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The functional remission or recovery of schizophrenia patients is a challenging task which relies on pharmacotherapy but also on the timing of psychotherapy and other therapeutic interventions. The study aimed to assess the difference in strength and structure of symptoms networks between early and late phase schizophrenia. Our secondary objective was to check whether the overall, positive, negative, and general symptoms severity change over the course of treatment and disorder.This nested cross-sectional analysis combined the samples from two studies performed during 2014-2016 at University Psychiatric Hospital Vrapče, Zagreb, Croatia on the consecutive sample of men 30-60 years old diagnosed with schizophrenia, 85 of them in the early (≤5 years from diagnosis), and 143 in the late phase of the illness. The study was funded by the project: "Biomarkers in schizophrenia - integration of complementary methods in longitudinal follow up of FEP patients".Median (IQR) age of the participant in the early phase was 36 (32-45) years and in the late phase 44 (38-49) years. Patients in the early phase had significantly higher odds for being in the symptomatic remission compared to the patients in the late-phase schizophrenia (OR=2.11; 95% CI 1.09-4.09) and had 10% less pronounced negative symptoms. The global strength, density, and structure of the symptoms network were not significantly different between the two study groups.Negative symptoms severity change with the course of illness and differ from the early to the late phase of schizophrenia. However, the overall network of psychotic symptoms is relatively stable, and overall strengths or density and the partial relationship between particular symptoms do not change significantly. The observed worsening of negative symptoms is probably at least partially caused by the lack of clear guidelines and effective treatment options aimed specifically toward negative symptoms.

Background The aim of study was to analyze neurocognitive profiles in patients with first-episode psychosis (FEP) and patients with schizophrenia (SCH), and their correlations with other clinical features. Subjects and methods We performed a multicentric cross sectional study including 100 FEP and 100 SCH recruited from three Croatian hospitals during 2015-2017. Assessment included a set of neurocognitive tests, psychiatric scales and self-reporting questionnaires. The main analysis was done by multigroup latent profile analysis. Results Multigroup latent profile analysis resulted in three structurally equivalent neurocognitive profiles ("Best", "Medium", "Worst"), with differences in the severity of neurocognitive deficits measured with successfulness in solving domain specific tasks. The "Best" profile was statistically significantly more prevalent in FEP and "Worst" profile in the SCH. Negative symptom score was the highest in patients with the "Worst" profile and the lowest among those with the "Best" profiles. Conclusions Differences in neurocognitive profiles between FEP and SCH appear to be quantitative rather than qualitative nature, possibly reflecting a specific trait of illness that may progress over time. Defining neurocognitive profiles from the first episode of psychosis could help in tailoring individualized treatment options with focus on neurocognitive and negative symptoms and possible influence on patients' overall clinical outcome.

Uvod: Problemi mentalnog zdravlja i mentalni poremećaji karakterizirani su visokom učestalošću kako u svijetu tako i u Republici Hrvatskoj. Osim visoke učestalosti, sama priroda mentalnih poremećaja, koja nerijetko zahvaća radno aktivno stanovništvo, značajno doprinosi opterećenju bolestima. Upravo navedeno zahtijeva sveobuhvatnu organizaciju skrbi za osobe oboljele od mentalnih poremećaja koja će uključivati sve mjere prevencije, liječenja i rehabilitacije. Cilj ovoga rada je prikazati stanje i trendove organizacije skrbi za osobe s mentalnim poremećajima u Republici Hrvatskoj te dati preporuke za unaprjeđenje skrbi sukladno rezultatima Twinning projekta: „Osiguravanje optimalne zdravstvene skrbi za osobe s poremećajima mentalnog zdravlja“. Metode: Za potrebe ovoga rada korišteni su podatci Hrvatskog zavoda za javno zdravstvo o broju i karakteristikama bolničkih liječenja za mentalne bolesti ukupno te za pojedinačne dijagnoze u razdoblju od 2000. do 2016. godine u Republici Hrvatskoj. Analizirane su usporedne dobnostandardizirane stope smrtnosti zbog samoubojstava u Republici Hrvatskoj i pojedinim zemljama Europe. Korišten su pregled literature povezano s ocjenom stanja organizacije psihijatrijske skrbi u Hrvatskoj i postojeće smjernice te objavljeni znanstveni radovi s opisom dobre prakse. U radu je korištena analitičko-deskriptivna metoda. Rezultati: Prema procjeni opterećenja bolestima za Republiku Hrvatsku mentalni poremećaji su na trećem mjestu među vodećim skupinama bolesti. Osim toga, mentalni poremećaji su i vodeći uzroci bolničkog pobola u radno aktivnoj dobi, dok na razini primarne zdravstvene zaštite pobol iznosi oko 4-5 % od ukupnih uzroka obolijevanja. Dobno-standardizirane stope smrtnosti zbog samoubojstva za Republiku Hrvatsku su više od prosječne stope za zemlje članice Europske unije. Iako se bilježi kontinuirani pad bolnoopskrbnih dana od 2000. do 2016. godine, ukupni broj hospitalizacija u odnosu na 2000. godinu povećao što se poglavito odnosi na depresivne poremećaje, a i oboljeli od shizofrenije vode u broju dana provedenih u bolnici. Prikazani su izolirani primjeri dobre prakse koji se odnose na rehabilitaciju oboljelih od poremećaja s psihozom, liječenje prvih psihotičnih poremećaja, bolesti ovisnosti te programi borbe protiv stigme i samostigme. Rasprava: Iz prikazanih pokazatelja može se zaključiti kako su mentalne bolesti sv e veći problem s obzirom na trend rasta stopa hospitalizacija kao i broj dana provedenih u bolnici. Zaključak: Potrebno je potaknuti reformu sustava mentalnog zdravlja prema izgradnji balansiranog i dobro koordiniranog bolničkog i izvanbolničkog sustava. Preporuke razvijene u okvirima Twining projekta mogu služiti kao smjernice za razvoj i provedbu na dokazima utemeljene i provedive strategije mentalnog zdravlja čiji će cilj biti oporavak koji uključuje socijalnu uključenost u život zajednice., Aim: Issues surrounding mental health and mental disorders are characterized by high prevalence globally, as well as in the Republic of Croatia. Besides its high prevalence, the bare nature of mental disorders, which often seizes workforce or economically active population, considerably contributes to the burden of diseases. This makes organization of comprehensive care for persons with mental health disorder an imperative, including all measures of prevention, treatment and rehabilitation. The aim of this paper is to present the condition, shape and trends in organization of care for persons with mental health disorder in the Republic of Croatia, and to provide guidelines for its improvement according to fi ndings and recommendations of the Twining project under the title Ensuring Optimal Health Care for People with Mental Health Disorders. Methods: For the purpose of this paper, data from the Croatian National Institute of Public Health were used, including data on the number, rates and characteristics of hospital treatments for mental disorders in total and separately for particular diagnostic categories during the 2000-2016 period. Age-standardized rates of suicides were analyzed for the Republic of Croatia and some European countries. Review of the literature, current guidelines, and scientifi c papers were used to determine the condition and shape of the organization of mental health services in the Republic of Croatia. Analytical-descriptive methods were used in analysis. Results: According to estimates of the burden of diseases for the Republic of Croatia, mental disorders rank third in the leading group of diseases. In addition, mental disorders are the main cause of hospital morbidity in active population, while morbidity at the level of primary care is 4%-5% of all causes of morbidity. Age-standardized rates of suicides for the Republic of Croatia are higher than the average ones for other European Union member states. Although there was a continuous decline in hospital days from 2000 to 2016, the total number of hospitalizations increased from 2000, which is especially evident for depressive disorders. Patients with schizophrenia are still leading by the number of days spent at the hospital. Examples of good practice are reviewed and presented. Most of them are related to rehabilitation from fi rst psychotic disorders, treatment of fi rst psychotic disorders, addiction, and programs addressing issues of stigma and self-stigma. Discussion: According to the indicators displayed, it is concluded that mental disorders are a growing issue in the Republic of Croatia, which is most evident from the trend of rising hospitalization rates and number of days spent in the hospital. Conclusion: There is a need for mental health reform by ensuring balance and coordinated inpatient and outpatient system of care. Recommendations developed within the Twining project can serve as guidelines for the development and implementation of evidence based and applicable strategies of mental health services that should be grounded in recovery, which includes full social participation in the life of community.

AIM: To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia. ----- METHOD: The cross-sectional study including male in-patients with paranoid schizophrenia with (N=104) and without (N=102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between groups. Binary logistic regression model was used to determine the predictors of violent offending. ----- RESULTS: Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending. ----- CONCLUSION: This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.

The Day of Right of Persons with Psychic Disorders in the Republic of Croatia

IntroductionEven though it is not the most common type of dementia, frontotemporal dementia (FTD) is a major health problem. It affects people younger than 65 with similar frequency as Alzheimer's dementia (AD) and has a progressive course that leads to inevitable deterioration in functioning. Still, FTD is not a unique entity in ICD- 10 classification.ObjectivesTo investigate the diagnostic and treatment difficulties in FTD.AimsTo show very rapid and progressive deterioration in people with early onset FTD.MethodsWe will present a series of cases showing progressive cognitive deterioration and prominent personality changes in patients with FTD hospitalised at University Psychiatric Hospital Vrapce since 2013 to 2015. Collected data included anamnestic and heteroanamnestic information, blood tests and neroimaging.ResultsOur findings showed a significance of early onset FTD, with subtle, untypical symptoms at the beginning, and galloping deterioration during the course of illness.ConclusionsPresented patients with FTD showed rapid and progressive nature of disease with infaust prognosis. Even though early onset patients make 20% of overall number of patients with FTD, we consider that it is necessary to separate them from late onset patients in future classification systems.Disclosure of interestThe authors have not supplied their declaration of competing interest.

We describe the legal possibilities for the treatment of criminal case offenders, and especially the offenders found not guilty for the reason of insanity (OFGRI). The treatment of the criminal case offenders in Croatia is regulated by the special legal acts, and is dependent on the expert opinion of a psychiatrist (court expert). The judge can send a person for a psychiatric treatment (together with the prison sentence or parole) only in criminal case offenders found being of significantly diminished responsibility. In case of alcohol dependence or any other type of psychoactive substance dependence the treatment is regulated by special Criminal code articles, no matter what was the criminal offence. Offenders found not guilty for the reason of insanity are not considered guilty and no criminal or legal punishment is allowed to be used. The treatment of these offenders is regulated by the Act on protection of people with mental problems. The first version of this Act was published at the end of 1997, and implemented on the 1st of January 1998. There have been several changes in the Act, mainly regarding the outpatient treatment. After the final decision of the court in the case of the OFGRI persons, the court sends a person for the involuntary hospitalization in one of the four forensic institutions in Croatia (Popovača, Vrapče, Ugljan and Rab). There are 380 beds altogether in all the four institutions. The treatment can be, according to this Act, either outpatient or inpatient.

Schizophrenia is a serious public health problem and is ranked among the most disabling diseases in the world. The sub-study presented here was part of a larger project to characterize the burden of schizophrenia on healthcare systems and on individuals living with the disease in Central and Eastern Europe (CEE).This sub-study aimed to assess and analyze the impact of schizophrenia on many aspects of the lives of patients and caregivers.Psychiatrists from selected centers in seven Central and Eastern European countries were asked to complete a questionnaire in order to collect information about the disease history, characteristics, treatment protocols and resources used for each randomly selected patient. All data were statistically analyzed and compared between countries.Data from 961 patients with schizophrenia (mean age 40.7 years, 45.1% female) were included in the analysis. The mean number of days spent in hospital per patient per year across all seven countries was 25.3 days. Hospitalization occurred on average once per year, with psychiatrist visits 9.4 times per year. Of the patients in the study, 61% were single, 12% divorced and 22% married or cohabiting. Almost 84% were living with relatives or a partner; only 17% lived alone and, on average, 25% of patients received support from social workers. Relatives provided care for approximately 60% of patients and 4% of them had to stop working in order to do so. Twenty-nine percent of the patients were unemployed, and 56% received a disability pension or were retired, with only 19% in full-time employment or education.Schizophrenia has a significant effect on the lives of patients and caregivers and impacts their social integration.

Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to neuroleptic medications that is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. NMS often occurs shortly after the initiation of neuroleptic treatment, or after dose increases. Malignant hyperthermia (MH) or malignant hyperpyrexia is a rare life-threatening condition that is usually triggered by exposure to certain drugs. The 46-years-old female patient was diagnosed schizophrenia at the age of 22. Currently, she is hospitalized due to psychotic decompensation. The patient was admitted with following daily dose therapy of: haloperidol 15 mg, biperiden 4 mg and diazepam 15 mg. During this hospitalization she developes muscle rigidity, tremor, hyperthermia, and laboratory results showed increase of enzimes CPK and LDH, so we started treatment of suspected malignant neuroleptic syndrome. After a treatment and recovery with complete withdrawal of all presented symptoms, our patient developed a malignant hypertermia that was resistant to all applicated medications. Our dilemma is whether presented symptoms of malignant hyperthermia are related to malignant neuroleptic syndrome or not?Disclosure of interestThe authors have not supplied their declaration of competing interest.

According to earlier observations, minor physical anomalies (MPAs) are more prevalent in psychotic disorders, especially in schizophrenia, and represent an indicator of abnormal fetal development. Limited research has been conducted on these structural abnormalities among patients with unipolar depression, with and without psychotic features. We hypothesized that the mean total MPA score would be greater in patients with psychotic depression than depressive patients without psychosis and control subjects. An extended scale of MPAs was used to detect the presence or absence of 51 MPAs in women with recurrent unipolar depression with psychotic symptoms ( n =50), women with recurrent unipolar depression without psychotic symptoms ( n =50) and healthy female controls ( n =50). Women with recurrent depression had significantly more MPAs than controls. With regard to MPAs of specific body regions, depressive patients had significantly higher rates of MPAs in the mouth area than control subjects. Higher rates of MPAs were not significantly related to psychotic features of depression. The study results are indicative of possible early neurodevelopmental disturbance in recurrent unipolar depression.

Cilj Odrediti smanjuju li atipični antipsihotički lijekovi stopu rehospitalizacije bolesnika s novodijagnosticiranom ili kroničnom shizofrenijom više nego tipični lijekovi. Postupci Od 1. siječnja 2003. do 31. prosinca 2004. retrospektivno smo uspoređivali dvogodišnje stope rehospitalizacije 135 bolesnika s novodijagnosticiranom i 398 bolesnika s kroničnom shizofrenijom (62%, odnosno 65% muškaraca) koji su otpušteni s liječenja u Psihijatrijskoj bolnici Vrapče u Zagrebu u razdoblju između 1. siječnja 2002. do 31. prosinca 2002. a bili su im prepisani atipični (olanzapin, risperidon ili klozapin) ili tipični (haloperidol ili flufenazin) antipsihotici. Vrijeme do ponovnog primanja u bolnicu određeno je Kaplan-Meierovom formulom za analizu preživljenja. Rezultati Za vrijeme dvije godine koliko je trajalo praćenje rehospitalizirana su 52 (39%) bolesnika s novodijagnosticiranom i 197 (47%) bolesnika s kroničnom shizofrenijom. Nije bilo značajnih razlika u vremenu do rehospitalizacije s obzirom na vrstu uzimanog lijeka između bolesnika s novodijagnosticiranom (P=0,378) i bolesnika s kroničnom shizofrenijom (P=0,531). Zaključak. Stopa rehospitalizacije u bolesnika kojima su prepisani atipični antipsihotici bila je slična stopi u bolesnika kojima su prepisani tipični antipsihotici i za bolesnike s novodijagnosticiranom i za bolesnike s kroničnom shizofrenijom., Aim To determine if atypical antipsychotic agents reduce the rehospitalization rates of patients with newly diagnosed or chronic schizophrenia in comparison with typical antipsychotic drugs. Methods From January 1, 2003, to December 31, 2004, we retrospectively compared two-year rehospitalization rates of 135 patients with newly diagnosed schizophrenia and 398 patients with chronic schizophrenia (62% and 65% men, respectively), who were initially discharged from Vrapče Psychiatric Hospital, Zagreb, with the prescription of atypical (olanzapine, risperidone or clozapine) or typical (haloperidol or fluphenazine) antipsychotic treatment between January 1, 2002 and December 31, 2002. Time-to-readmission was determined with Kaplan-Meier formula for survival analysis. Results In the two-year follow-up, 52 (39%) newly diagnosed patients and 197 (47%) patients with chronic schizophrenia were rehospitalized. No significant differences in time-to-rehospitalization were observed with respect to the type of medications in patients with newly diagnosed schizophrenia (P = 0.378) or patients with chronic schizophrenia (P = 0.531). Conclusions. Rehospitalization rates of patients who were prescribed atypical antipsychotic drugs were similar to those of patients who were prescribed typical antipsychotic drugs for both the group with the first psychotic episode and group with chronic schizophrenia.

Klinika za psihijatriju Vrapče (nazvana „Zavod za umobolne Stenjevec“) sagrađena je 1878./79. Osim za smještaj i liječenje bolesnika, njoj je od samog osnutka namijenjena i uloga ustanove u kojoj će se provoditi edukacija. Naime, tijekom priprema gradnje, naglašeno je da „pošto ludnica nije samo lječilište i opskrbilište, već mora da je i učilištem, to se ima kraj Zagreba graditi, gdje se ustrojava sveučilište“…). Prvi programi edukacije bili su oni namijenjeni prvim zaposlenicima bolnice koje je osmislio i provodio prvi ravnatelj bolnice dr. Ivan Rohaček. Kasnije se edukacijski programi usmjeravaju prema drugim zaposlenicima, u prvom redu liječnicima, a vrlo brzo i prema onima koji se u svom radu susreću s duševnim bolesnicima, a nisu zaposlenici bolnice. Prvo je u Bolnici organizirana nastava iz psihijatrije za studente Medicinskog fakulteta, a kasnije i drugih fakulteta Zagrebačkog sveučilišta (Pravnog, Edukacijsko-rehabilitacijskog, Filozofskog i Farmaceutsko-biokemijskog fakulteta te Hrvatskih studija) i Zdravstvenog veleučilišta. Posebno visoka razina edukacijskih programa je ona namijenjena studentima postdiplomskih studija (iz pojedinih grana psihijatrije, psihologije i farmacije) i specijalizantima iz psihijatrije te subspecijalizantima iz forenzičke (i drugih grana) psihijatrije. Poseban vid edukacije provodi se kroz organizaciju raznih predavanja, savjetovanja, simpozija i okruglih stolova. U provođenje svih tih edukacijskih programa, odnosno u edukaciji svih onih kojima su ti programi namijenjeni bio je, i sada je, uključen veliki broj istaknutih vrapčanskih stručnjaka (27 stručnjaka bolnice „Vrapče“ dobilo je znanstveno nastavna zvanja; devet je bivših zaposlenika Bolnice, na temeljima onoga što su ponijeli iz „Vrapča“, akademska zvanja ostvarilo u drugim nastavnim bazama). Bolnica ima izvrsnu infrastrukturu za provođenje svih tih edukacijskih programa (Edukacijski centar s dvoranom za 250 sudionika koja se pregrađuje u dvije dvorane od po 100 mjesta, pet dvorana s pedesetak i sedam dvorana s 20 do 30 mjesta)., The University Psychiatric Hospital Vrapče (under the name „Stenjevec Department for the Mentally Ill“) was built in 1878 and 1879. In addition to housing and treatment of patients, it was also intended to perform the role of an educational institution from its inception. During construction, it was emphasized that „since the madhouse is not only for treatment and storage, but has to also be a place of learning, it must be built near Zagreb, where the university is being formed“…. The inital educational programs were intended for the first employees of the hospital and were developed and conducted by the first Director of the hospital, Dr. Ivan Rohaček. Later, the educational programs were directed towards other employees, and soon towards those who encounter persons with mental illness in their work but are not employed at the hospital. Initially, psychiatry classes were organized in the hospital for Medical School students, and later also for students of other branches of the University of Zagreb (the Faculty of Law, Faculty of Education and Rehabilitation Sciences, Faculty of Humanities and Social Sciences, Faculty of Pharmacy and Biochemistry and the Centre for Croatian Studies) and the University of Applied Health Sciences. A particularly high level of educational programs is provided for postgraduate students (from individual branches of psychiatry, psychology, and pharmacy) and psychiatry specialists and subspecialists in forensic psychiatry (and other branches). Another aspect of education is the organization of various lectures, consulting, symposiums and round tables. A large number of prominent Vrapče Hospital professionals have been taking part in all of these education programs, i.e. in the education of those for whom the programs are intended (27 professionals from the Vrapče Hospital received teaching or research positions at the university; nine former employees of the hospital, based on the knowledge that was imparted to them at Vrapče Hospital, achieved positions in other educational fields). The hospital has an excellent infrastructure for conducting all these education programs (an Education Center with a lecture hall for 250 participants that can be divided into two halls with 100 seats each, five halls with around fifty and seven halls with 20 to 30 seats).

Vodeći čimbenici rizika za agresivno ponašanje bolesnika sa shizofrenijom su antisocijalne osobine ličnosti, pozitivni simptomi u kliničkoj slici te ovisnost ili zlouporaba psihoaktivnih tvari. S ciljem analiziranja utjecaja i povezanosti kliničke slike i pojedinih simptoma shizofrenije na agresivno ponašanje uspoređivali smo skupinu agresivnih (N=60) i neagresivnih (N=60) muškaraca sa shizofrenijom. S obzirom da se u literaturi raspravlja o mogućoj zajedničkoj osnovi hetero- i autoagresivnosti, agresivni su ispitanici razdvojeni na heteroagresivnu (N=32) i suicidalnu skupinu (N=28). Prisutnost i intenzitet pojedinih simptoma shizofrenije ocijenili smo PANSS-om, stupanj heteroagresivnosti OAS (Overt Aggression Scale), a suicidalnosti C-SSRS (Columbia-Suicide Severity Rating Scale) i InterSePT (International Suicide Prevention Trial) ljestvicama. U heteroagresivnoj skupini značajno je viši ukupni PANSS te njegova pozitivna i opća podljestvica. Stupanj heteroagresivnosti u pozitivnoj je korelaciji s ukupnim PANSS-om i impulzivnošću, a u negativnoj korelaciji s depresivnošću i imperativnim halucinacijama. Stupanj suicidalnosti u pozitivnoj je korelaciji s depresivnošću i imperativnim halucinacijama, a u negativnoj s ukupnim PANSS-om, stupnjem heteroagresivnosti i impulzivnošću. Jedini je značajni prediktor izrazitog agresivnog ponašanja viši rezultat pozitivne podljestvice PANSS-a. Ovi rezultati upućuju na nužnost prepoznavanja pozitivnih simptoma shizofrenije kao značajnog čimbenika za pojavu agresivnosti s ciljem što ranijeg terapijskog djelovanja i sprečavanja agresivnih incidenata.

IntroductionNeurocognitive impairment in schizophrenia is associated with functional disability and poorer quality of life, and is the most resistant of all schizophrenia symptoms to current psychopharmacotherapy.ObjectivesTo compare the differences in neurocognitive status during the acute phase of first psychotic episode and stable symptomatic remission.AimsTo investigate the pattern of neurocognitive impairment in patients with first episode psychosis during acute phase and stable remission phase.MethodsWe performed a longitudinal study, including 150 patients with first episode of psychosis at two time points: during their hospitalization at Zagreb university hospital centre or university psychiatric hospital Vrapče, at acute phase of illness and after 12–18 months, during stable remission. Assessment included detailed clinical interview, clinical rating of neuropsychiatric symptoms using standardized psychiatric scales, self-assessment scales and comprehensive neurocognitive testing.ResultsWhile our preliminary results (n = 40) showed statistically significant improvement in various neurocognitive domains, including visuo-learning abilities, verbal learning, executive functions, attention and processing speed, initial impairment in semantic and phonetic fluency observed in acute psychosis remained unchanged in remission as well.ConclusionsAlthough our results showed improvement in most of cognitive domains during time, language abilities remained unchanged. This further confirms the hypothesis that language impairment is a trait marker of psychotic disorder.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Introduction. Psychiatric treatment in developed countries has significantly changed in the last few decades, with a significant shortening of the duration of hospitalization. Numerous West European countries are undertaking health system reforms to improve treatment efficiency. Objective. The aim of the study was to present the structure of hospitalized patients according to diagnostic categories of International Classification of Diseases and Related Health Problems - 10th Revision (ICD-10), and average duration of hospitalization from 2001 till 2010. Methods. Data was collected from hospital medical charts for the period from 2001 till 2010 on the number of hospitalized patients, diagnosis and duration of hospitalization. Results. Number of hospitalized patients increased by 27% (6309 vs. 8032). Average duration of hospitalization decreased for 45.1% (72.3 vs. 39.7 days), while the number of hospitalized patients decreased from 1284 (20.4%) in 2001 to 995 (12.4%) in 2010, the number of patients hospitalized because of depressive disorder increased from 309 (4.9%) in 2001 to 994 (12.4%) in 2010. The number of patients hospitalized because of enduring personality changes increased from 104 (1.7%) in 2001 to 449 (5.6%) in 2010. Conclusion. In the last decade the number of hospitalized patients suffering from schizophrenia at the Psychiatric Clinic Vrapce decreased, while the number of those suffering from depression and enduring personality change increased. The number of hospitalizations in the observed period increased overall. Observed changes can be explained by new therapeutic approaches, but also by objective social and economic factors and organization of the healthcare system.

Aggressive behavior and negative symptoms are two features of schizophrenia that may have a hormonal basis.The aim of this study was to compare testosterone level with clinical features of schizophrenia, focusing on negative symptoms and aggressive behavior.The study population consisted of 120 male schizophrenic patients (ages 18-40) classified into non-aggressive (n = 60) and aggressive (n = 60) groups. Depending on the type of aggression that was manifested prior to admission, the aggressive group was divided into violent (n = 32) and suicidal (n = 28) subgroups. Psychopathological severity, violence and suicidality were assessed using the Positive and Negative Syndrome Scale (PANSS), Overt Aggression Scale and Columbia Suicide Severity Rating Scale, respectively. Total serum testosterone level was determined on the same morning that symptoms were assessed.In the non-aggressive group, testosterone level was negatively correlated with the score on the negative subscale of PANSS (P = 0.04) and depression (P = 0.013), and positively correlated with excitement (P = 0.027), hostility (P = 0.02) and impulsive behavior (P = 0.008). In the aggressive group, testosterone level had non-significant correlation with these parameters, and with violent or suicidal behavior.The results confirmed that non-aggressive male schizophrenic patients with lower levels of testosterone had a greater severity of negative symptoms. In aggressive patients, there was no correlation between testosterone and clinical features of the disorder or the degree or type of aggression. These findings indicate that therapeutic strategies targeting testosterone could be useful in the treatment of negative symptoms of schizophrenia.

One fifth to one third of all patients diagnosed with schizophrenia are resistant to drug treatment, which makes it a major clinical challenge. Genetic studies have focused on the association between treatment resistant schizophrenia (TRS) and a number of candidate genes, including serotonin and dopamine system genes. We explored associations between carefully characterized TRS and DAT-VNTR, SERT- PR and SERT-in2 polymorphisms. There were 173 patients enrolled in the study that were clinically evaluated using Positive and Negative Syndrome Scale and Clinical Global Impressions Scales and divided into two groups based on treatment resistance (92 patients in TRS group). Patients with a combination of SERT-in2 II and DAT 9/10, 9/11, 9/9 and 6/6 genotypes were more likely to have TRS, compared to those with 10/10 or 10/12 genotype (OR = 5.1 ; 95% CI = 1.6-16.8). In the group of patients with DAT 10/10 or 10/12 genotype, those who also shared SERT-in2 Is or ss genotype were more likely to have TRS, compared toll genotype carriers (OR = 2.7 ; 95% CI = 1.0- 7.0). The model in which interaction between SERT-in2 and DAT polymorphisms is linked to TRS can possibly explain contradictory previous results regarding role of DAT and SERT in TRS, but further research is needed. (C) 2014 Elsevier B.V. All rights reserved.

Nasilje je fenomen koji je obilježio ljudsku povijest od njenog samog početka i koji je područje od interesa za različite struke poput psihologije, prava, sociologije, kriminologije. Fenomen je to oko kojega, kao i oko razumijevanja agresivnog ponašanja općenito, postoje različiti prijepori, ali i fenomen koji se često shvaća u kontekstu postojanja duševnih poremećaja. Cilj ovoga pregleda nije psihijatrizacija nasilja i agresije nego u svom uvodu istaknuti različite poglede na agresiju i nasilje te naznačiti kako je agresivnost kod ljudi, iako se zasniva na istim (biološkim) procesima kao i kod životinja, modificirana čimbenicima kulture, etičkih normi i socijalne situacije. S obzirom na činjenicu postojanja agresivnog ponašanja u sklopu određenih duševnih poremećaja, kao i na percepciju javnosti o ulozi koju duševni poremećaji imaju u nasilju, ovaj rad donosi i kratak pregled značajki agresivnog ponašanja u okviru različitih psihijatrijskih dijagnostičkih kategorija.

Agresivno ponašanje nije specifično za ljude i dovoljan je i površan pogled kako bi se uočilo postojanje i uloga agresivnog ponašanja u životinjskom svijetu koje se u tom kontekstu ne može shvatiti kao aberacija. Istraživanja na životinjama pokazala su utjecaj određenih moždanih struktura na agresivno ponašanje, a primjeri ozljeda ili bolesti kod ljudi potvrdili su ulogu specifičnih centara i kod ljudi. Brojne su teorije pokušale povezati centre u središnjem živčanom sustavu i nasilno ponašanje a gotovo sve priznaju važnu ulogu forntalnog korteksa i subkortikalnih limbičkih struktura uključenih u procesuiranje straha, doživljavanje zadovoljstva i strateško planiranje i donošenje odluka, ali u konceptualizaciji neurobiologije agresije nemoguće je ne spustiti se i na razinu neurotransmitera, receptora i gena. Cilj je ovog rada dati kratki pregled osnovnih koncepata neurobiologije agresije i nasilja no ne smije se u raspravi o složenim fenomenima poput nasilja zaboraviti da se biologija kao čimbenik tih fenomena ne nalazi izolirana nego pod utjecajem brojnih čimbenika okoline i socijalnog prostora.

AIM To investigate the relationship between total serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with posttraumatic stress disorder (PTSD) without psychiatric comorbidity. ----- METHODS A total of 203 male PTSD outpatients were assessed for the presence of depression, aggression, and suicidality using the 17-item Hamilton Depression Rating Scale (HAM-D17), Corrigan Agitated Behavior Scale (CABS), and Scale for Suicide Ideation (SSI), respectively, followed by plasma lipid parameters determination (total cholesterol, high density lipoprotein [HDL]-cholesterol, low density lipoprotein [LDL]-cholesterol, and triglycerides). PTSD severity was assessed using the Clinician-Administered PTSD Scale for DSM-IV, Current and Lifetime Diagnostic Version (CAPS-DX) and the Clinical Global Impressions of Severity Scale (CGI-S), before which Mini-International Neuropsychiatric Interview (MINI) was administered to exclude psychiatric comorbidity and premorbidity. ----- RESULTS After adjustments for PTSD severity, age, body mass index, marital status, educational level, employment status, use of particular antidepressants, and other lipid parameters (LDL- and HDL- cholesterol and triglycerides), higher total cholesterol was significantly associated with lower odds for having higher suicidal ideation (SSI≥20) (odds ratio [OR] 0.09; 95% confidence interval [CI] 0.03-0.23], clinically significant aggression (CABS≥22) (OR 0.28; 95% CI 0.14-0.59), and at least moderate depressive symptoms (HAM-D17≥17) (OR 0.20; 95% CI 0.08-0.48). Association of total cholesterol and HAM-D17 scores was significantly moderated by the severity of PTSD symptoms (P

Cobalamin deficiency is associated with a wide spectrum of hematologic, neurologic, gastroenterologic and psychiatric disorders or symptoms. We report a case of a 50-year-old man with complex partial seizures with secondary generalization, mood oscillations and psychotic symptoms alternating with confusion and reversible dementia secondary to cobalamin deficiency in the absence of typical neurologic and/or hematologic symptoms and signs. Exclusion of epilepsy, acute, atrophic or expansive lesion of central nervous system and usual etiology associated with reversible dementia (infectious diseases, an endocrine etiology and deficiency of vitamins other than cobalamin); finding of cobalamin deficiency only and complete neuropsychiatric recovery after substitution, confirmed etiology. Typical and atypical psychiatric manifestations due to cobalamin deficiency that precede neurologic and/or hematologic signs and symptoms can recover completely after adequate replacement therapy.

Based on this experience, we find that glucose monitoring should be considered during treatment with olanzapine. In order to evaluate frequency of hyperglycemia, the probability of glucose elevation during olanzapine therapy, as well as the connection of hyperglycemia with olanzapine therapy, further clinical investigations are necessary.

The presence of posttraumatic stress disorder (PTSD) in male war veterans has been linked with family dysfunction and psychopathology in their children [1, 2]. This study aimed to evaluate self-reported emotional and behavioral symptoms, parent–adolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans and determine the degree that parent–child bonding and family functioning contributed to adolescent behavior problems. Internalizing and externalizing behavior problems, parent–child bonding and family functioning were assessed in a sample of clinically referred Croatian PTSD veterans adolescent offspring (N = 122) and non-PTSD veteran adolescent offspring (N = 122) matched for age, sex, educational level, family income, parental employment status, ethnicity, and residential area. Youth Self-Report, Parental Bonding Instrument, Family Assessment Device were used. Adolescent offspring of PTSD veterans reported having significantly more internalizing and externalizing problems than non-PTSD veteran offspring, and also more difficulties in their family functioning, lower levels of maternal and paternal care, and more impaired mother–child and father–child bonding than control subjects. Internalizing symptoms were associated with family dysfunction, while externalizing symptoms were associated with paternal overcontrol/overprotection, and low maternal and paternal care. In conclusion, the increase in internalizing and externalizing symptoms as well as family and parental dysfunction among clinically referred adolescent offspring of PTSD veterans compared to their non-PTSD veteran counterparts indicates a need for early detection and interventions targeting both adolescent psychopathology and family relationships.

Rad analizira stanje mreže forenzičko psihijatrijskih kreveta u Hravtskoj te daje prijedlog prijedlog mreže centara za izvanhospitalno liječenje

Problem nasilničkog, i općenito kriminogenog ponašanja u osnovi kojeg je psihijatrijski poremećaj ili ovisnost o alkoholu ili drogama sve je izraženiji. Sudovi sve češće izriču zaštitne i sigurnosne mjere obveznog psihijatrijskog liječenja ili liječenja od ovisnosti. Upućuju bolesnike u psihijatrijske ustanove radi provođenja tih mjera (liječenja), no psihijatrijske ustanove još uvijek nisu kadre prihvatiti i adekvatno tretirati te pacijente. Zato smo u Klinici za psihijatriju Vrapče osmislili i početkom 2012. godine uveli program „intermitentnog liječenja“ forenzičko-psihijatrijskih pacijenata koji se liječe na slobodi. Na Zavodu za forenzičku psihijatriju taj je program prilagođen ambulantnom liječenju počinitelja kaznenih djela u u neubrojivom stanju. Interdisciplinarnom suradnjom stručnjaka cijele bolnice i angažmanom triju zavoda - Zavod za forenzičku psihijatriju, Zavod za bolesti ovisnosti i Zavod za socijalnu psihijatriju, provodi se program liječenja nasilnika ovisnika i onih s nekim drugim psihičkim smetnjama. Početni rezultati su ohrabrujući pa se očekuje da isti program bude prihvaćen i u drugim psihijatrijskim ustanovama.

Kvaliteta života ima bitnu ulogu u svakodnevnom životu. U ovom istraživanju, istraživala se kvaliteta života studenata i osoba oboljelih od prve epizode shizofrenije u stanju remisije. U istraživanju je bilo uključeno 50 studenata i 50 osoba oboljelih od prvih epizoda shizofrenije u stanju remisije. Procjena kvalitete života provedena je Upitnikom o kvaliteti života Svjetske zdravstvene organizacije (WHOQOL – BREF). Rezultati su pokazali da mlade osobe oboljele od prve epizode shizofrenije u remisiji u odnosu na studente socijalnog rada, procjenjuju vlastitu kvalitetu života lošijom u domeni socijalnih odnosa. Nije nađena statistički značaja razlika u domenama psihičkog zdravlja, fizičkog zdravlje i okolišne dimenzije. Rezultati ovog istraživanja potvrđuju neophodno sveobuhvatno i učinkovito liječenje i skrb za bolesnike oboljele od prvih epizoda shizofrenije pri čemu je posebno važna kvalitetna socijalna rehabilitacija., The quality of life has an important role in everyday life. In this study, the quality of life of social work students (N=50) and young people with first-episode schizophrenia (N=50) in remission was studied. The assessment of the quality of life of patients and students was conducted using the World Health Organization’s Quality of Life Questionnaire (WHOQOL-BREF). The results show that young people with first-episode schizophrenia assess their quality of life as worse in the domain of social relationsin comparison to social work students. There were no statistically significant differences in the domains of mental health, physical health, and environmental dimensions. The results confirm the necessity of a comprehensive and effective treatment and care for patients with thefirst episode of schizophrenia in which special attention should be given to quality social relations and rehabilitation.

IntroductionParricide (referring as parental homicide) is a rare event among homicides, yet challenging and intriguing from psychiatric point of view. Still, literature concerning parricide is sparse and most studies concern small or heterogenous samples or anecdotal cases.ObjectiveTo analyze differences in parricide offenders among forensic psychiatric inpatients at the university psychiatric hospital Vrapče's centre for forensic psychiatry.AimsTo test some differences between parricide offenders with regard to specific type of parricide.MethodsAvailable retrograde data of 50 years forensic inpatients (n = 430). We identified parricide cases of matricide and patricide included.ResultsThe analysis included a total of 22 parricide offenders. All parricide offenders were male adults. Matricide was more prevalent then patricide (13 vs. 9). Matricide offenders were in average younger when committed crime, had more prevalence of psychotic disorders and earlier onset of symptoms in comparison with patricide group.ConclusionWe identified differences and similarities between these two parricide offenders groups. It is important to expand research further including different types of motives and family dynamics regarding the type of parricide victim.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionRisk prediction for suicide in schizophrenia is known to be complex. Illness-related risk factors are important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions.AimsTo analyze the impact of clinical features of schizophrenia on suicidal behaviour and analyze relationship between violence and suicidality.MethodsWe compared a group of 28 suicidal, 32 hetero-aggressive and 60 non-aggressive male patients with schizophrenia. The severity of the psychopathology was assessed using PANSS, hetero-aggressiveness using OAS and suicidality using C-SSRS and InterSePT scales.ResultsSuicidality is in positive correlation with the presence of depression (r = 0.485, P < 0.001) and imperative hallucinations (r = 0.391, P < 0.001) but in negative correlation with total PANSS score (r = –0.297, P < 0.001), impulsiveness (r = –0,237, P < 0.001) and hetero-aggressive behaviour (r = –0.551, P < 0.001). Previous attempt was found in 53% suicidal patients (P = 0.047). Heteroaggressiveness is in positive correlation with total PANSS (r = 0.43, P < 0.001) and impulsive behaviour (r = 0.57, P < 0.001). This study supports the contention that high impulsivity in schizophrenia patients is significant in the etiology of violent but not suicidal behaviour.ConclusionIn the order to diminish the level of suicide among patients with schizophrenia we must be aware of the importance of depressive symptoms, imperative hallucinations and previous attempts. This study supports the contention that high impulsivity in schizophrenia patients is significant in the etiology of violence but not suicidal behaviour.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionPrevious studies have demonstrated that family history is associated with earlier age at onset, severity of positive and negative symptoms, and the duration of untreated illness. Hereditary factors may contribute a vulnerability for antisocial and/or violent behaviour per se, and for other stable characteristics such as aggressive behaviour.AimTo analyze the impact of family history of schizophrenia and aggressive behavior among members of family on severity of disease and aggressive behavior of patients.MethodThe study population consisted of 120 male schizophrenic patients classified into non-aggressive (n = 60) and aggressive (n = 60) groups, based on indication for admission in hospital (aggression/anything else but aggression). For severity of disease, we assessed psychopathology using the Positive and Negative Syndrome Scale (PANSS), the number of hospitalizations and the total equivalent dose of therapy (collected from medical record). The presence of a family history and aggression in family was assessed using a semi-structured interview of patients and, when available, family members.ResultsTwenty-seven (22.5%) participants were determined to have at least one family member with schizophrenia or another psychotic disorder, with no difference between aggressive (10%) and non-aggressive (12.5%) group. There was no significant interaction between family history and severity of disease (PANSS, number of hospitalizations, total equivalent dose of therapy). Aggressive behaviour in first-degree family member had no influence on aggressive behaviour of patients with schizophrenia.ConclusionFamily history of schizophrenia does not affect the severity of disease nor aggressive behaviour.Disclosure of interestThe authors have not supplied their declaration of competing interest.

This study, primarily aimed at identification of familial risk factors favoring drug addiction onset, was carried out throughout 2008 and 2009. The study comprised a total of 146 addicts and 134 control subjects. Based on the study outcome, it can be concluded that in the families the addicts were born into, familial risk factors capable of influencing their psychosocial development and favoring drug addiction onset had been statistically more frequently encountered during childhood and adolescence as compared to the controls. The results also indicated the need for further research into familial interrelations and the structure of the families addicts were born into, as well as the need for the implementation of family-based approaches to both drug addiction prevention and therapy.

Introduction: In the last 20 years a lot of efficient psychiatric medications were marketed. That led to improvement in treatment of patients suffering from various mental disorders. Regardless of personal experience and impression that, at the moment, Croatia has no major problems regarding availability of the newest psychiatric medications to our citizens, we decided to check that availability and comment the results. Aim and methods: The aim of this work was to check the availability of psychiatric medications to Croatian healthcare users, changes in that availability through time, dynamics of introduction of new medications on the drug list of Croatian Institute for Health Insurance, and how availability of these medications, especially antipsychotics, influenced psychiatric hospital morbidity in Croatia. We analyzed all drug lists in Croatia between 1989 and 2011. Changes in use of different antipsychotics were observed through the example of University Psychiatric Hospital Vrapče, Zagreb. Results: Analysis of the 22-year dynamics of psychiatric drugs being included on the list of Croatian Institute for health Insurance shows that number of drugs in certain subcategories increased many times, especially in case of antipsychotics and antidepressants whose number increased 5 times. Conclusions: There was a steady yearly reduction in number of patients hospitalized because of schizophrenia and schizophrenia spectrum disorders, as use of newer atypical antipsychotics increased. We can be satisfied with drugs available on the drug list of Croatian Institute for Health Insurance, especially if compared to the situation in neighboring countries that are not yet part of the European Union.

Integracija psihijatrije u primarnu zdravstvenu zaštitu pomaže u ranom otkrivanju poremećaja, smanjenju stigme i djelotvornom liječenju mentalnih poremećaja. Psihijatrijska služba je glavni nosilac organizacije službe za mentalno zdravlje. Očekuje se sukladno praksi u Europi da liječnici obiteljske medicine značajnije sudjeluju u liječenju mentalnih poremećaja. Trajanje i sadržaj aktualne dodiplomske i poslijediplomske izobrazbe ne osposobljava liječnika dostatno za ovu ulogu. Rad uspoređuje sadašnje stanje u primarnoj zdravstvenoj zaštiti s novonastalim potrebama te predlaže promjene, u skladu s činjenicom da se najbolji rezultati u ranom otkrivanju i liječenju mentalnih poremećaja postižu uz: a) organizaciju psihijatrije po modelu psihijatrije u zajednici; b) postojanje programa borbe protiv stigme; c) kontinuiranu edukaciju liječnika obiteljske medicine iz područja mentalnih poremećaja; d) mrežu psihijatara konzultanata, Integration of the psychiatry in primary care is beneficial for tlie early detection of mental disorder, better outcome of mental disorder and reduction of stigma. Psychiatry is a leading profession in organisation of mental health services. General practitioners (GPs) in Europe deal with mental disorders in their everyday practice, so the same is expected in Croatia. Graduate and postgraduate education of our GPs is insufficient for this new role. The paper compares actual situation in Croatia with forthcoming needs. The paper suggests that community psychiatry, anti-stigma program, continuing medical education of GPs and network of consultant psychiatrists give the best results in the early detection and treatment of mental disorder.

AIM: To study demographic characteristics, comorbidities, and diagnoses of patients admitted for personality disorders to Psychiatric Hospital Vrapče between 1879 and 1929. ----- METHODS: Data were collected from the archives of Vrapče Psychiatric Hospital for a 50-year period from November 1879 to December 1929. The ratio between the number of patients with personality disorder and the number of all admitted patients was determined. We used 3 systems of definitions of personality disorder: for cases before 1923, we used Prichard’s concept of moral insanity and unpublished definitions of one of the hospital managers at that time; for cases after 1923, we used Schneider’s classification of psychopathic personalities and unpublished definitions of one of the hospital managers at that time. ----- RESULTS: The total number of admissions during the study period was 18 960, 141 (0.74%) of which were for a personality disorder. Of the admitted patients, 85.8% were men and 59.7% were single. The average age was 29.7 } 9.5 years. Most of them (61.7%) were sent to the hospital by courts or police, and the median length of stay was 92 days (interquartile range, 92.0 - 127.5 days). The first patient with a personality disorder was admitted in 1889 with a diagnosis of moral insanity. Until 1920, only 3 terms were used for personality disorder: moral insanity, psychopathic inferiority, and psychopathy. The term was subdivided only after that year. Of the 141 patients admitted for personality disorder, 34 (24.1%) were discharged with comorbid disorders, mainly substance abuse. The most common single comorbid diagnosis was Ganser syndrome (prison psychosis). ----- CONCLUSION: Archives of the Vrapče Psychiatric Hospital contain reliable data about the earliest nomenclature of personality disorders, the increase in the prevalence of personality disorders, and further subdivision of the term personality disorder. Nomenclature for these disorders used at the Vrapče Psychiatric Hospital was consistent with that used in clinical practice in other parts of the world at the time.

The authors discuss the frequency of indication for and the results of CT and MRI brain scans in patients hospitalized in Vrapce Psychiatric Hospital. They wanted to contribute to the solving of the dilemma whether neuroradiologic tests should be a part of a routine diagnostic procedure in all psychiatric patients. Retrospectively, on the basis of case histories, the patients were analyzed in the first nine months of 2006. In this period 90 CT brain scans and two MRI brain scans were done, most often in the patients who were treated under the diagnoses of endogeneous psychoses, psychoorganic syndrome (dementia), affective disorders and epilepsy. Most CT findings (59%) and both MRI findings were normal. Abnormal findings were most often described as various forms of brain atrophy. Only one brain tumor was found. Electroencephalographic findings quite more often differed significantly from normal in the patients with abnormal CT findings compared with the patients with normal CT findings. The conclusion is that very small number of positive findings, except the brain atrophy, does not give good reason for routine CT and MRI brain scan in all hospitalized psychiatric patients. Indication must be made selectively on the basis of clinical psychiatric-neurologic evaluation. EEG, with limitations, can be of help in this matter.

The aim of this study was to determine the characteristics of psychiatric inpatients who committed suicide in the Vrapce Psychiatric Hospital with respect to clinical, ethical, and legal context. The study included all patients hospitalized in the Vrapce Psychiatric Hospital between 1 January 1996 and 31 December 2006 who committed suicide (n = 25). The suicide rate in the observed period was 32.9 per 100.000 (suicide coefficient, 50), which is similar that in general population. Based on the characteristics of hospitalized patients who committed suicide, we obtained a typical profile as follows: a middle- aged person, single, unemployed, repeatedly hospitalized, with schizophrenia and a history of suicide attempts, committing suicide using a violent method after more than three weeks of hospital treatment. If further prevention of hospital suicide will be treated as a legal rather than medical issue, the hospital atmosphere would be totalitarian rather than therapeutic. The success of psychiatric treatment is the perception of both of these aspects of suicide as well as their efficient balancing.

OBJECTIVE: To present the case of a patient with anxiety and depressive symptoms who developed the clinical picture of stiff-person plus syndrome (SPS-plus). BACKGROUND: Before the onset of typical SPS symptoms, psychiatric symptoms (like depression and anxiety) may be prominent and as such misleading, resulting in the diagnosis of a psychiatric condition. METHOD: We describe the case of a woman who initially presented with anxious depression and remained resistant to treatment with different classes of antidepressants and additional therapy with lithium and atypical antipsychotics. RESULTS: Evidence of neurologic dysfunction and significantly increased levels of serum autoantibodies for glutamic acid decarboxylase supported the diagnosis of SPS. The patient appeared to benefit from short-term immunosuppressive therapy with methylprednisolone. CONCLUSIONS: The authors believe that anxious depression and SPS-plus seen in this patient are the result of the same underlying autoimmune process, together forming a unique syndrome. Anxious and depressive symptoms in SPS can be explained by alterations in GABAergic neurotransmission.

It can be said that (re)integration of mental patients is the basic goal of psychiatry as a medical discipline. Throughout the history of psychiatry different approaches to treatment and rehabilitation of mental patients and their social (re)integration have been identified and monitored. There have always existed different impediments to the (re)integration of mental patients, as a manifestation of the times when treatment and rehabilitation took place. In the beginning of psychiatric development, the principal goal, in line with the social development and social awareness of human rights, was to isolate the patient away from his/her social environment and place him/her into a psychiatric hospital, preferably for life. Lately, as fighting for human rights grew into a matter of fashion and prestige rather than an ethical and legal issue, the media have often spoken about the human rights of mental patients and, explicitly or implicitly, advocated their social (re)integration. This cry for human rights of mental patients has virtually rooted out the advocates for permanent social isolation, even in this region. However, the Croatian media often give out the so called mixed messages when it comes to treating mental patients. This article analyzes such contradictory communication and attempts to offer certain solutions.