OBJECTIVE:The DSM-5 Alternative Model for Personality Disorders (AMPD) and Kernberg's object relations theory are prominent frameworks for assessing personality dysfunction. This study investigates their structural overlap and evaluates their specific capacity to predict clinical outcomes using a multi-method approach. METHODS:A sample of 189 Hungarian psychotherapy inpatients (127 females, 55 males, 7 undisclosed; mean age = 34.0 years) were assessed using four personality dysfunction measures (SCID-5-AMPD, STIPO-R, LPFS-BF, IPO) alongside measures of functional impairment (WSAS) and alcohol use risk (AUDIT). Confirmatory Factor Analysis (CFA) and Structural Equation Modelling (SEM) evaluated latent structures and predictive validity. RESULTS:CFA supported a model with three distinct latent constructs: levels of self-functioning, interpersonal functioning, and personality organisation, alongside specific method factors. SEM revealed distinct predictive patterns: general functional impairment was uniquely predicted by descriptive self-functioning, while alcohol use risk was associated with the level of personality organisation. However, these findings are limited to a low-risk inpatient psychotherapy sample and should not be generalised to broader substance-dependent populations. CONCLUSIONS:The AMPD and Kernberg models are complementary rather than redundant. Assessing both descriptive functioning and dynamic organisation via a multi-method approach provides a more comprehensive, clinically actionable understanding of personality pathology and specific behavioural risks.
INTRODUCTION:Capgras syndrome (CS) is a recurrent and transient delusional misidentification disorder in which an individual is firmly convinced that a familiar person has been replaced by an identical impostor. The aim of the study was to evaluate neuropsychiatric characteristics of CS in a cohort of patients with Alzheimer's disease (AD). METHODS:150 participants [84 (56.0%) women, mean age 77.4 ± 7.5 years)] were collected within the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer disease (CATIE-AD). According to the Neuropsychiatric Inventory, patients were classified into Capgras+ and Capgras-. RESULTS:Fifty-five (36.7%) AD patients were Capgras+. CS was strongly associated with other misidentification syndromes including phantom boarder (p < 0.001) and misidentification of places (p < 0.001). Moreover, Capgras+ were presented more frequently with agitation (p = 0.036), depressive (p = 0.018) and anxious (p = 0.004) symptoms, and aberrant motor behaviours (p = 0.020). CONCLUSIONS:According to our findings, CS was not an 'isolated' phenomenon but rather a complex neuropsychiatric syndrome frequently associated with other misidentification syndromes and specific behavioural disturbances.
OBJECTIVE:Regulatory frameworks governing artificial intelligence (AI) in medical practice vary widely across European Union (EU) member states. We assessed the extent to which national medical bodies' codes of conduct address the clinical use of AI. METHODS:Codes of conduct issued by national medical regulatory bodies in EU member states were analysed and rated for AI-specific content using a four-point scoring system. RESULTS:Six countries (Belgium, France, Germany, Lithuania, Poland and Spain) had established AI-specific guidance within their medical ethical frameworks, with scores of 3 to 4; the remaining member states had none. France and Belgium showed the most progressive approaches, emphasising innovation while maintaining ethical standards, whereas Germany and Poland were more conservative, imposing stringent requirements for AI deployment in clinical settings. EU-wide instruments such as the AI Act and the High-Level Expert Group (HLEG) guidelines provide overarching frameworks but do not address the codes of medical practice that govern day-to-day clinical decision-making in member states. CONCLUSION:The heterogeneous landscape reflects the challenge of balancing technological advancement with patient safety. Harmonised national ethical guidelines and closer collaboration between medical regulatory bodies are needed to support responsible AI adoption while preserving ethical practice across the EU.
OBJECTIVE:Deep brain stimulation (DBS) is used to treat movement disorders, but it is rarely used for psychiatric indications. We aim to demonstrate clinical effects in randomised-controlled trials (RCTs) of DBS for clinically used neurological and psychiatric indications. METHODS:We searched databases for RCTs conducting blinded comparisons of active to sham DBS for: obsessive-compulsive disorder (OCD), major depressive disorder (MDD), Gilles-de-la-Tourette syndrome (GTS), Parkinson's Disease (PD), essential tremor (ET), dystonia (DYT) and epilepsy (ED). We compared 28 studies with a meta-analytic approach of the indication-specific scores. RESULTS:For psychiatric indications, we found a standardised mean difference (SMD) of -0.22 for MDD (p = .204), a SMD of -0.72 for OCD (p = .004) and a SMD of -1.22 for GTS (p = .014). For neurological indications, we found a SMD of 0.74 in PD (p < .001), a SMD of -1.42 in ET (p = .0003), a SMD of -0.71 for DYT (p = .006) and a SMD of -0.09 for ED (p = .790). CONCLUSIONS:Effect sizes in clinical trials were highest in ET in neurology and in GTS in psychiatry. These results underscore that wider clinical use in the psychiatric indications OCD and GTS is justifiable.
OBJECTIVE:To examine associations of chronotype and social jetlag (SJL) with psychiatric symptoms and melatonin secretion in healthy adults. METHODS:In this cross-sectional study, 95 relatively young, university-affiliated students and staff completed the MEQ, SCL-90-R, MCTQ and a one-week sleep diary. SJL was defined as the workday-free-day difference in midsleep. Overnight workday urinary 6-sulfatoxymelatonin (6-SMT) was assayed by ELISA and indexed to creatinine. RESULTS:Evening chronotypes had longer SJL than intermediate and morning chronotypes (F = 16.70, p < .001). Higher MEQ scores were associated with shorter SJL and earlier midsleep (r = -0.54 to -0.66, all p < .001). Total SCL-90-R scores did not differ across chronotypes (p = .367), whereas obsessive-compulsive symptoms were higher in the evening group (p = .027). Urinary 6-SMT/creatinine did not differ by chronotype (F = 0.823, p = .442) or relate to SJL; BMI correlated inversely with 6-SMT (r = -0.21, p = .043). Lower MEQ scores independently predicted longer SJL (B = -2.82, β = -0.54, p < .001). CONCLUSIONS:Eveningness was associated with greater SJL and obsessive-compulsive symptoms, whereas overnight 6-SMT was not linked to chronotype or SJL. The inverse BMI-6-SMT association may suggest metabolic relevance.
OBJECTIVE:To evaluate whether the pan-immune-inflammation value (PIV), derived from blood parameters, can distinguish first-episode psychosis (FEP) from healthy controls (HCs) and to compare its performance with other indices. METHODS:In this retrospective study, 68 drug-naïve patients with FEP and 83 healthy controls were included. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), C-reactive protein-to-albumin ratio (CAR), and PIV were calculated from complete blood count and biochemistry. Receiver operating characteristic (ROC) analysis identified the optimal PIV cut-off, and its diagnostic value was tested using univariate and multivariate logistic regression. RESULTS:Mean PIV values were 378.10 in the FEP group and 170.07 in HCs, with significantly higher levels in patients (p < 0.001). PIV showed the highest discriminative ability (The area under the ROC curve (AUC) = 0.755 (95% CI: 0.674-0.837)). A cut-off of 170.7 yielded 75.0% sensitivity and 72.3% specificity. Individuals with PIV ≥ 170.7 had increased odds of FEP (univariate OR = 7.83; multivariate OR = 9.31 after adjustment for age and sex; p < 0.001). Other indices were also significant but showed lower AUCs. CONCLUSION:PIV may outperform traditional inflammation indices in distinguishing drug-naïve FEP patients from HCs and could support risk stratification.
INTRODUCTION:Autism Spectrum Disorder (ASD) affects around 1% of the population, and its diagnosis is primarily clinical. Therefore, the study of biological markers is essential. The retina and optic nerve have been studied in many ocular and non-ocular diseases using non-invasive techniques such as Optical Coherence Tomography (OCT) and OCT Angiography (OCT-A). METHODS:A systematic literature search was performed using the Covidence® platform across promimnent databases including PubMed, PsycINFO and Embase up to February 2023. RESULTS:The analysis of the included studies revealed differences in retinal parameters between individuals with ASD and neurotypical controls (NT). These variations encompassed changes in macular thickness and volume, RNFL thickness and volume, and in vascular perfusion and vessel density. Furthermore, certain changes were found to be correlated with clinical measures of ASD features. CONCLUSIONS:Current evidence reported diverse changes in neuroretinal parameters in ASD individuals. OCT and OCT-A have shown promising results in evaluating neuroretinal alterations in individuals with ASD. These techniques hold potential as biomarkers for early detection and monitoring of ASD. However, further research is necessary to fully explore the diagnostic and therapeutic potential of OCT and OCT-A in ASD population.
OBJECTIVES:Depressive symptoms are common in schizophrenia spectrum disorders and may influence how patients engage with treatment. This study examined whether depressive symptom severity affects motivation for treatment or satisfaction with inpatient care in patients with schizophrenia spectrum disorders. METHODS:A total of 48 inpatients were divided into two groups: no or mild depressive symptoms (Group 1; N = 24) and moderate to severe depressive symptoms (Group 2; N = 24). Symptom severity was assessed at admission and discharge using the Hamilton depression rating scale and the positive and negative syndrome scale. Attitudes towards treatment (FPTM) were assessed at admission, and treatment satisfaction (ZUF-8) at discharge. RESULTS:Treatment satisfaction was generally high and did not differ between depressive symptom groups. Greater depressive symptom severity was associated with higher mental distress. Higher initiative to engage in psychotherapy correlated positively with treatment satisfaction. Older age was also associated with greater satisfaction. CONCLUSIONS:Treatment satisfaction in schizophrenia spectrum disorders appeared largely independent of depressive symptom severity. In contrast, patients' motivation to engage in treatment was closely related to satisfaction, suggesting that motivation may play a more decisive role in shaping treatment experience than symptom severity alone. Early support of treatment motivation and further integrative research are warranted.
OBJECTIVE:Premature termination of treatment (PTT) is prevalent among patients with eating disorders (ED) and post-traumatic stress disorder (PTSD). PTT is associated with negative outcomes. This study examined whether variables collected at admission and during hospitalisation predicted PTT among female patients treated for PTSD and/or EDs. METHOD:A total of 76 women hospitalised between 2019 and 2023 at the 'By Your Side' inpatient facility participated. PTT was defined as unplanned discharge without re-admission. Quantitative measures were analysed using t-tests and U-tests; qualitative measures were assessed using chi-square tests, followed by binary logistic regression. RESULTS:A total of 97% of participants met DSM-5 Criterion A for trauma; 96% were diagnosed with PTSD, 74% with an ED and 70% with both. 43.4% terminated treatment prematurely. PTT was significantly associated with sexual risk-taking behaviours (χ2 = 4.601, df = 1, p = 0.032), impulsive departures from treatment (χ2 = 7.165, df = 1, p = 0.007) and fewer prior hospitalisations (B = 0.535, df = 1, p = 0.026). No differences were found in socio-demographic or clinical symptom scores. Outcomes were comparable between patients who left treatment and returned and those who remained continuously. CONCLUSIONS:Findings highlight the need to address impulsivity and risk-taking behaviours, and to support therapeutic re-engagement.
OBJECTIVE:To examine psychiatrists' prescribing patterns, attitudes, and knowledge regarding clozapine use in Saudi Arabia, and to identify factors associated with clozapine prescribing. METHODS:A cross-sectional survey was distributed to psychiatrists and trainees across Saudi Arabia between January and June 2024. The questionnaire assessed demographics, prescribing patterns, attitudes, and clinical decision-making regarding clozapine. Descriptive statistics summarised responses, and comparisons between consultants and trainees were conducted using chi-square and t-tests. Binary logistic regression was applied to identify independent predictors of clozapine prescribing. RESULTS:Ninety-seven psychiatrists participated; 69.1% had prescribed clozapine during the previous year. Consultants were significantly more likely than trainees to prescribe clozapine (p = 0.012). The majority (79.4%) agreed that clozapine is the most effective antipsychotic, yet 71% viewed its initiation as an administrative burden. Only 42.3% reported confidence in managing side effects, and 36.1% indicated access to clozapine-specific clinics. Logistic regression showed that perceiving clozapine initiation as an administrative burden significantly reduced the likelihood of prescribing (B = -1.44, p = 0.045, OR = 0.24, 95% CI = 0.06-0.97). CONCLUSIONS:Despite high awareness of clozapine's efficacy, administrative and structural barriers continue to limit its use among psychiatrists in Saudi Arabia.
BACKGROUND:Differences in blood cells and inflammatory markers occur during the first psychosis episode. Our study compared blood cell counts and inflammation markers among bipolar disorder, schizophrenia spectrum and healthy controls. METHODS:The study involved 55 patients with schizophrenia spectrum disorders and 68 with bipolar disorder with psychotic features (manic episode), all hospitalised for a first psychotic episode with no prior psychiatric treatment, along with 61 age- and sex-matched healthy controls. Hemogram data from medical records were used, specifically those obtained within the first 48 h of hospitalisation. RESULTS:Both patient groups had higher white blood cell, neutrophil, and monocyte counts than healthy controls. Patients with bipolar disorder had lower red blood cell counts, while schizophrenia patients showed lower eosinophil levels. Both groups also had elevated monocyte-to-lymphocyte ratios (MLR) compared to controls. No significant differences in blood cell counts or inflammatory markers were found between bipolar disorder and schizophrenia spectrum groups. CONCLUSIONS:Subtle Immune changes, including elevated MLR, monocytes and neutrophils, are observed in first-episode psychosis patients with bipolar disorder and schizophrenia spectrum diagnoses. Condition-specific findings, like decreased RBCs in bipolar disorder and eosinophils in schizophrenia, suggest unique early haematological profiles. These indicate low-grade inflammation may contribute to early psychotic disorders and underline the need for more longitudinal research.
OBJECTIVE:Pharmacotherapy guideline concordance for the treatment of major depressive disorder (MDD) is associated with improved symptom severity, but it is unclear whether such associations vary by patients' characteristics or their comorbidity burden. We sought to determine whether guideline concordance varied significantly by 1) sociodemographic characteristics or 2) comorbidity. METHODS:This study evaluated 1,403 U.S. adults (67% female, 85% non-Hispanic/Latino White, mean age of 43 years) with non-psychotic MDD and complete data (n = 1,241/1,403). We used a guideline concordance algorithm (GCA-8) to measure pharmacotherapeutic concordance with the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines and multivariable general linear and proportional odds models to examine associations between this GCA-8 score and patients' characteristics. RESULTS:Being male was significantly associated with higher guideline concordance, but guideline concordance did not vary significantly by any other sociodemographic characteristics. Similarly, no comorbidities examined by this study presented substantial evidence of associations with guideline concordance. Within this sample, the GCA-8 algorithm consistently measured the degree of guideline concordance across different patient types. CONCLUSIONS:This study suggests that guideline concordance for MDD pharmacotherapy, as measured by the GCA-8, does not significantly vary by the comorbidities or sociodemographic characteristics analysed in this study, except for patient-reported gender.
OBJECTIVES:To investigate the potential role of atomoxetine in triggering manic episodes in a patient with ADHD and to explore diagnostic and therapeutic challenges posed by overlapping symptoms, temperament traits, and polypharmacy. METHODS:We report the case of a 20-year-old male diagnosed with ADHD in childhood and treated long-term with atomoxetine and risperidone. Following a depressive episode after bereavement, the patient developed manic symptoms. The relationship between atomoxetine use, medication adjustments, temperament traits, and symptom onset was evaluated. The Naranjo Adverse Drug Reaction Probability Scale was used to assess causality. RESULTS:Manic symptoms emerged while continuing atomoxetine (80 mg/day) and reducing risperidone to 1 mg/day due to its suspected depressogenic effects. The Naranjo score indicated a possible association between atomoxetine and mania onset. However, temperament characteristics and environmental stressors likely contributed to mood destabilisation. Mood stabilisation was achieved after initiating lithium. CONCLUSIONS:While the Naranjo score suggests a possible association between atomoxetine and mania, this episode may also represent the natural emergence of bipolar disorder. Atomoxetine might contribute to mood destabilisation in vulnerable individuals, particularly when concurrent antipsychotic doses are altered. Comprehensive monitoring of temperament and early mood instability is essential.
BACKGROUND:The effort invested in establishing and maintaining social relationships is a key component of socialisation, yet it remains difficult to assess. Understanding the difficulties that individuals with schizophrenia experience in forming social connections through a self-reported assessment appears particularly important. AIMS:This study aimed to adapt the Social Effort and Conscientiousness Scale (SEACS) into Turkish and examine its psychometric properties in individuals with schizophrenia. METHODS:Sixty-four patients with schizophrenia and 70 healthy controls completed the SEACS-TR and related scales. Psychometric analyses included internal consistency, factor analysis, and convergent validity. RESULTS:SEACS-TR demonstrated good internal consistency (α = .86). Using principal component analysis, we identified a three-factor solution (social initiation, connection, conscientiousness) explaining nearly 60% of the variance. A preliminary confirmatory factor analysis conducted within the same dataset supported the three-factor model with good fit (CFI = .927). Patients scored significantly lower than controls (t = 3.844, p < .001). SEACS-TR scores correlated moderately to strongly with social functioning, anhedonia, and negative symptoms. CONCLUSIONS:SEACS-TR is a reliable and valid tool for assessing social effort in schizophrenia and may inform personalised interventions.
OBJECTIVES:The aims of this study were to estimate the frequency of 'sundown syndrome' (SS) in a large sample of patients with Alzheimer's disease (AD) and to assess its associated socio-demographic and clinical variables. METHODS:Three hundred and sixty-one AD patients (age 78.4 ± 8.3 years) collected within the National Institute of Mental Health Genetics Initiative were included. A subsample was autopsy-confirmed. SS was identified within a caregiver-structured interview. Sociodemographic, clinical and neuropsychiatric features of sundowners and non-sundowners were compared by logistic regression. RESULTS:One hundred eighty-five patients (51.2%) were sundowners. SS was positively associated with several neuropsychiatric symptoms (i.e., hallucinations, suspiciousness, wandering and aggression; all p-values < 0.01), and negatively associated with Mini-Mental State Examination and voluptuary habits (all p values < 0.05). Subsample analysis carried out in the autopsy group confirmed the findings. CONCLUSIONS:SS is common in AD and is associated with several neuropsychiatric features and voluptuary habits. The identification of SS predictive factors may allow preventive and targeted therapeutic interventions.
BACKGROUND:Treatment-Resistant Depression (TRD) often persists despite adequate pharmacotherapy. Intranasal Esketamine and accelerated repetitive Transcranial Magnetic Stimulation (aTMS) are rapid-acting options, but head-to-head comparisons remain limited. METHODS:We conducted a retrospective study on TRD patients receiving either aTMS (n = 18) or Intranasal Esketamine (n = 22). Depression severity (Montgomery-Asberg Depression Rating Scale, MADRS) was assessed at baseline and 1, 3, and 6 months. Primary outcomes were response (≥50% MADRS reduction) and remission (MADRS <10). Longitudinal change was modelled with linear mixed-effects; moderators included clinical and demographics features. RESULTS:At 1 month, aTMS showed higher response (72.2% vs 20%; p < 0.001) and remission (66.6% vs 10%; p = 0.0031) than Esketamine. Between-group differences were not significant at 3 months or 6 months. Mixed-effects models showed greater MADRS reduction with aTMS at 1 (p < 0.001) and 3 months (p = 0.007), but not at 6 months (p = 0.057). Psychiatric comorbidities were associated with greater improvement at 3 and 6 months within the Esketamine subgroup, with no analogous association in the aTMS subgroup. CONCLUSIONS:aTMS showed a stronger early antidepressant effect, but its advantage over esketamine progressively diminished and was no longer evident at six months. Prospective, well-powered comparative trials are required to validate these findings.
A team of six researchers, including three people who have had ECT themselves, respond to an Editorial entitled 'Electroconvulsive therapy and its image: between human rights, evidence, and clinical responsibility'. Their work is portrayed as polarising debate and scaring psychiatrists and services away from offering ECT. The researchers argue that they are contributing to the ethical principle of informed consent. They provide research evidence regarding the safety and efficacy of ECT, including their own recent international survey of patients and relatives, to support their argument.
OBJECTIVE:To explore sex, racial and ethnic disparities in esketamine clinical trials for mental health disorders registered on ClinicalTrials.gov. METHODS:We conducted a registry-based cross-sectional analysis of interventional esketamine trials with results posted on ClinicalTrials.gov (cut-off date: 10 February 2025). Using predefined eligibility criteria, two investigators independently extracted and verified trial-level data on sex, race, ethnicity and site locations as reported in the registry. RESULTS:Among 13 eligible trials (n = 5116), women constituted 62.9% of participants, while men comprised 37.1%. The racial distribution included White (69.08%), Asian (13.31%), Black or African American (3.60%), and American Indian or Alaska Native (0.08%). Native Hawaiian or Other Pacific Islander participants accounted for only 0.04%. Hispanic or Latino representation ranged from 10.57% to 11.02% due to discrepancies in results reporting in trial NCT02493868. CONCLUSIONS:Esketamine clinical trials demonstrate significant racial and ethnic disparities, with underrepresentation of racial and ethnic minority groups. Regulatory efforts to improve diversity must lead to more effective recruitment for fair representation in future research.
BACKGROUND:The advantages of lithium in treating bipolar disorder (BD) are inconsistent with a declining trend in lithium prescriptions worldwide. Understanding lithium prescription patterns and serum concentrations could improve lithium clinical practices. METHODS:This multicentre study used latent variable analysis to explore lithium prescription patterns and changing trends in lithium serum concentrations. A regression model was used to identify their underlying associated factors. RESULTS:High- and low-dose prescription patterns were discovered in patients with mania and bipolar depression (BD-D), respectively. Patients with BD-D tended to receive lower lithium dosages. Lithium combination therapy was mainstream for BD. Factors associated with prescription patterns differed between patients with mania and BD-D. The lithium concentration-to-dose (C/D) ratio initially decreased but then increased. The final lithium serum concentration was mainly associated with dose titration. CONCLUSIONS:In this study, lower lithium dosage combined with second-generation antipsychotics is commonly used in the treatment of BD, and lithium prescription patterns fail to follow the guideline recommendations for BD. There are episode-specific factors associated with lithium prescriptions. A non-linear trend in the C/D ratio appears to be one of the factors contributing to lithium delay effects. Adjusting the lithium dosage is a direct way to change its serum concentration. Key PointsLower lithium dosage combined with SGAs is commonly used in the treatment of BD, and lithium prescription patterns fail to follow the guideline recommendations for BD.Factors associated with lithium prescription patterns differed between patients with mania and BD-D.In the context of a standardised lithium dosage (1 g), lithium plasma levels initially decrease before gradually increasing, which appears to be one of the factors contributing to lithium delay effects.
