarding demographic characteristics, physical and mental health data, and issues related to the pandemic and the imposed restriction measures, such as perceived changes in participants' biorhythms, habits, and relationships with their colleagues, friends, and family. In addition, participants were asked to complete psychometric scales with regard to anxiety, depression and suicidal ideation, family functioning, anger and resilience. During the first national lockdown in Greece (April 7 to May 3) a total of 5,748 adults from the community participated in the survey by anonymously completing the aforementioned questionnaire on a secure website of NKUA. A considerable effort was devoted to make the sample as representative as possible and to include members of the community who do not usually participate in such surveys, as individuals of older age or individuals with health conditions. The 5.20% two-week prevalence of suicidal ideation found in our study is an intermediate rate with respect to the 2.4% one-month prevalence in 2008, the 6.7% in 2011 and the 2.6% prevalence in 2013.5 Among the respondents, 14.1% were potential cases of anxiety, while 26.5% of depression. Independent risk factors for suicidal ideation included anxiety, depression, impaired family functioning, being unmarried or divorced, having a mental health history, as well as a poor perceived quality of physical health. In contrast, higher resilience, positive feelings with regard to the lockdown measures, relationship with friends, and faith in a Supreme Being emerged as protective factors for suicidal ideation.6 Investigating the risk and protective factors for suicidal ideation is especially important during this difficult period of the pandemic. There was an additional significant finding in this study: individuals who completed the questionnaire during the last two weeks of the first lockdown reported statistically significantly higher suicidal ideation, depression, and anxiety than those who completed it in the previous two weeks, while a similar finding was revealed in a study from USA.7 Therefore, we were looking forward to the results of our survey conducted during the second lockdown.8 From the 5,116 individuals who had fully completed our questionnaire with respect to suicidal ideation during the first lockdown, 811 fully completed it for the second time from November 22 to December 21, 2020. Suicidal ideation was not found significantly different compared to the first lockdown. Independent risk factors for suicidal ideation during the second lockdown were depression, anxiety, living with a person with frail health and vulnerable for COVID-19 and suicidal ideation during the first lockdown. It is noted that during the second lockdown the rates of potential depression cases remained unchanged, whereas anxiety rates increased. Greater accessibility to health services, state financial support and increased mobility might have contributed to the stability of suicidal ideation despite the greater severity of the second wave of the COVID-19 pandemic. The aforementioned studies determined the prevalence of suicidal ideation and its association with various demographic, clinical, social, familial, and psychopathological factors in a cohort context at different stages of the COVID-19 pandemic, with the relevant literature being rather poor. We consider that the provision of such data is critical for the plans of health system in pandemic conditions, while this longitudinal study is in progress during the subsequent waves of the pandemic.

To describe mental health workers' attitudes to severe mental illness and to explore its socio-demographic and professional correlates, including the influence of empathy. A total of 127 mental health staff working on the psychiatric hospitals of Attica participated in the study. Stigma was assessed with the Attitudes to Severe Mental Illness scale (ASMI) and the Greek Social Distance scale; whilst Empathy with the Interpersonal Reactivity Index. Participants' unfavourable attitudes to severe mental illness were limited to pessimism about recovery, difficulty in viewing people with mental illness as similar to other people and desire to keep distance in intimate encounters. Professional group and personal experience with mental illness were found to predict stigma. Only perspective taking was associated with both stigma measures; while Fantasy was positively correlated with social distance. Anti-stigma interventions in mental healthcare should prioritize nurses and psychiatrists and aim at enhancing perspective taking.

Contradictory findings have been reported regarding the association between self-esteem and aggression. Most studies have dealt with non-criminal populations. This study aimed to explore the relationship between self-esteem and aggression and investigate possible differences in self-esteem and aggression between female inmates and women without criminal records (non-criminals) in the prefecture of Attica, Greece. One hundred fifty-seven female inmates in the Attica's Korydallos Female Prison and 150 non-criminals from Attica's general population completed the BussPerry Aggression Questionnaire and Rosenberg's Self-esteem Scale between February 2012 and April 2014. Lower self-esteem was associated with higher aggression among women independent of criminality. Self-esteem was lower in inmates (

There is ongoing debate about the similarities and differences between bipolar disorder (BD) and borderline personality disorder (BPD). Very few studies have concurrently assessed their neuropsychological profile and only on a narrow array of neuropsychological tests. We aimed to investigate the differences of these two patient groups on visual memory, executive function, and response inhibition. Twenty-nine BD patients, 27 BPD patients and 22 controls (all female) were directly compared on paired associates learning (PAL), set shifting (ID/ED), problem solving (SOC), and response inhibition (SSRT) using Cambridge Neuropsychological Test Automated Battery (CANTAB). Rank-normalized outcomes were contrasted in one-way ANOVA tests. Discriminant analysis was finally performed to predict BD or BPD patient status. BD patients performed significantly worse than controls on all tasks. BPD patients performed significantly worse than HC on all tests except SST. Significant differences between the two patient groups were recorded only on ID/ED, where BPD patients performed worse (p = 0.044). A forward stepwise discriminant analysis model based on ID/ED and SOC predicted correctly patients' group at 67.9% of cases. In conclusion, BD and BPD female patients appear to be more similar than different as regards their neuropsychological functions. This study is the first to show that BPD patients display more deficits than BD patients when directly compared on the set shifting executive function test, a marker of cognitive flexibility. Discerning BD from BPD patients through neuropsychological performance is promising but would improve by using additional subtler tests and psychometric evaluation.

Childhood trauma (CT) is correlated with suicidality among patients with bipolar disorder (BD). However, it has not been adequately investigated if a third factor, for instance impulsivity, mediates the effect of CT on suicidality in BD. This study aimed to explore potential mediatory effects of impulsivity in the pathway from CT to suicidality in BD. CT was assessed with the Early Trauma Inventory Self Report-Short Form (ETI-SR-SF), impulsivity with the Barratt Impulsivity Scale-11 (BIS-11) while lifetime suicidality was investigated with the Suicidal Behaviors Questionnaire-Revised (SBQ-R). The effect of childhood trauma on suicidality and impulsivity as well as the effect of impulsivity on suicidality were examined with multiple linear regressions, including gender, age and diagnosis (BD-I, BD-II) as covariates. Structural equation models were built and path analyses were performed (with AMOS 25 software and using bootstrapping in 1000 samples) for the examination of the mediatory role of BIS-11 and its subtypes in the effect of childhood trauma and its subtypes on suicidality. We included 78 BD euthymic patients (60.3% female, 67.9% BD-I). ETI-SR-SF significantly predicted SBQ-R (p=0.004) and BIS-11 (p

Neurological manifestations are not uncommon during infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A clear association has been reported between cerebrovascular disease and coronavirus disease 2019 (COVID-19). However, whether this association is causal or incidental is still unknown. In this narrative review, we sought to present the possible pathophysiological mechanisms linking COVID-19 and cerebrovascular disease, describe the stroke syndromes and their prognosis and discuss several clinical, radiological, and laboratory characteristics that may aid in the prompt recognition of cerebrovascular disease during COVID-19. A systematic literature search was conducted, and relevant information was abstracted. Angiotensin-converting enzyme-2 receptor dysregulation, uncontrollable immune reaction and inflammation, coagulopathy, COVID-19-associated cardiac injury with subsequent cardio-embolism, complications due to critical illness and prolonged hospitalization can all contribute as potential etiopathogenic mechanisms leading to diverse cerebrovascular clinical manifestations. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been described in case reports and cohorts of COVID-19 patients with a prevalence ranging between 0.5% and 5%. SARS-CoV-2-positive stroke patients have higher mortality rates, worse functional outcomes at discharge and longer duration of hospitalization as compared with SARS-CoV-2-negative stroke patients in different cohort studies. Specific demographic, clinical, laboratory and radiological characteristics may be used as ‘red flags’ to alarm clinicians in recognizing COVID-19-related stroke.

BackgroundHealthcare services are increasingly confronted with challenges related to old age mental disorders. The survey aimed to provide an overview of existing psychogeriatric services in Albania, Bulgaria, Greece, and North Macedonia.MethodsAfter identification of psychogeriatric units across the four countries, their head physicians were asked to provide data on their clinical, teaching, and research activity, as well as staff composition. Moreover, the attitudes of head physicians to current needs and future service development were explored.ResultsA total of 15 psychogeriatric units were identified (3 in Bulgaria, 8 in Greece, and 4 in North Macedonia). Results show wide variation regarding the location, team size and composition, service availability, numbers of patients attending, and inpatient treatment length. Most head physicians underscored the urgent need for breakthroughs in the graduate and postgraduate education in psychogeriatrics of medical and nonmedical professionals, as well as in the interconnection of their units with community primary healthcare services and long-term care facilities for seniors via telemedicine. They would welcome the development of national standards for psychogeriatric units, potentially embodying clear pointers for action. A number of head physicians advocated the development of nationwide old age mental health registries.ConclusionsRegional disparities in resources and services for seniors’ mental health services were unveiled. These data may enrich the dialogue on optimizing psychogeriatric services through planning future cross-border collaborations mainly based on telemedicine services, especially in the era of the novel coronavirus pandemic, and training/education in psychogeriatrics of mental health professionals.

The aim of this study was to investigate the prevalence of suicidal ideation in the community as well as the risk and protective factors of suicidal ideation during restriction measures in Greece, after the outbreak of the COVID-19 pandemic. Α web-based anonymous survey was conducted during the first lockdown period. Participants completed the Generalized Anxiety Disorder scale (GAD-2), the Patient Health Questionnaire (PHQ-2), the Systemic Clinical Outcome and Routine Evaluation (SCORE-15), the Connor-Davidson Resilience Scale (CD-RISK-2), and a self-report questionnaire for COVID-19 pandemic-related data. From a total of 5,116 adults included in the study, 5.20% reported suicidal thoughts, 14.17% were potential clinical cases of anxiety, and 26.51% of depression. Participants presented significantly higher suicidal ideation rates during the last two weeks of the lockdown compared to its previous two weeks. Unmarried or divorced marital status, mental health history, poor perceived quality of physical health, impaired family functioning, anxiety and depression symptoms were independently associated with higher odds of suicidal ideation, whereas higher resilience, positive feelings with regard to the lockdown measures, relationship with friends, and faith in a Supreme Being were associated with lower suicidal ideation odds. According to the findings, suicidal ideation prevalence might be considered elevated and its increase during the lockdown period alarming. The risk and protective factors identified in the study offer valuable information for the development of preventive strategies against suicidal ideation, especially in times of crisis.

There is evidence that frequency of suicide attempts of fertile women is related to the menstrual cycle phases, while the influence of hormonal and psychiatric features has been hypothesized. This study aims to explore the distribution and possible differences in clinical characteristics of women who attempted suicide in relation to menstrual cycle. Seventy fertile female psychiatric patients, hospitalized in psychiatric department after a suicide attempt, were studied. Depression was assessed using Beck Depression Inventory, suicide intent with the Suicide Intent Scale, and aggression using the Buss-Perry Aggression Questionnaire. A profile of psychopathology was obtained by using Symptom Check List SCL-90-R. Attempts were more frequent during the last 4 days of luteal phase and during the 4 days of menses, with 59% of attempts to occur during these 8 days. Patterns of number of attempts and cycle phase were similar for subgroups regarding diagnosis, violent/non-violent mode of suicide attempt, and one or repeated attempts. Although attempts were unequally distributed during the cycle, none of the psychiatric features assessed in the present study were related to the higher frequency of attempts during premenstrual/menstrual days, indicating the need to include additional aspects of suicidal behavior in future studies.

Objective It still remains unclear whether psychotic features increase the risk of suicidal attempts in major depressive disorder. Thus, we attempted, through a systematic review coupled with a meta-analysis, to elucidate further whether unipolar psychotic depression (PMD) compared to non-PMD presents higher levels of suicidal attempts. Method A systematic search was conducted in PubMed, EMBASE, PsycINFO as well as in various databases of the so-called gray literature for all studies providing data on suicidal attempts in PMD compared to non-PMD, and the results were then subjected to meta-analysis. Results Twenty studies met our inclusion criteria, including in total 1,275 PMD patients and 5,761 non-PMD patients. An elevated risk for suicide attempt for PMD compared to non-PMD patients was found: The total (lifetime) fixed-effects pooled OR was 2.11 (95% CI: 1.81-2.47), and the fixed-effects pooled OR of the five studies of the acute phase of the disorder was 1.93 (95% CI: 1.33-2.80). This elevated risk of suicidal attempt for PMD patients remained stable across all age groups of adult patients. Conclusion Despite data inconsistency and clinical heterogeneity, this systematic review and meta-analysis showed that patients with PMD are at a two-fold higher risk, both during lifetime and in acute phase, of committing a suicidal attempt than patients with non-PMD.

Resilience can be defined as the ability to maintain health in the face of adversity. Resilience has been associated with personality traits. Personality traits in the context of Eating Disorders (ED) have also been examined. However, the relationship between resilience and personality profile in patients with ED has not been studied. The aim of this study is to investigate whether personality dimensions impact on resilience, in patients with ED, compared to healthy participants. Connor and Davidson resilience scale, as a measure of resilience and temperament—character inventory, as a measure of personality dimensions, were completed by 100 participants: 50 (50%) healthy University students (controls subgroup) and 50 (50%) patients with ED, matched on age and gender. Patients with ED showed lower resilience than healthy participants and scored higher on harm avoidance, and lower on reward dependence, self-directedness and cooperativeness than controls. Lower harm avoidance, higher persistence and higher self-directedness were associated with resilience in both subgroups. Self-directedness and persistence predicted resilience in both subgroups. Only Harm Avoidance predicted resilience in patients’ subgroup. To our knowledge, there are no existing data examining the effect of personality dimensions in resilience, in the context of ED. We found that only the effect of Harm Avoidance in resilience was different among the participants’ subgroups. In conclusion, Harm Avoidance could explain differences in resilience between healthy participants and patients with ED. Level III: case–control analytic study.

Purpose of review Previous studies suggest an association between depression and increased risk of various type of infections, including acute bacterial skin and skin structure infections (ABSSSI). Here, we review the latest advancement in our understanding of immunity in patients with depression and its relevance to disease management and diagnosis, with a special focus on patients suffering from ABSSSI. Recent findings Recent studies have highlighted the role of hypothalamic-pituitary-adrenal axis, neuro-endocrine stress signaling pathways and behavioral attitudes (substance abuse and homelessness) in the pathogenesis of infections in depressed patients. Furthermore, acute bacterial infections, in turn, have emerged as a possible risk for depression development because of different mechanisms including antibiotic-driven changes in the microbiota. Summary Recent evidences have emphasized the threat that comanagement of depression and infection pose to infectious disease physician and psychiatrist. Depressed patients with ABSSSI must be closely monitored for drug side-effects, drug-drug interactions, toxicity, and adequate compliance. New management strategies including new long-acting antibiotics (e.g., dalbavancin) are welcome.

Objective The association between adipokine dysregulation and weight loss of patients with anorexia nervosa (AN) has been long investigated, in search of a causal relationship. We sought to: a) synthesize the available evidence on potential differences between AN patients and controls with regards to adipokine measurements (namely, leptin, adiponectin, resistin, soluble leptin receptor, visfatin, vaspin and omentin), b) estimate the potential differences between constitutionally thin (CT) subjects and AN patients, and c) present the available evidence with regards to biomarker efficacy of adipokines in AN. Methods A structured literature search, last updated in 2/2019, was conducted in the following databases: MEDLINE, clinicaltrials.gov, PsycINFO, PSYNDEX and WHO Registry Network. The primary outcome was the standardized mean difference of each adipokine between AN patients and controls of normal BMI. Secondary outcomes included the correlation of leptin with BMI and bone mineral density among AN patients. The study protocol is published in PROSPERO (CRD42018116767). Results In a total of 622 screened studies, after exclusion of non-relevant articles and duplicates, 84 reports on leptin, 31 reports on adiponectin, 12 on resistin, 10 on soluble leptin receptor, 5 on visfatin, 3 on vaspin and omentin were finally included in the meta-analysis. Publication bias assessment underlined the possibility of non-significant studies being underrepresented; still, significant heterogeneity renders this statement inconclusive. Leptin [ELISA: SMD (95% CI): -3.03 (-4, -2.06)], radioimmunoassay [RIA: -3.84 (-4.71, -2.98)] and resistin [-1.67 (-2.85, -0.48)] were significantly lower in patients with AN compared with controls, whereas visfatin decrease did not reach significance (-2.03 (-4.38, 0.3). Mean adiponectin, vaspin and soluble leptin receptor levels were significantly higher. In subgroup analysis, a significantly attenuated SMD was reported in ELISA studies compared with RIA studies. Leptin was significantly lower in AN patients compared to CT subjects and BMI marginally did not appear to confound the result. In all analyses, except for the correlation of leptin with BMI in AN patients, high heterogeneity was present. Meta-regression analysis indicated a potential confounding action of controls’ BMI and age on leptin SMD and between-assay differences. Publication bias assessment underlined the possibility of nonsignificant studies being underrepresented; still, further investigation did not corroborate this and significant heterogeneity renders this statement inconclusive. Conclusion A distinct profile of adipokine dysregulation is apparent in AN patients, following the anticipated pattern of low BMI. A precise estimation of the magnitude is hindered by heterogeneity, partly caused by varying assays and methodologies. Interestingly, while mean leptin levels are lower in AN subjects compared with constitutionally thin women, there is an overlap in individual levels between the two groups and therefore, they cannot be used to differentiate between these states.

This longitudinal study aimed to investigate the predictive factors of suicidal ideation during the second lockdown in Greece. The respondents presented a 4.32% suicidal ideation in the second lockdown, which did not differ significantly to the initial 4.81%. Anxiety, depression, suicidal ideation during the first lockdown and living with a person with frail health and vulnerable for COVID-19 severe infection emerged as significant risk factors for suicidal ideation during the second lockdown, after controlling for gender, age, and mental health history. Depression was found as the only significant prognostic factor for suicidal ideation incidence of the second lockdown.

The aim of this study was to investigate the differential effect of various delusion categories, namely, guilt, paranoid, impending disaster, and somatic on suicidal attempts in elderly patients experiencing unipolar psychotic major depression (PMD), because the evidence on this is scarce. The sample consisted of 65 consecutively admitted patients 60 years or older, experiencing PMD, and assessed by means of Structured Clinical Interview for DSM-4 (Patient Edition), Hamilton Depression Rating Scale, Mini-Mental Status Examination (MMSE), and by a physical impairment rating scale. Patients with guilt delusional beliefs had 5.31 times higher odds (95% confidence interval, 1.37-25.40) of a suicidal attempt than the patients without guilt delusional beliefs, controlling for sex, age, prior history of suicide attempt, MMSE, and hallucinations. In addition, 17 PMD patients with lifetime suicidal attempt compared with 48 PMD patients without lifetime suicidal attempt presented only higher age of disorder onset (p = 0.008). Of the four categories of delusions assessed, only guilt delusions were associated with an increased risk for suicidal attempt.

This study aimed to assess hopelessness in 170 hospitalized individuals with recent suicide attempt and examine its association with patients' characteristics, with a view to improving awareness in health professionals and especially nurses, who are among the first to take care of these patients. Participants completed Beck Hopelessness Scale and Beck Depression Inventory. More than half (51.18%) experienced moderate-to-severe hopelessness. A multiple linear regression analysis showed that age, attempted suicide method, past suicide attempt, and psychiatric diagnosis contributed statistically significantly to hopelessness prediction. Hopelessness assessment could efficiently help health professionals to minimize both inpatient suicide and suicidal acts after discharge.

Additional file 1. Additional figures.

There is evidence that patients with multiple suicide attempts in their history are at greater risk to repeat attempt and eventually die by suicide compared to those with a single attempt. This cross-sectional study aimed to explore possible differences in clinical characteristics between patients with a single attempt and patients with repeated attempts. Two hundred thirty one patients hospitalised in psychiatric department after suicide attempt were studied. Comparisons were made in relation to age, gender, psychiatric diagnosis, aggression, depression severity, suicide intent and mode of attempt. Highest frequencies of patients with repeated attempts were found for bipolar disorder (69%) and lowest for adjustment/personality disorders (39%). In patients with repeated attempts, female gender was associated with non-violent attempt mode. Depressive symptomatology was higher in patients with repeated attempts among females. In patients with depression those with repeated attempts were younger than patients with single attempt. In patients with mood disorders, total aggression and hostility scores were higher in females with repeated attempts but not in males. Psychiatric diagnosis, gender and attempt mode are features that differentiate patients with single and repeated attempts and should be considered to identify patients at increased risk to repeat attempt and design effective prevention interventions.

OBJECTIVE: This study aimed to systematically review available evidence relevant to the following issues: (1) whether psychotic major depression (PMD) in older people differs in overall severity from non-PMD, besides the presence of psychotic symptoms; (2) whether it constitutes a distinct clinical entity from non-PMD; and (3) whether it differs from PMD in younger adults. DESIGN: A computerized MEDLINE, PsycINFO and the entire Cochrane Library search has been performed in June 2013 for prospective controlled studies investigating PMD features in older people. RESULTS: Thirty-five relevant studies were identified. PMD in older people compared with non-PMD has been shown to present with overall more severe depressive symptomatology, more psychomotor disturbance, more guilt feelings, more depressive episodes with psychosis, worse prognosis, more severe executive dysfunction associated with frontal lobe atrophy, and lower serum dopamine β-hydroxylase activity. No differences in the efficacy of an antidepressant plus antipsychotic combination versus antidepressant monotherapy in the acute treatment as well as in the maintenance treatment were found. PMD in older patients is characterized by more somatic complaints and delusions of hypochondriacaland impending disaster content and by a lower comorbidity with anxiety disorders compared with PMD in younger adults. CONCLUSIONS: Psychotic major depression in older people is associated with higher severity in most clinically important key features than in non-PMD. However, available evidence is still insufficient for the conclusive elucidation of its nosological status. Finally, the differences between PMD in older and younger patients can be attributed to biological and psychosocial changes of old age. Language: en

Objective: There is evidence that suicidal behavior, among others, is an abnormal response to stress caused by a dysfunction in the activity of hypothalamus-pituitary-adrenal axis, and that cortisol levels are low in a considerable number of people attempting suicide. In this study, we aimed to search for associations of plasma cortisol levels with the clinical characteristics of a group of psychiatric suicide attempters. Method: The cortisol was measured in the morning in 200 psychiatric patients hospitalized after a suicide attempt, with diagnoses of major depressive disorder, bipolar disorder, psychosis, and personality/adjustment disorder, and compared to the levels of 138 healthy controls. Comparisons were also made for diagnostic subgroups and across diagnoses, with regard to depressive symptomatology, mode of attempt, suicide intent, number of attempts, and age. Results: Cortisol levels were significantly lower for the whole group of attempters compared to controls. Furthermore, low cortisol levels characterized attempters with personality/adjustment disorder, higher depressive symptomatology, low suicide intent, non-violent attempt mode, repeated attempts, and of younger age. Conclusions: Certain clinical characteristics were identified in attempters with low cortisol levels. In previous studies, low cortisol levels have been associated with impairments in cognitive control, decision-making, and emotional processing that may lead, in the presence of stressors, to suicidal behavior, frequently with non-fatal outcome. Adding plasma cortisol levels to demographic and psychopathological data may help in identifying a subpopulation of attempters with neurocognitive deficits linked to dysfunction of Hypothalamic-Pituitary-Adrenal-axis activity, with implications for treatment.

To evaluate body mass index (BMI) and its correlate plasma leptin levels that have been associated with psychiatric morbidity and suicidal behaviour, in relation to clinical features in psychiatric patients after a suicide attempt.BMI and plasma leptin were assessed in 198 patients (66 males, age range of 21 to 80 years) who were admitted to the hospital after a suicide attempt, 98 with major depressive disorder, 28 with bipolar disorder, 30 with psychosis, and 42 with personality or adjustment disorder, compared to data of 134 healthy subjects, and evaluated in relation to gender, diagnosis, mode of attempt, and pharmacological treatment before attempt. The ratio leptin/BMI was used as a measure of adipocyte leptin secreting activity.Drugs taken for treatment before attempt, among them atypical neuroleptics, were not associated either to BMI or to plasma leptin. The positive correlation between BMI and leptin was significant in all groups. Compared to same gender controls, significant differences were found only for female patients, namely higher BMI for patients with psychosis and patients with bipolar disorder, while leptin/BMI ratio was higher only in females with bipolar disorder.BMI and plasma leptin in psychiatric suicide attempters are elevated in certain diagnostic groups in females, not related to previous pharmacologic treatment. The lack of a control group without a history of suicide attempts does not allow the attribution of enhanced leptin secreting activity found in female bipolar attempters specifically to suicidal behavior or to the disorder as a diagnostic entity.

Christodoulou C, Douzenis A, Papadopoulos FC, Papadopoulou A, Bouras G, Gournellis R, Lykouras L. Suicide and seasonality. Objective: Seasonal variation of deaths by suicide offers an important pathway in the study of possible suicide determinants of suicide and consequently suicide prevention. Method: We conducted a review of the literature on suicide seasonality, assessing articles published between 1979 and 2009. Results: The majority of the studies confirm a peak in spring, mainly for men, older individuals, and violent methods of suicide. A secondary peak during autumn is observed. There is no common seasonality pattern for suicide methods. However, there are also certain studies that did not confirm seasonal variation. Inconsistent results with reduced, unchanged, and even increased suicide seasonality have been reported. Aspects on the association between seasonality and suicides are discussed. Except sex, age, and method of suicide, other parameters were taken into account to find more specific characteristics of seasonality in suicides as well. The influence of clinical, bioclimatic, sociodemographic as well as biological factors seems to affect the seasonal variation. Conclusion: Studies from both the Northern and the Southern hemisphere report a seasonal pattern for suicides. These studies are not only an important source of epidemiological data for suicides but also represent a global effort to uncover hidden parameters of this self-destructive behaviour.

The aim of the study was to ascertain suicide seasonality in the Greek population and to associate this seasonal variation with age, sex, and suicide method. Studying seasonality can be of help in establishing a public health policy, related with suicide prevention. This is an epidemiologic study based on forensic evidence. We studied the deaths caused by self-injury (trauma), namely deaths by violent suicide (not self-poisoning). Statistically significant suicide seasonality was established with a peak in May. This seasonal variation is attributed mainly to males. As for the method, suicide by hanging peaks in June and by shooting in April. It was also observed that seasonality for individuals above the age of 45 peaks in early May. Suicide Life Threat Behav

Objective The present study attempted to investigate the clinically important broader dimensions of clinical characteristics of delusions, through multivariate analysis, in a pure sample of elderly unipolar delusional depressives as well as to test their external validity against a set of demographic, anamnestic and psychopathological validators. Methods Fifty inpatients suffering from psychotic major depression (PMD) in the context of major depressive disorder, 60 years old or older, were assessed on the basis of SCID IV, HRSD, MMSE and by three-point ordinal scales of 12 clinical, intrinsic or relational characteristics of delusions tested for their inter-rater reliability. Results Principal Component Analysis resulted in the extraction of five factors, jointly accounting for 69.7% of the total variance. The five factors were interpreted as representing the dimensions of delusional strength, acute upsetting, delusional organization, incomprehensibility and incitation to actions. Most of the factors were differentially associated with patients' demographic, anamnestic and clinical variables. Conclusion Our results overlap in part with those of another similar study in delusional depressives of all age-ranges, differing, however, in respects possibly attributable to peculiarities of elderly depressives. Overall, the findings of the present study contribute to the further elucidation of major clinical dimensions of delusions in PMD in the elderly and the testing of their external validity. Copyright © 2008 John Wiley & Sons, Ltd.

Quetiapine is an atypical antipsychotic that is believed to have a low D2 binding affinity in striatal and extrastriatal regions. We report the case of a female patient with the diagnosis of schizoaffective disorder (using DSM-IV-TR criteria) who initially received amisulpride for 3 months, discontinued gradually because of persistent and distressing extra-pyramidal symptoms, and who developed tardive dyskinesia 3 months later after the initiation of quetiapine. A trial with ziprasidone resulted in a further worsening of tardive dyskinesia symptoms. A further trial with aripiprazole, improved her tardive dyskinesia symptoms. Although, it is under consideration the possibility that the improvement could have been due to the discontinuation of quetiapine, we conclude that aripiprazole improved the TD symptoms.

The role of brain-derived neurotrophic factor (BDNF) is to promote and modulate the neuronal responses across neurotransmitter systems in the brain. Therefore, abnormal BDNF signaling may be associated with the pathophysiology of schizophrenia. Decreased BDNF levels in the brain and the serum of patients with psychotic disorders have been reported. In the present study, we assessed serum BDNF levels in a group of 14 drug-naive first-episode patients with schizophrenia (FEP), compared to 15 healthy controls. The serum BDNF levels in the sample of FEP patients was significantly reduced compared to normal controls (23.92+/-5.99 ng/ml vs. 30.0+/-8.43 ng/ml, F=5.01, df=1, p=.034). Negative correlations were shown between serum BDNF levels of the patients and the PANSS Positive and Negative subscale scores. Our findings indicate that BDNF levels at the onset of schizophrenia may reflect associated pathophysiological processes as well as the severity of positive and negative psychotic symptoms.

Background Auditory hallucinations occupy, along with delusional beliefs, the center stage of active or “positive” psychotic clinical psychopathology. During the last decade, several sets of auditory hallucinations' clinical features were subjected to multivariate statistical analyses to disclose major dimensions of psychotic patients' overall hallucinatory experience and behavior. However, these studies failed, to a large extent, to provide satisfactory external validations of the thereby extracted factors. Methods We investigated the major clinical dimensions of verbal auditory hallucinations in a sample of 100 inpatients with schizophrenic disorders. Patients (61 men and 39 women) were examined before the initiation of antipsychotic treatment and their assessment included 18 major clinical features of auditory hallucinations. Brief Psychiatric Rating Scale, Hamilton Depression Rating Scale, Global Assessment Scale, and Mini-Mental State Examination were used as external validators. Results Principal component analysis resulted in the extraction of 5 factors interpreted as the dimensions of severity of auditory hallucinations, emotional and behavioral impact, rate of their intrusion in self-consciousness, delusional elaboration, and similarity to ordinary auditory perception, respectively. The second and third factors extracted in our study correlated with short duration of illness, whereas the first, fourth, and fifth ones correlated with chronicity. Our second factor correlated with clinical severity of patients' current mental state, the fifth factor with severity of their cognitive impairment, and the first and fourth ones with lower clinical depression despite patients' chronicity. Conclusion The findings of our study contribute to the further elucidation of the major clinical dimensions of auditory hallucinations and the testing of their external validity.

This study examines the role of an introductory course in cognitive therapy and the relative importance of trainees’ characteristics in the selection process for an advanced course in cognitive therapy. The authors assessed the files of all trainees who completed one academic year introductory course in cognitive therapy over the last seven consecutive years (N = 203). The authors examined variables such as previous training, overall involvement during the course, performance, and ability to relate to others, as well as the trainer’s evaluations of their performance. Interaction skills in group situations and performance in written assignments were better predictors for admission into the advanced course. Trainees’ abilities to learn and to successfully relate to others in group situations are critical for entering an advanced cognitive therapy training course. These findings question the policy of full-scale training in cognitive therapy based merely on the candidates’ professional background, stressing instead the merits of an introductory course as an appropriate screeningprocedure.

Primary polydipsia (PP) is etiologically associated with physical factors and psychiatric disorders ("psychogenic polydipsia"). We present the case of a 28-year-old man with severe symptoms of polydipsia and polyuria. After a comprehensive physical assessment, the only finding was a lesion suggestive of pituitary microadenoma in the magnetic resonance imaging (MRI) scan of the brain. A thorough clinical and diagnostic assessment and the administration of a wide range of psychometric tools revealed no major psychiatric disorder apart from chronic anxiety and mild depressive symptoms. Our patient's PP symptoms might be associated with a dysfunction of the thirst center, which is located closely to the neuroanatomical lesion found in the MRI scan. Given that the underlying pathophysiology of PP remains, to a large extent, unclear, we emphasize on the difficulties to distinguish between PP's subtypes.

Self-mutilating behaviors could be minor and benign, but more severe cases are usually associated with psychiatric disorders or with acquired nervous system lesions and could be life-threatening. The patient was a 66-year-old man who had been mutilating his fingers for 6 years. This behavior started as serious nail biting and continued as severe finger mutilation (by biting), resulting in loss of the terminal phalanges of all fingers in both hands. On admission, he complained only about insomnia. The electromyography showed severe peripheral nerve damage in both hands and feet caused by severe diabetic neuropathy. Cognitive decline was not established (Mini Mental State Examination score, 28), although the computed tomographic scan revealed serious brain atrophy. He was given a diagnosis of impulse control disorder not otherwise specified. His impulsive biting improved markedly when low doses of haloperidol (1.5 mg/day) were added to fluoxetine (80 mg/day). In our patient's case, self-mutilating behavior was associated with severe diabetic neuropathy, impulsivity, and social isolation. The administration of a combination of an antipsychotic and an antidepressant proved to be beneficial.

Background Despite the fact that smoking is a crucial morbidity factor among psychiatric patients, little progress has been made in order to reduce smoking during psychiatric hospitalization. Methods We studied the smoking behaviour of patients admitted to a non-smoking psychiatric ward, after monitoring them for smoking habits and helping them cope in order to modify their smoking behaviour. For a period of 12 months, we conducted a prospective study of simple smoking avoidance measures in the 2nd Department of Psychiatry of Attikon University Hospital in Athens. Results From 330 admitted patients, 170 (51.5%) were smokers; they were monitored for their smoking habits and encouraged by the nursing staff to reduce smoking. The mean number of cigarettes per day (CPD) at admission was 32.2 (sd 22.1) and upon discharge 14.1 (sd 14.8) (t = 11.7, p

Background: It has been established that depressed patients manifest a higher risk of committing suicide. The role of delusional experiences accompanying depressive symptomatology as a risk factor for suicidal behaviour has been investigated but the results are inconsistent. Method: In the present study, 40 elderly depressed inpatients with psychotic features (DSM-IV criteria) were compared to 64 elderly depressed patients without such features in terms of suicide attempts. Results: The results of univariate and multivariate analyses were negative: Psychotic and nonpsychotic depressed patients did not differ with respect to attempted suicide. Conclusion: The results of the present study support the notion that psychotic features do not increase the risk for the elderly depressed patients to attempt suicide.

IntroductionThere is a continuing debate about the differences and similarities between bipolar disorder (BD) and borderline personality disorder (BPD).ObjectivesOnly few studies have focused on the neuropsychological profile of these two disorders.AimsWe studied the differences on memory, executive function and inhibitory control between BD and BPD patients.MethodsTwenty-nine patients with BD in euthymia, 27 patients with BPD and 22 healthy controls matched for age and education were included in the study. All of them were female. BD patients who could also be diagnosed with BPD were excluded from the study. Participants were administered a series of tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB), accessing memory, executive function and inhibitory control.ResultsBD and BPD patients performed worse than controls in general. Significant differences were found in the PAL test; BD patients had 46.71, BPD patients had 36.56 and controls had 15.77 errors (P = 0.004). BPD patients performed worse in the IE/ED set-shifting test; they made 48.16 errors while BD patients made 23.64 and controls 16.14 (P = 0.001). BPD patients performed better in the problem-solving task (SOC), they solved 10.0, BD patients 6.32 and controls 8.32 problems (P < 0.001).BD and BPD patients had similar performance in the SST inhibition task but worse than controls (P = 0.03).ConclusionsBD and BPD seem to have differences in neuropsychological performance. BD patients show more deficits in memory learning and problem solving while BPD patients show more deficits in set shifting.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The influence of family factors on the development and/or on maintenance of heroin addiction still remains unclear.The aim of this study was to investigate family factors, which might be associated with heroin addiction in a sample of male individuals.A group of 40 heroin addicts' families was compared with a group of 17 families with a member presenting schizophrenia and a group of 27 families with mentally healthy members in regard to (1) parents' rejection attitudes toward their adult child, (2) quality of parental bond, as perceived by the adult child, and (3) stressful life events in the nuclear family.The main findings showed that the degree of rejection by the fathers in the heroin addicts' families as well as in the subjects with schizophrenia was significantly higher compared to the fathers' degree of rejection in the control group. Moreover, the degree of rejection by mothers in the heroin addicts' families was significantly higher compared to the mothers' degree of rejection in the control group. Heroin addicts reported that they had perceived less care from their fathers than healthy controls. The total number of stressful life events in the nuclear family was higher in the patients with schizophrenia in comparison to the healthy controls. Also, in the heroin addicts' group, a significantly higher number of fathers presented a current or past psychiatric disorder.The findings of this study showed the importance of negative family factors in the course of heroin addiction.