Recently, suicides in Greece, have drawn national and international interest due to the current economic crisis. According to published reports, suicides in Greece have increased up to 40%. Specifically, lay press has highlighted Crete as an area with the sharpest increase of suicides in Greece.

To explore whether the economic crisis is associated with increased suicide rates in Crete.

To investigate the suicide rates in Crete between 1999-2011.

Data on suicides were selected from the Department of Forensic Medicine files of the University Hospital of Heraklion/Crete, as well as from the Forensic Medicine Files of Crete.

Our analysis showed that during the period examined (1) Crete, although has the highest suicide rate in Greece, there is no significant increase between 1999-2011, (2)Deaths due to suicide are four times more frequent in men compared to women, (3) In women there is a significant decrease of suicides, (4) There is a decreasing trend for suicides in Western Crete whereas, there is an increasing trend in Eastern Crete.

Crete has the highest suicide rates in Greece, which however, has not increased during the last 13 yrs. There is a relative increase of suicides in Eastern compared to Western Crete during this period. Our findings do not support the popular belief of increased suicides due to the current economic crisis. The relative increase of suicides in Eastern Crete may be explained by other factors, i.e the lack of community psychiatric services in the area.

To evaluate the long-term outcome of a multidisciplinary rehabilitation program for patients with chronic fatigue syndrome.

98 patients fulfilling chronic fatigue syndrome criteria (Fukuda) participated at a six-month CBT associated with GET based on adaptive pacing strategy in a group therapy and were included in a prospective outcome study at the university outpatient Chronic Fatigue Reference Center.

Multidimensional assessments at baseline, after treatment and at 6 and 12 months follow-up : Checklist Individual Strength; Epworth Sleepiness Scale; Pittsburgh Sleep Quality Index; HADS; Symptom Checklist; Short Form General Health Survey ands Self Efficacy Scale.

After the revalidation program, subjective outcome parameters as fatigue severity, concentration troubles, somatic complaints, sleep disturbances and behavioral consequences of fatigue as activity reduction improve significantly (p< 0,001). The QoL related to health perception, measured in items as vitality, role-physical limitations and social functioning, also improve significantly (p< 0,001). Treatment doesn’t change HADS-scales but the scores don’t differ significantly from a healthy population at baseline. At 6 and 12 months follow-up, we didn’t notice significant decreases in outcome results. Significant improvements correlate significantly with an increase of sense of control of the symptoms (Self Efficacy Scale).

Symptoms, health-related QoL and psychosocial functioning in patients with chronic fatigue syndrome improve after a six-month multidisciplinary rehabilitation program. The one-year follow-up study without any therapeutic intervention proves that outcome can be maintained. The correlation between the persisting outcome results and the increase of Self Efficacy will be discussed.

Pregabalin is indicated for the treatment of GAD in adults in Europe. The efficacy and safety of pregabalin for the treatment of adults and elderly patients with GAD has been demonstrated in 6 of 7 short-term clinical trials of 4 to 8 weeks.

To characterise the long-term efficacy and safety of pregabalin in subjects with GAD.

Subjects were randomised to double-blind treatment with either high-dose pregabalin (450-600 mg/d), low-dose pregabalin (150-300 mg/d), or lorazepam (3-4 mg/d) for 3 months. Treatment was extended with drug or blinded placebo for a further 3 months.

At 3 months, mean change from baseline Hamilton Anxiety Rating Scale (HAM-A) for pregabalin high- and low-dose, and for lorazepam ranged from -16.0 to -17.4. Mean change from baseline Clinical Global Impression-Severity (CGI-S) scores ranged from -2.1 to -2.3 and mean CGI-Improvement (CGI-I) scores were 1.9 for each active treatment group. At 6 months, improvement was retained for all 3 active drug groups, even when switched to placebo. HAM-A and CGI-S change from baseline scores ranged from -14.9 to -19.0 and -2.0 to -2.5, respectively. Mean CGI-I scores ranged from 1.5 to 2.3. The most frequently reported adverse events were insomnia, fatigue, dizziness, headache, and somnolence.

Efficacy was observed at 3 months, with maintained improvement in anxiety symptoms over 6 months of treatment. These results are consistent with previously reported efficacy and safety trials of shorter duration with pregabalin and lorazepam in subjects with GAD.

This study was funded by Pfizer Inc.

Pregabalin is indicated for the treatment of generalised anxiety disorder (GAD) in adults in Europe. When pregabalin is discontinued, a 1-week (minimum) taper is recommended to prevent potential discontinuation symptoms.

To evaluate whether a 1-week pregabalin taper, after 3 or 6 months of treatment, is associated with the development of discontinuation symptoms (including rebound anxiety) in subjects with GAD.

Subjects were randomised to double-blind treatment with low- (150-300 mg/d) or high-dose pregabalin (450-600 mg/d) or lorazepam (3-4 mg/d) for 3 months. After 3 months ~25% of subjects in each group (per the original randomisation) underwent a double-blind, 1-week taper, with substitution of placebo. The remaining subjects continued on active treatment for another 3 months and underwent the 1-week taper at 6 months.

Discontinuation after 3 months was associated with low mean changes in Physician Withdrawal Checklist (PWC) scores (range: +1.4 to +2.3) and Hamilton Anxiety Rating Scale (HAM A) scores (range: +0.9 to +2.3) for each pregabalin dose and lorazepam. Discontinuation after 6 months was associated with low mean changes in PWC scores (range: -1.0 to +3.0) and HAM A scores (range: -0.8 to +3.0) for all active drugs and placebo. Incidence of rebound anxiety during pregabalin taper was low and did not appear related to treatment dose or duration.

A 1-week taper following 3 or 6 months of pregabalin treatment was not associated with clinically meaningful discontinuation symptoms as evaluated by changes in the PWC and HAM A rating scales.

This study was funded by Pfizer Inc.

To measure changes in causal attribution in chronic fatigue syndrome. The cause of chronic fatigue syndrome (CFS) is still unknown. Behavioral, cognitive and affective factors may play a major role in perpetuating fatigue.

175 patients fulfilling Fukuda CFS criteria participated in a six-month CBT associated with GET based on adaptive pacing strategy, in a group setting. Causal attribution was measured with the Causal Attribution List (CAL). Therapy didn’t aim change in causal attribution. All patients were included in a prospective outcome study at the university outpatient Chronic Fatigue Reference Center (UCL), with multidimensional assessments at baseline and after treatment: Checklist Individual Strength (CIS); Short Form General Health Survey (SF36), Causal Attribution List (CAL).

At baseline, SFC patients were more likely to attribute their fatigue to physical than psychosocial causes (p< 0.001). After treatment, fatigue severity and behavioural consequences (CIS) and the most factors of health-related quality of live (SF36) improved significantly (p< 0,001). After treatment, patients had more causal attributions (CAL) than at baseline (p< 0,001). Correlation analyses indicated that improvement of subjective fatigue (CIS-severity, SF36-vitality) was not correlated significantly neither with physical or psychosocial causal attributions scores at baseline, nor with individual changes of physical or psychosocial causal attributions after treatment.

Causal reattribution is not necessary in chronic fatigue syndrome CBT. In our study (n=175) improvement of subjective fatigue is not correlated with changes in causal attribution. The advantages of abstention from causal reattribution in psychosomatics will be discussed.

Epistatic effects between gene variants of 5-HTTLPR (L=long, S=short), MAOA-VNTR (L=long, S=short), and BDNF Val/Met have been found with regard to behaviour in experimental animals as well as indicated in human samples in relation to neuroticism and depression. In the present study we studied epistatic effects of the above gene variations in an interaction with environmental adversity on adolescent criminality.

Family maltreatment, sexual abuse and criminality were measured by self-reports in a Swedish adolescent population-based sample (n=1819). Genomic DNA was isolated from saliva and used for genotyping of the BDNF, the 5-HTT and MAOA genes.

BDNF genotype showed a main effect on adolescent criminality. BDNF also showed a two-way interaction with 5- HTT and Family maltreatment. 5HTT showed two-way interactions with MAOA and Family maltreatment. MAOA also showed a two-way interaction with Family maltreatment. Significant three-way interactions were found for; BDNF-5-HTT-Family maltreatment; BDNF-MAOA-Family maltreatment; BDNF-MAOA-Sexual abuse; and 5HTT-MAOA-Family maltreatment. Significant four-way (G*G*G*E) interactions were found for BDNF-5-HTT-MAOA-Family maltreatment and BDNF-5-HTTMAOA- Sexual abuse, respectively.

Boys showed a stronger effect of environmental adversity compared to girls. However, there were no significant sex-gene interactions. Furthermore, the two most genotypically divergent groups, according to expression levels, showed the highest criminality scores (MAOA-LL + 5-HTT-LL + BDNF Val-Val vs. MAOA S/LS + 5-HTT-S/LS + BDNF Val-Met/Met-Met), when exposed to environmental adversity.

There are significant epistatic effects between 5-HTT, MAOA and BDNF genotypes and environmental adversity for criminal behavior. Two distinct “types” can be recognized with regard to genotype.

Therapeutic Drug-Monitoring (TDM) for bupropion is limited by bupropion's instability at room temperature and by the absence of a well-defined therapeutic reference range. Further it is unclear to what extent bupropion and its metabolites contribute to therapeutic effects, though hydroxybupropion seems to account for the major antidepressant effects.

The aim of this examination was to check if measurement of only hydroxybupropion is useful to guide the antidepressant therapy with bupropion.

Hydroxybupropion plasma levels were measured by high performance liquid chromatography with ultra violet detection and related to therapeutic effects measured by the Clinical Global Impression Scale for improvement.

The study included 52 patients (50% female). Patients who were very much improved according to CGI had significantly (p=0.042) higher hydroxybupropion serum levels than patients with moderate or minimal improvement (mean±SD, 1113±576 ng/ml, 825±398 ng/ml and 475±331 ng/ml, respectively). Receiver operating characteristics analysis revealed significant predictive properties of hydroxybupropion serum levels (p=0.002) for improvement with a lower threshold level of 858 ng/ml. Women attained significantly higher serum levels than men and also exhibited a better therapeutic effect (p= 0.018), though they did not receive significantly higher doses.

Measurement of hydroxybupropion plasma levels can be used to optimize the therapeutic outcome of patients treated with bupropion. Plasma levels between 850 and 1500 ng/ml can be regarded as optimal. Potential sex differences in bupropion pharmacokinetics, probably due to differential activities of CYP2B6, should be taken into account.

We investigate, in 36 STN DBS PD patients, depression, anxiety and mania at baseline, 3-mounth post-surgery and 6-mounth post-surgery. At baseline, demographic data and clinical characteristics (duration of disease, PD medication, past psychiatric history were also collected. Scores at motor section of the unified Parkinson disease rating scale and PD medication were evaluated at baseline, 3-mounth post-surgery and 6-mounth post-surgery. A multivariate analysis and a factorial discriminant analysis (FDA) were considered to study differences between surgical outcomes considering an adjustment on disease duration.

Thirty six patients with Parkinson's disease treated with STN-DBS were analyzed considering stimulating electrodes localization (‘in’, ‘frontier’, ‘out’ of STN).

Concerning the pre-surgical parameters, no configuration was found.

Considering only 3-mounth post-surgery parameters (electrodes localization, motor scores, psychiatric data, PD medication) patients differ according to surgical positioning: ‘frontier’/’out’ and ‘in’ but the best separation between the 3 groups of localization was obtain including pre-surgical post-surgery parameters. This segregation was maintained at 6-mounth postsurgery.

Our work provides preliminary answer to the question of impact of the exact electrode position on neuropsychological side effects of STN-DBS and enhances the importance of combining pychiatrico-neuro-surgical data.

The aim of the study was to identify sociodemographic, clinical and service delivery risk factors for suicide in the population of service-users (SUs) and non-service users (NSUs) plus gender-related characteristics of suicidal behaviour; in a limited geographic region.

Data were collected on 68 cases of suicide (ICD-10 X60-X84) for residents on the Isle of Wight between January 2006 and December 2009.

Significantly (p=0.0006) more men than women (male/female ratio 3:1) died by suicide. Relatively (p=0.07) more women (56.2%) than men (32.7%), and significantly more (p=0.05) SUs (45.3%) than NSUs (13.3%) were unemployed. Significantly more (p=0.0006) SUs (64%) than NSUs (20%) had a history of suicide and relatively (p=0.06) more (50.9%) SUs than NSUs (20%) had attended the A & E prior to their death. 69% had an adverse life event within a year prior to their suicide. Depression was significantly (p=0.008) more frequent in women (66.6%) than men (23.7%). Suicide by hanging was the commonest cause acounting for death of 71% of men and 50% of women. 57.3% of deaths occurred at their place of residence and 75% of on weekdays. 50% of women died in autumn, compared to 28.8% of men. There were three inpatient deaths (4.4%). Relatively (p=0.08) more women (56.2%) than men (32.7%) have contactacted serivces before their death.

80% suicides were conducted by people suffering from a mental disorder. Men are at a significant risk of suicide. Anxiety disorders in men and depression in women are the most common mental disorders.

NMS is an infrequent, life-threatening neurologic emergency usually associated with the use of neuroleptics and some other agents that affect central dopaminergic neurotransmission. Because of its low frequency, heterogeneous nature and clinical variability it might be difficult to diagnose.

To identify risk factors to develop a NMS and to set effective treatments.

Literature search was performed in PubMed and UpToDate. Report of a case at our center: 69 year old man with psychotic depression which do not improve with optimal doses of SSRIs, Mirtazapine and Benzodiazepines. Olanzapine (10mg) was added and symptoms compatible with a neuroleptic malignant syndrome were appeared. Supportive care was needed because of medical complications. A treatment with bromocriptine, sertraline, lorazepam and dantrolene was begun with little improvement. It was decided to begin ECT.

It was applied a ECT therapy (12 bifrontotemporal sessions, 380mCu) with a high and effective response. Pshycosis and pshycomotor symptoms disappeared and depression decreased significantly.

Hence a high index of suspicion is needed in the diagnosis of NMS in order to reduce mortality and secuelae. Differential diagnosis must be performed with confusional states due to medical cause, catatonia, serotoninergic syndrome and other neurologic states. As for the treatment, general support meassures and several farmacologic options have been used, though none of them have proved to decrease mortality. ECT remains a good option for improvement of the syndrome as well as the pychiatric condition. No systematic clinical trials evaluating the efficacy of different treatments have been done so far.

Aberrant salience consists of the unusual or incorrect assignment of salience, significance or value to different innocuous stimuli. It has been hypothesized that subjects with an aberrant salience could be proneness to develop psychosis. Despite the importance of this concept in psychosis, only few instruments assess aberrant salience.

To evaluate aberrant salience processing in a clinical trans-diagnostic sample and its relationship with psychotic symptoms.

Thirty-six outpatient subjects attending the Psychiatric Unit of the University of Florence were recruited: 9 with Major Depression Disease (MDD), 8 with Schizophrenia (SC), 19 with Bipolar Disorder (BD). Patients were assessed by means of a clinical interview (SCID-I/P) and several questionnaires, including the Aberrant Salience Inventory (ASI).

The three groups showed significant differences in the lifetime presence of psychotic symptoms, with higher frequency in BD and SC patients (p< 0.01). Significant differences in ASI scores were found between MDD and BD (p< 0.01), and SC and BD (p< 0.01), while any difference between BD and SC was observed. Subjects with positive ASI (cut-off>14) reported more frequently past and lifetime psychotic symptoms (p< 0.01) and constituted a distinct cluster from patients with ASI score < 14.

Aberrant salience is significantly associated to lifetime psychotic symptoms. Thus it represents a relevant psychopathologic dimension that requires a careful investigation in patients with an history of psychotic events. The ASI could represent an useful instrument to evaluate the proneness of clinical and pre-clinical samples to develop psychotic symptoms.

Since 1960, a decade after the introduction of phenothiazine drugs, there were reports of drug related ocular opacities and pigmentation in patients who had been receiving continuous high dose therapy, particularly with chlorpromazine. These ocular effects seem to be related to high doses of phenothiazines and are potentially irreversible. The purpose of our study is to evaluate the pathophysiology of ocular damage, risk factors, treatment and any potential reversibility.

Bibliographic research used PubMed and PsychINFO and conduced to 12 papers.

Analysis of papers has shown that the main pathophysiological mechanism is related to an alteration of excretion of catecholamines, that exposure to sunlight presents a risk factor for the development of corneal deposits and cataract while, as regards the reversibility of these effects, the data are still controversial.

It is necessary, for psychiatrists, the information of the various ocular adverse effects of therapy with phenothiazine so that can be arranged to create a closer and more effective collaboration with an ophthalmologist to prevent and treat this disease.

Moreover, other studies are necessary to lead to an appropriate treatment plan.

Even though 0.3-0.8% percent of the male population are born with hypospadias, it is not known if this is associated with an increased risk for psychiatric morbidity later in life.

The aim of this study was to assess the association between hypospadias and risk of psychiatric disorders in affected individuals.

The association between hypospadias and psychiatric disorders was examined in a population-based cohort study using Swedish registers. Individuals born in Sweden between 1973 and 2009 were included in the study. Among them, 11,156 patients with hypospadias were identified and matched with 1,098,714 distinct controls by year of birth and county. The following outcomes were evaluated: 1- suicide attempt, 2- psychotic, 3- mood, 4-anxiety, 5- eating, 6- personality disorders, 7- disorders due to psychoactive substance use, 8- ADHD, 9- pervasive developmental disorders, 10- intellectual disabilities, and 11- other childhood emotional disorders.

After adjusting for socio-economic and perinatal factors, malformations and/or genetic syndromes, patients with hypospadias were more likely to be diagnosed with pervasive developmental disorders (OR 1.4; 95% CI 1.1-1.6), intellectual disabilities (OR 1.8; 95% CI 1.6-2.1), ADHD (OR 1.2; 95% CI 1.0-1.4) and other childhood emotional disorders (OR 1.3; 95% CI 1.1-1.4) compared to the controls. No relation between other psychiatric diagnosis and hypospadias was found.

Hypospadias is associated with an increased risk of neurodevelopmental disorders.

Restless legs syndrome (RLS) is a sensorimotor disorder characterized of an urge to move the legs during periods of rest or inactivity, such as lying or sitting.

Drug-induced RLS, still remains an under- or misdiagnosed condition.

We present a case of a female patient, who received a combination of low dose of quetiapine in addition to venlafaxine and manifested RLS.

Our patient was admitted because of a mixed episode of bipolar II disorder. At admission she was under valproic (1.5gr/QD, plasma levels: 79mg/litre), topiramate (100mg/QD) and venlafaxine (300mg/BID). Quetiapine 150 mg/QD was started at bed time and within 48 hours the patient showed RLS. The physical, neurological and laboratory examination was normal.

The tapering of venlafaxine resulted in the elimination of RLS within 48 hours. After discharge the patient remained in a normothymic state, without RLS, taking valproate 1,5gr/QD, topiramate 100mg/QD and quetiapine 150mg/QD. After 6 months, because of depression, quetiapine was reduced to 100mg/QD and venlafaxine 75mh/QD was added. The previously described RLS symptoms emerged again within 48 hours. This time the tapering of quetiapine and its substitution by olanzapine 10 mg/QD resulted in a prompt and complete elimination of RLS symptoms.

Neither quetiapine alone, nor venlafaxine alone induced RLS to our patient. Clinicians should not overlook the possibility a RLS to be induced by quetiapine-vanlafaxine combination. The removal of one of the two drugs might be beneficial in the RLS's successful treatment.

The association between depression and metabolic syndrome is becoming more obvious.

We examined the relationship between the number and individual components of metabolic syndrome and late-life depressive symptom clusters.

In 1279 individuals aged 50 through 70 participating in the Nijmegen Biomedical Study (Cross-sectional populationbased survey), we measured all metabolic syndrome components and depressive symptoms using the Beck Depression Inventory (BDI). Principal components analysis of BDI-items yielded two factors, representing a cognitive-affective and a somatic-affective symptom-cluster. Multiple regression analyses adjusted for confounders were conducted with BDI sum score and both depression symptom-clusters as dependent variables, respectively. We explored the differences in this association between men and women.

In fully adjusted models, both presence of the metabolic syndrome as well as number of components was associated with the BDI sumscore(resp. β=0.063;p=0.022 vs. β=0.112;p< 0.001), the latter showing the strongest association. These associations were primarily driven by the somatic-affective symptom-cluster. Testing individual components of the metabolic syndrome, showed that in men waist circumference, triglycerides and HDL cholesterol were significantly associated with depression, whereas in women only the waist circumference.

The specific association somatic-affective symptoms suggest confounding by a (subclinical) somatic condition in stead of a real association with classical depression. The identified sex-differences suggest different pathways between depression and metabolic perturbations in men only. However, as vascular disease develops at higher ages in women and findings were in the same direction but non-significant in women, future research in older women sample should confirm our findings.

PERDOVE study is a prospective observational cohort study, which providing follow-up at one year, aims to investigate the socio-demographic and clinical characteristics of patients in in the 23 medium-long term RFs of the St John of God Order.

1. (1) To describe the sociodemographic, clinical, and treatment-related characteristics of RF-patients during an index period in 2010;

2. (2) to identify predictors and characteristics associated with discharge at 1-year follow-up;

3. (3) to evaluate clinicians’ predictions about each patient's likelihood of Home Discharge (HD).

All patients staying in September 2010 with a primary psychiatric diagnosis received a set of standardized assessment instruments, including a “Patient Schedule”, BPRS, HONOS, PSP, PHI, and SLOF. Detailed socio-demographic and clinical data were also collected. Logistic regression analyses were run to identify independent discharge predictors.

The study involved 403 patients. 66,7% is male, mean age is 49 (±10). 70.7% is unmarried. The average duration of illness of these patients is 23 years. Primary diagnosis is represented by schizophrenic spectrum disorders (67.5%). At 1 year follow-up, 104 patients (25.8%) were discharged: 13.6% to home, 8.2% to other RFs, 2.2% to supported housing, and 1.5% to prison.

The main variables associated with a higher likelihood of being discharge to home were: to have an illness duration of less than 15 years and to have an available and effective social support in the last year. Lower severity of psychopathology, and higher working skills were also associated with a significantly higher likelihood to be discharged to home.

Before fulfilling the criteria for anorexia nervosa syndrome, many young females already display symptoms of dysfunctional eating attitudes and behaviour. If also accompanied by increased perfectionism and body shape concerns and dissatisfaction, this can indicate a high-risk group for eating psychopathology.

The study group consisting of 45 randomly selected female students of University of Belgrade, mean age of 22.27 years (min 19, max 27), scored above the cut-off of 30 on the Eating Attitude Test (EAT-40), indicating symptoms of anorexia nervosa.The Frost Multidimensional Perfectionism Scale (FMPS), which measures different dimensions of perfectionism, and the Body Shape Questionnaire (BSQ), which evaluates body concerns and dissatisfaction, were applied, and the Quetelet Index (QI) was calculated.

Descriptive statistics indicate as follows: EAT (M=42.71; SD=13.541), FMPS (M=104.80; SD=14.609), BSQ (M=100.69; SD=29.215), QI (M=21.21; Min 15.64, Max 29.38). Only 24.4% (N=11) of the students were not concerned with body shape. 80% of the study group were of normal weight, 11.1% were underweight, 8.9% were obese, and one member of the group (2.2%) had QI=15.64, indicating anorexia nervosa syndrome. Correlation analysis indicates that there is a positive correlation (r=,393) between perfectionism scores and concerns about body shape (p< 0.01).

Our results confirm previous research on the positive correlation between perfectionism and body shape concerns in females with disturbed eating attitudes and behaviour.This means that these features should be systematically assessed in female students and focus be given to prevention campaigns against eating psychopathology.

Many cross-sectional studies have explored the relationship between subjective QOL of people with schizophrenia and different socio-demographic characteristics, clinical and psychosocial factors. Only few studies tried to identify factors that influence the QOL of these patients using a longitudinal design.

Aim of the present study was to determine influence of clinical factors, socio-demographic variables, spirituality and satisfaction with services on QOL, to identify clinical predictors associated with quality of life at one year follow-up.

Measures at baseline included: demographics, BPRS, PHI, RBANS, FPS, HoNOS, SWBS, VSSS, and the Italian version of the WHOQoL-Brief. Measures at follow up included: HONOS, BPRS, FPS, WHOQoL-Brief. Logistic regression models were adopted to evaluate the association between WHOQoL-Brief scores and patient's sociodemographics, clinical characteristics, spirituality and services’ satisfaction.

The study included 171 patients: 64% males; mean age 48.7 (sd=8.9) with primary diagnosis of schizophrenia. Different domains of QOL were predicted by different indicators at baseline. Younger age, more time spending doing nothing, lower BPRS, lower satisfaction with services were explanatory variables for low quality of life in psychological facet. Spirituality and religiousness were associated with Environmental domain and VSSS was associated to all QOL domains.

Rehabilitation plans for people with schizophrenia living in RFs should pay attention to mediators of change in subjective QOL such as level of activities, social support, spirituality and satisfaction with mental health services. In particular, anxiety and depressive symptoms remain as long-term outcomes of QOL at one year follow up.