According to studies done in recent years regarding the treatment of patients with recurrent depressive disorder, a shift of interest from studies evaluating the effectiveness of therapy to the study of remission is seen. According to the literature, complete remission occurs in only 40–50% of patients, in other cases there is residual symptoms.

Evaluating the effectiveness of art therapy in treatment in patients with recurrent depressive disorder on the quality of remission.

The study involved 135 patients: 60 male and 75 female patients aged from 18 to 30 years old. The main group of patients apart the combined treatment also participated in group art therapy with the use of drawing techniques, while the control group – statutory standard therapy. We used clinical, psychopathological, psychodiagnostic and statistical methods.

The results of the effectiveness of art therapy in complex treatment in patients with recurrent depressive disorder is detected primarily in reducing of the level of anxiety at the early stages of treatment, as well as in reducing of the severity of anhedonia and improving the quality of life in remission period.

These results support the use of art therapy in treatment in patients with recurrent depressive disorder during period of active treatment, and after achieving clinical remission contributes to achieving and maintaining high-quality and stable remission with full restoration of quality of life and social functioning.

The authors have not supplied their declaration of competing interest.

The author has not supplied his declaration of competing interest.

The study focused on the level of expressed emotion of family members of schizophrenia patients prior to and during their long-term hospitalization and how that affected the course of treatment.

The retrospective study included 112 patients diagnosed with schizophrenia and their family members. The patients had been court-ordered to undergo psychiatric treatment for a crime they committed. The following scales were used to assess the level of expressed emotion: Five minute Speech Sample (FMSS), Level of Expressed Emotional Scale (LEE), Family Attitude Scale (FAS) and Perceived Criticism (PC). Socio-demographic parameters were also used in the research.

The results show that expressed emotion of family members was high before and during long-term hospitalization of 71.4% of patients who experienced clinical worsening. This is particularly true for parents (62.5%), and more frequently for mothers. Course of the illness was better in the group of patients whose family members had low expressed emotion.

Successful treatment and favourable outcome of schizophrenia depend on the quality of relationship between the patient and his family members. High level of expressed emotion is one of the risk factors for relapse in schizophrenia.

Tramadol, initially introduced in Germany in 1977, is a synthetic analgesic and appears to have a dual mechanism of action; a weak μ-opioid receptor agonism and a reuptake inhibition of serotonin and noradrenaline. It is marketed in Tunisia since 2001. Generally, Tramadol is considered to have a very low risk of dependence and abuse, but rare cases of tramadol dependence have been described in patients without prior substance abuse history. We describe one such case in a relatively young, otherwise healthy patient.

Mr AR, a 47-year-old man, presented to get help with tramadol addiction. He had no previous history of illicit drug use, did not smoke cigarettes or drank alcohol.

Mr AR was started on tramadol treatment about 2 years earlier for back pain. He did have better pain control with tramadol, but he gradually started taking more and more. Ultimately, his pain resolved but he was unable to stop taking tramadol: he was taking up to 1700 mg/d of tramadol and had made multiple efforts to stop. When he stopped taking tramadol, he had dysphoria, muscle cramps, anxiousness, restlessness, and a sensation of insects crawling all over his body. His withdrawal symptoms were severe enough to interfere with his work and family life.

Tramadol dependence is very rare but can happen in a patient without substance abuse history. We, as medical practitioners, should be open to the possibility of tramadol dependence and should resort to optimal and judicious use of such a substance.

Valproic acid (VPA) is a valuable treatment for bipolar disorder, schizoaffective disorder, and agitation1. However, potential side-effects include sedation, headaches, tremors, ataxia, gastrointestinal issues, neural tube defect, 3 and mild hyperammonemia even in normal liver function test 1 and VPA level.

To illustrate clinical presentation of VIHE and provide literature review on post-VIHE treatment options.

A 59-year-old male with PMH of Diabetes Mellitus, Hypertension, Hyperlipidemia, LVH, COPD, s/p CVA, and PPH of schizoaffective disorder, bipolar type. Patient stable on VPA 1250mg daily and Olanzapine 5mg daily for >2years until recent manic decompensation resulting to up-titration of VPA to 1500mg H.S. Thereafter, he presented with altered mental status, with VPA level (111.4 ug/ml), hyponatremia (119 mmol/L) and hyperammonemia (84 umol/L). Subsequently, admitted as a case of VIHE and hyponatremia.

VPA has shown to cause hyperammonemia alone or when combined with antipsychotics6. VIHE reported in up to 47.7% of patients on VPA1, but symptomatic in approximately 10% of patients on VPA with blood ammonia level about 2-fold the normal range8. VIHE presents with confusion, ataxia, blurred vision, delirium, and seizures3. Treatment options include VPA discontinuation, switch to other mood stabilizers (lithium carbonate, lamotrigine), utilization of medications to lower blood ammonia levels (Lactulose, Rifaximin/Neomycin) ,3 antipsychotic monotherapy, and supplements (Levocarnitine or Carglumic acid) in the prevention, maintenance, and treatment of VIHE. These supplements can be added to VPA if the benefits of re-initiating or continuing VPA outweighs the risk3.

Further research is needed.

No significant relationships.

As a result of long-term heroin abuse we can see impairment of cerebral structures that leads to specific deficits in cognitive and conative area. Reaction time(RT) is an interval between reception of the certain stimulus and movement execution, as a response to received stimulus. It includes unharmed perceptive functions, attention, concentra- tion and psychomotor coordination. The aim of this study was to evaluate the effect of heroin abuse on RT.

90 heroin addicts, divided in tree groups, regarding to abuse duration, were included in study. Reaction time was estimated by specially designed computer program, based on the modified Donders's model of reaction time.

Averige RT increase in corelation to duration of heroin addiction

Results have shown that heroin abuse is connected with the prolongation of simple and choice reaction time, in both visual and auditory modality. Also, there is significant relation between prolongation of choice reaction time and duration of heroin abuse.

Heroin abuse duration is related to decrease of psychomotor speed and impairment of psychomotor coordination.

To assess perception of stigma in patients suffering from combat-related posttraumatic stress disorder.

Sixty one veterans from 1991-1995 war in Croatia (mean age 43,8 years SD 6,3) with diagnosis of PTSD according to the 10th revision of the International Classification of Diseases hospitalized consecutively on acute psychiatric department during 6 months were assessed. Stigma was measured with Internalized Stigma Mental Illness inventory that has five subscales: Alienation; Stereotype Endorsement; Perceived Discrimination; Social Withdrawal and Stigma Resistance, and with Devaluation-Discrimination Scale both rated on four possibilities Likert scale: (1-strongly disagree to 4-strongly agree). Mississippi Scale for Combat-related PTSD was used to determine the severity of PTSD symptoms. It consists of 35 statements that are rated on a 5-point Likert scale (1 - “absolutely incorrect” to 5 - “absolutely correct”). A 100mm long visual analogue scales anchored with “not at all” and “very strongly” were used for assessing religiosity, social support and family problems caused with patient's illness.

Discrimination-devaluation scale was correlated with social support (r=0,373 p=0,003) indicating less discrimination with higher social support and with intensity of PTSD (r=-0,320 p=0,017). ISMI was correlated with intensity of family problems (r=0,299; p=0,019) and M-PTSD (r=0,588; p=0,001). Regression analyses indicated social support as significant predictor of less discrimination (R=0,570; p=0,021), and intensity of symptoms as predictor of high perceived stigma (R=0,653;p=0,001). Unsolved veteran invalidity status was associated with higher number of hospitalizations (t=2,097; df=59; p=0,042).

Stigma perception in PTSD depends on social support and intensity of the symptoms.

Risk-taking (RT) and self-harm (SH) occur across the lifespan, but many types of RT and SH typically appear for the first time in adolescence. According to Vrouva, Fonagy, and Fearon (2010), it is important to measure RT and SH simultaneously because they are clinically, empirically, and conceptually linked.

1. (1) analyse the prevalence of risk-taking and self-harm behaviours in community adolescents, controlling the effect of genderand age;

2. (2) examine the link between RT and SH behaviours;

3. (3) investigate the relationship between attachment style and RT and SH behaviours.

346 adolescents (girls: n = 194, 56%) aged between 12 and 18 years (M = 15.10, SD = 1.77) completed a sociodemographic questionnaire, the Risk-Taking and Self-Harm Inventory for Adolescents (RTSHIA) and the Attachment Questionnaire for Children (AQ-C).

RT behaviours more prevalent are taking chances while doing one’s hobbies, smoking tobacco and cheating. SH behaviours more frequent are self-demeaning thoughts and behaviours intentionally. Boys showed higher RT behaviours than girls. There is a positive association between age and both behaviours (RT and SH). Insecurely attached teenagers reported higher SH behaviours than did securely attached adolescents.

This study shows the prevalence of RT and SH behaviours in a community sample of adolescents, showing how gender and age can influence the expression of both behaviors. It seems that secure attachment may be protective to the engagement in SH behaviors, strengthening the important role of quality of relationships on psychological adjustment in adolescents

Depression is associated with the metabolic syndrome (MS). Recently, the concept of ‘metabolic depression’ has been proposed based on a protracted course of depressive symptoms over time.

Within the Netherlands study of depression in older persons, we examined whether metabolic dysregulation predicted the two-year course of depression.

A cohort study (n = 285) of depressed persons (≥60 years) with two-year follow up. Depression was classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Severity of depression was assessed with sum score as well as subscale scores of the Inventory of Depressive Symptomatology (IDS) at six-month intervals. The metabolic syndrome was defined according the National Cholesterol Education Program (NCEP-ATP III). We applied logistic regression and linear mixed models adjusted for a wide range of confounders and severity of depression at baseline.

The number of MS-components predicted non-remission at two-years (OR = 1.28 [95% CI: 1.00–1.58], P = 0.047), which was driven by waist-circumference, HDL-cholesterol and triglycerides. MS was only associated with the somatic symptom subscale score of the IDS over time, but not with its sum score (interaction time × somatic subscale, P = 0.002). This effect was driven by waist circumference, elevated fasting glucose level and hypertension.

Metabolic dysregulation predicts the course of late-life depression. This effect seems to be driven by visceral obesity (as indicated by the waist circumference) and lipid dysregulations and with respect to the somatic symptoms of depression.

The authors have not supplied their declaration of competing interest.

Sexual dysfunction is a common condition in patients taking antipsychotic medication, with a reported prevalence of 45-80% in males, and 30-80% in females (1). Ziprasidone induced spontaneous orgasm (2) and priapism (3) were reported in the literature. Here, we report a case of increased sexual arousal after ziprasidone treatment.

A twenty-three-year old, single, female patient was admitted to our clinic with reference and persecutory delusions, auditory and visual hallucinations. Her complaints had been persisting for about one month. Her mental status examination revealed the following: attention and concentration were diminished, speech was slow, delusions of reference and other Schneiderian first-rank symptoms, and hallucinations were present, reality testing was impaired, judgment and abstract thinking skills partially preserved. The patient was not able to tolerate her treatment due to side effects. Therefore, it was changed to ziprasidone 40 mg/day and the dosage was increased gradually. After increasing the ziprasidone dose to 60 mg/day, she complained about increased sexual arousal. No other symptoms suggestive of a manic episode were present, and no other medical causes were detected. The patient also said that she never had a similar period in her life previously. Ziprasidone was tapered slowly, and quetiapine 300 mg/day was started. She indicated that increased sexual arousal disappeared after the cessation of ziprasidone.

Ziprasidone has been reported to cause sexual dysfunction at a much lower rate than other antipsychotics. To the best of our knowledge, this is the first case report of increased sexual arousal with ziprasidone.

Assess prevalence and clinical relevance of 'with mixed features” using a more liberal (2 opposite pole symptoms) compared to the more conservative DSM-5 (3 opposite pole symptoms) threshold in depressed bipolar disorder (BD) patients.

BD outpatients were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Prevalence and clinical correlates of baseline depressive episodes 'with mixed features” were compared using a more liberal threshold and the more conservative DSM-5 threshold.

Among 503 BD patients, 151 (30.8%) had baseline syndromal major depressive episodes, among whom 'with mixed features” occurred in 22.5% (34/151) using a more liberal threshold, but in only 9.9% (15/151) using the more conservative DSM-5 threshold. Hence, the rate of 'with mixed features” for depressive episodes using the more liberal compared to the conservative threshold was more than twice (2.3 times) as high (Chi-square=8.8, p=0.004). Moreover, the more liberal threshold yielded more important statistically significant clinical correlates of 'with mixed features” compared to pure depressive episodes, which were not significant using the more conservative DSM-5 threshold. Specifically, using the more liberal threshold, mixed compared to pure depression was associated with more anxiety disorder comorbidity and alcohol use disorder comorbidity, and less antidepressant use.

Further studies are warranted to assess our preliminary observation that a more liberal 'with mixed features” threshold for bipolar depression may be more inclusive and have more clinical relevance.

To find out clinical and social factors contributing to specific female crimes - infanticide and neonaticide.

Psychopathological, psychological, statistical.

A cohort of 16 females who had killed their children was examined. All women were victims of violence by their husbands or partners. Domestic abuse resulted in long-term mental problems of women. Clinical assessment has revealed depression, anxiety, fear, PTSD, alcohol abuse.

There were two types of homicides. Women of the first subgroup (9) had committed infanticide and they displayed pathological altruistic motivation of the crime. Women of the second subgroup (7) had committed neonaticide. Alongside with clinical factors neonaticide reflects mostly social factors. Women of the second subgroup were younger and often exposed to psychogenic situations with high level of stress (financial and housing problems, concealment of illegitimate pregnancy, violence of the partner). In accordance with the Criminal Code of Russia the special article (106) governs infanticide and neonaticide. This law takes into account the psychogenic situation which caused the crime (battered women syndrome) and the fact that at the time of child murder the mental state of mother was affected by childbirth.

In cases of infanticide and neonaticide the court is free to make verdict more lenient and its reflects more humane approach to such complicate phenomenon as child murder.

Delirium is associated with poor outcomes and high mortality. Current research shows conflicting results regarding mortality rates in patients with delirium.

The aim was to examine the hazard risk associated with delirium in elderly medically ill patients at 1 year follow-up, controlling for baseline risk factors and interaction effects.

This was a prospective, observational, longitudinal study carried out in the medical wards of Sligo Regional Hospital. All acute medical admissions of patients 70 years old and over were approached. Each patient was assessed twice weekly for 2 weeks or until discharge. The following scales were used: CAM, DRS-98R, MoCA, Barthel Index, APACHE II. Primary outcome was time of death during 1 year. Cox proportional hazards were estimated and compared across patients who had delirium during hospitalisation and those who did not.

Two hundred patients agreed to take part in the study. The mean age of the studied sample was 81.13 (SD = 6.45; minimum 70 and maximum 100 years old) with 100 (50%) females. One hundred fifty four (77%) patients never developed delirium during hospitalization. Thirty four (17%) had delirium at admission and 12 (6%) developed prevalence delirium while inpatients. A total of 55 (27.5%) patients died during the one year follow-up. Significant risk factors for 1 year mortality were length of hospital staying, severity of illness (APACHE II), and cognition (MoCA).

Delirium was not found as an independent risk factor for 1 year mortality after controlling for other confounder variables.