Research on humanitarian aid workers (HAWs) deployed to intentional human-made catastrophe contexts—such as armed conflicts—is scarce and seldom grounded in systematic theoretical frameworks, leaving psychopathological comorbidity largely unexamined. Guided by the p Factor and Hierarchical Taxonomy of Psychopathology frameworks, we assessed anxiety, depression, and post-traumatic stress disorder symptom caseness in HAWs (N = 432) using validated self-report instruments and hierarchical log-linear modeling. Symptom co-occurrence exceeded statistical independence, pairwise association strengths differed by spectrum, and comorbidity patterns deviated from chance distributions. These results are consistent with transdiagnostic clustering of psychopathology under extreme stress, supporting integrated approaches in humanitarian contexts.
Background and objectives Antipsychotic-induced weight gain is a very common adverse effect in first-episode psychosis (FEP) and contributes to an increased risk of cardiometabolic comorbidities, which is associated with a significant reduction in life expectancy. Although physical activity (PA) may reduce this weight gain and the associated metabolic complications, evidence regarding its impact during the early stages of the illness remains limited. This study aimed to evaluate PA adherence and its association with weight gain and metabolic outcomes in FEP. Methods A 3-month prospective longitudinal study was conducted in 165 patients with FEP. Sustained PA adherence was defined as meeting World Health Organization (WHO) PA recommendations at both baseline and the three-month follow-up. The primary outcome was clinically significant weight gain (>7% of baseline weight). Secondary outcomes included changes in weight, body mass index (BMI), waist circumference, fasting glucose, lipid profile, and glycated hemoglobin (HbA1c). Results Only 15.2% of patients met physical activity recommendations. At three months, 50.9% experienced weight gain greater than 7%, with a lower proportion among adherent compared with non-adherent patients (p = 0.001). In multivariable analyses, adherence to WHO PA recommendations was independently associated with lower odds of clinically significant weight gain (OR = 0.084; 95% CI: 0.022–0.320; p < 0.001). Conclusions Adherence to WHO PA recommendations was associated with lower odds of early clinically significant weight gain. Intervention studies are needed to determine whether increasing PA adherence produces clinically meaningful reductions in antipsychotic-related weight gain.
Background and objectives Recovery‑oriented care has become a central paradigm in schizophrenia treatment, yet gaps persist between evidence and clinical implementation. The RECOVERY project aimed to identify unmet clinical needs and propose practical initiatives to enhance recovery‑oriented practice within the Spanish mental health system. Methods A structured, three phase expert consensus was conducted (2022–2024), involving a Scientific Committee and two Multidisciplinary Working Groups. Participants reviewed evidence, identified needs, and developed actionable recommendations through iterative meetings. Results Ten key needs were identified, including individualized treatment planning, improved training in recovery principles, implementation of shared decision making, reduction of stigma, rational pharmacotherapy, attention to physical health, coverage of basic needs, access to psychological treatments, strengthened community support, and integration of new technologies. For each need, practical and evaluable proposals were formulated. Conclusions This consensus provides a realistic, adaptable framework for advancing recovery-oriented care in Spain. Adoption of these recommendations could improve functional outcomes, quality of life, and the alignment of mental health services with patient-centered values.
Background and objectives Antidepressant treatment in adolescents with depressive episodes has been associated with an increased risk of suicidality and behavioural activation, particularly during the early phase of treatment. Emerging evidence suggests that underlying bipolar spectrum vulnerability may be associated with these adverse outcomes and could modify their risk. This study aimed to systematically evaluate the association between antidepressant exposure and early suicidality, behavioural activation, and treatment-emergent affective symptoms in adolescents, with a focus on unrecognised bipolar spectrum features as a potential moderator of risk. Methods A PRISMA 2020–compliant systematic review and meta-analysis was conducted using MEDLINE, Embase, PsycINFO, Web of Science, and CENTRAL. Randomised controlled trials and observational studies involving adolescents (≤18 years) with depressive episodes treated with antidepressants were included. Random-effects meta-analyses were performed where appropriate, with emphasis on early risk windows following treatment initiation. Results Twenty-two studies met inclusion criteria. Pooled analyses demonstrated an increased risk of suicidality and behavioural activation following antidepressant initiation, with the highest risk observed within the first 4–12 weeks. Effect sizes were consistently larger in samples characterised by mixed depressive features or indicators of bipolar spectrum vulnerability. Findings were broadly consistent across study designs, although heterogeneity varied across outcomes. Conclusion Antidepressant-associated suicidality and behavioural activation in adolescents appear to be temporally front-loaded and phenotype-sensitive. Unrecognised bipolar spectrum features may represent a clinically relevant vulnerability marker and a potential moderator of early adverse outcomes, although the available evidence does not establish a causal pathway.These findings underscore the importance of careful assessment for bipolar spectrum indicators, cautious dosing strategies, and close clinical monitoring during early treatment phases.
Background and objectives: Accurately assessing suicide risk requires tools that capture both its multidimensional nature and its temporal course. This study analyzes the psychometric properties of the Spanish version of the Suicidal History Self-Rating Scale (SHSS), a self-reported, multidimensional instrument designed to assess suicidal ideation and behavior across two time frames: the last 12 months and the lifetime before. Methods: Confirmatory factor analysis (CFA) was performed to compare unidimensional, two-factor, and bifactor models. Reliability was assessed using Omega coefficients, and concurrent validity was evaluated through correlations with the Paykel scale. The study used a convenience sample of 817 Spanish young adults (18-35 years old). Results: The bifactor models provided the best fit, identifying a prominent general suicide risk factor. Specific factors varied by period: suicidal ideation performed better in the 12-month frame, while suicidal behavior was more stable in the lifetime frame. The SHSS demonstrated excellent internal consistency (omega T = 0.96 - 0.97) and strong concurrent validity with the Paykel scale (rho = 0.645 - 0.695). Conclusions: These findings support the SHSS as a reliable, valid, and efficient self-report tool for screening suicide risk in young adults. Its 12-month subscale might be valuable in emergency psychiatry for predicting imminent risk. Simultaneously, the lifetime assessment allows for the identification of historical "acquired capability" and long-term risk trajectories.
Background and objectives: Treatment-resistant schizophrenia (TRS) is a severe subtype of schizophrenia. While negative and disorganised symptoms have been associated with cognitive dysfunction, the underlying neurobiological mechanisms remain unclear. Plasma neurofilament light chain protein (NfL), a biomarker of neuroaxonal damage, has shown promising associations in TRS. This study investigates the interrelationships between symptomatology, cognition, and NfL in TRS. Methods: Eighty-two clozapine-treated TRS participants were assessed using the Positive and Negative Syndrome Scale, Scale for the Assessment of Positive Symptoms, and Scale for the Assessment of Negative Symptoms. Cognitive functions were evaluated using the Cambridge Neuropsychological Test Automated Battery and Wisconsin Card Sorting Test. Plasma NfL concentrations were measured using a Single Molecule Array assay. General linear models and moderation analyses were employed. Results: In younger participants, NfL levels negatively correlated with excited factor (r =-0.26, 95% confidence interval [CI] = [-0.47,-0.04]), whereas in older participants, NfL levels positively correlated with blunted affect (r [95% CI] = 0.27 [0.05, 0.47]). Disorganised (unstandardised beta [B] =-0.07, 95% CI = [-0.11,-0.02]) and positive (B [95% CI] =-0.04 [-0.07,-0.005]) factors were significant predictors of executive dysfunction, independent of NfL levels. Importantly, NfL moderated the relationship between positive formal thought disorder and executive dysfunction (B [95% CI = 0.02 [0.001, 0.05]). Conclusions: These findings suggest distinct age-related neurobiological trajectories in TRS. While symptom-cognition relationships were relatively independent of NfL, its moderation effects point to potential compensatory or maladaptive responses that vary by illness stages.
Background and objectives: Personality traits and emotional domains have been hypothesised to influence surgery outcomes. This cross-sectional study explored associations between alexithymia and negative affectivity and early postoperative outcomes following colorectal resection. Methods: From a cohort of patients who underwent laparoscopic colorectal surgery at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust between March 2015 and November 2021, 146 patients completed the "Toronto Alexithymia Scale 20 items" (TAS-20) and the "Type-D Scale" (DS14) during a postoperative interview. Clinicopathological data and postoperative outcomes were prospectively collected. Statistical analysis included regression models using the TAS-20 and DS14 negative affectivity subscale as explanatory variables, adjusting for sociodemographic factors and correcting for multiple testing according to Benjamini-Hochberg. Results: Of the 146 patients, 43.1% met criteria for alexithymia, while 43.2% met criteria for negative affectivity. An association was found between negative affectivity and increased odds of postoperative complications (OR 4.42; p = 0.002) and need for analgesic intervention after the third postoperative day (OR 3.79; p = 0.015). Higher levels of alexithymia were associated with longer time to achieve a numeric pain rating scale score < 4 (beta 0.062; p = 0.038) on a scale going from 0 to 10. Conclusions: In this cross-sectional study alexithymia and negative affectivity were associated with selected early unfavourable postoperative outcomes. While these results may have implications for improving quality of life of individuals undergoing major surgery, they require confirmation in larger prospective studies that include preoperative psychological assessment.
Background: Frequent repeaters (>= 5 suicide attempts) remain poorly characterized despite their high vulnerability. We examined sex differences and 5-year mortality in this subgroup. Methods: This longitudinal study used the MCOSUL cohort (Lleida, Spain). Patients with >= 5 prior attempts and an index episode between 2009 and 2022 were followed for 5 years or until death. Baseline variables were compared by sex. Survival was analyzed using Kaplan-Meier curves (log-rank test) and a Cox model adjusted for age, sex, and somatic lethality of the index attempt. Results: The sample included 175 patients (71.8% women; median age = 43 years [IQR 33-51]). Women were more often employed (19%vs 6%), while men had higher unemployment (44%vs 26%) and alcohol use (58%vs 38%) (all p < 0.05). Eleven deaths (6.3%) occurred over 5 years, including 5 suicides (2.9%). Cumulative mortality was higher in men (12%vs 4%; p = 0.079). Kaplan-Meier curves showed significantly lower survival among men (log-rank p = 0.041). This pattern was confirmed in the multivariable Cox model, where female sex was associated with reduced mortality risk (HR = 0.29, 95% CI 0.09-0.98, p = 0.036). High somaticlethality of the index attempt showed a nonsignificant trend toward increased risk (HR = 2.97, 95% CI 0.86-10.3, p = 0.086). Conclusions: Among high-frequency attempters, men show poorer 5-year survival, while female sex independently predicts lower mortality risk. Prioritizing follow-up in men and in patients using somatic lethal methods may enhance preventive strategies.
Background and Objectives This study extends previous research on the feeling of emptiness in Borderline Personality Disorder (BPD) by revising and refining the Feeling of Emptiness Scale (FES) developed by Palomares et al. (2020)10. Through integrated statistical and theoretical analyses, this study aimed to improve the scale´s conceptual clarity and item quality while advancing understanding of feeling of emptiness as clinical construct. Methods A total of 205 patients primary diagnosis of BPD were assessed using the FES. We first conducted a confirmatory factor analysis (CFA) to confirm the exploratory structure from the original FES version. Given the unsatisfactory model fit, an Exploratory Graphical Analysis (EGA) and item redundancy analysis were conducted. Finally, the derived structure was subsequently validated through CFA. Finally, experts consensus was employed for the conceptual interpretation of the identified components. Results A 19-item version was obtained. A robust three-factor structure was identified through bootstrap EGA: “Frustrated Sense of Belonging” (6 items, ω = 0.854), “Lack of connection with self” (9 items, ω = 0.918), and “Lack of self-worth” (α = 0.919), indicating that the refined instrument provides a consistent measure of feeling of emptiness. Conclusions This comprehensive revision of the FES identifies three robust dimensions of feeling of emptiness in personality disorders: “frustrated belonging-inner loneliness” (interpersonal), “identity diffusion-loss of meaning” (identity-psychological), and “lack of intrinsic worth” (agency-identity). This refined structure provides a more precise conceptualization of the construct and a solid framework for specific clinical interventions.
Background and objectives: Depression and anxiety are leading causes of disability worldwide, however longitudinal data from low-and middle-income countries (LMICs) are scarce. This study aimed to examine trends and associated factors of depression and anxiety over a 10-year period in a Brazilian urban cohort. Methods: Data from the prospective cohort 'Health Survey of Sao Paulo: Physical Activity and Environment' were used. Participants (n = 978) were assessed in 2014-15, 2020-21, and 2023-24. Sociodemographic, health and physical activity-related characteristics, as well as self-reported measures of depression and anxiety, were investigated through a structured questionnaire. Associations were examined using hierarchical logistic regression models. Results: The prevalence of depression increased from 4.2 % in 2014-15 to 15.3 % in 2023-24, while anxiety increased from 10.1 % to 28.9 %. Women consistently showed three-to fourfold higher odds of both mental health conditions compared to men. Poor sleep quality was strongly associated with two-to fivefold higher odds depression and anxiety across waves. Presence of comorbidities and obesity were also associated with higher depression and anxiety prevalences. Leisure-time physical activity was inversely associated with depression in 2014-15. Participants who used bicycles for transportation were the only subgroup in which depression and anxiety prevalence did not increase significantly. Conclusions: This 10-year cohort study highlights a substantial increase in depression and anxiety in Sao Paulo. The protective associations of physical activity with mental health conditions reinforces the importance of promoting active lifestyles. The longitudinal design of the study and recent data collection in 2023-24 offer updated and representative insights for LMICs.
Background and Aims Individuals with schizophrenia exhibit markedly low levels of physical activity and prolonged inactivity, contributing to increased cardiometabolic risk and reduced life expectancy. Fatigue is highly prevalent in schizophrenia and frequently reported as a major barrier to physical activity; however, its relationship with objectively measured activity remains poorly understood. In particular, the role of maladaptive cognitive appraisals of fatigue has not been examined. This exploratory study investigated associations between self-reported fatigue, fatigue catastrophizing, and objectively measured physical activity in individuals with schizophrenia compared with non-clinical controls. Methods Sixty participants (27 individuals with schizophrenia and 33 non-clinical controls), matched on age, sex, and body mass index, wore a tri-axial wrist accelerometer continuously for seven days. Physical activity and inactivity were derived using standardized processing pipelines. Fatigue was assessed with the Multidimensional Fatigue Inventory and fatigue catastrophizing with the Fatigue Catastrophizing Scale. Associations between fatigue measures, physical activity, and clinical symptoms were examined. Results Compared with controls, individuals with schizophrenia showed significantly lower levels of light, moderate, and vigorous physical activity, alongside higher fatigue, fatigue catastrophizing, and depressive symptoms. In the schizophrenia group, fatigue severity was not associated with objectively measured physical activity. In contrast, higher fatigue catastrophizing was associated with lower moderate physical activity and reduced step count. Fatigue severity was associated with depressive and negative symptoms, but not with physical activity. Conclusion These findings suggest a dissociation between fatigue severity and actual physical activity behavior in schizophrenia and highlight fatigue catastrophizing as a key cognitive factor linked to reduced activity.
Background and objectives: Suicide is a leading cause of mortality among young people. This study examined temporal trends in suicide rates and methods among individuals under 30 years in Spain between 2000 and 2023, compared with adults. Methods: A time-series analysis of population-level suicide indicators based on data from the Spanish National Statistics Institute. A total of 85,299 suicides were classified by age group (<15, 15-29, >= 30 years), sex, and method. Joinpoint regression was used to evaluate trends. Annual Percent Change (APC) represents change within segments, whereas Average Annual Percent Change (AAPC) summarizes the overall period. Results: Among those under 15, rates increased from 2011 onward (APC = 12.1%; 95% CI: 1.6 to 75.9), with defenestration the predominant method (41.7%) and showing a marked upward trend (AAPC = 25.4%; 95% CI: 10.2 to 42.5). In individuals aged 15-29, rates declined among males between 2000 and 2010 but increased among females from 2010 (APC = 4.5%; 95% CI: 1.7 to 17.6); and non-violent methods (poisoning or drug overdose) also became more frequent. In adults aged >= 30, overall rates were relatively stable, although non-violent methods increased from 2018 (APC = 8.1%; 95% CI: 2.0 to 23.6). Conclusion: Although these estimates should be interpreted cautiously given the small number of events, the results indicate a recent increase in suicides among children under 15 and young women, as well as age- and sex-specific changes in the methods used. Defenestration and the use of non-violent methods showed increases among younger population groups.
Background and objectives Rapid cycling (RC) is a severe course specifier of bipolar disorder (BD), associated with worse clinical outcomes and increased treatment complexity. The objective of this study is to identify differences in clinical and biochemical parameters between bipolar patients with or without rapid cycling (RC). Methods A total of 468 inpatients were included in the present study. Demographic, clinical and biochemical data, related to the first day of hospitalization, were obtained through a screening of the clinical charts and intranet hospital applications. The two groups identified by the lifetime presence of RC were compared by t tests for continuous variables and chi(2) tests for qualitative ones; logistic regression models were subsequently performed. Results Logistic regressions showed that patients with versus without RC: were more frequently hospitalized for a depressive episode (p < 0.01), had more previous psychiatric hospitalizations (p < 0.01), presented more often multiple medical comorbidity (p = 0.05) and seasonality (p = 0.02) as well as lower Global Assessment of Functioning (GAF) scores at the time of hospitalization (p = 0.02). RC patients also exhibited lower creatine phosphokinase (CPK) (p < 0.01) and neutrophil levels (p < 0.01). Conclusions The presence of RC is important in designing a personalized treatment of bipolar patients as it is associated with (1) clinical variables of greater severity, (2) the tendency to a depressive profile and (3) multiple medical comorbidities. Further multi-center studies are needed to confirm the results of the present study in a framework of precision psychiatry.
Background and objectives Executive function (EF) impairment represents a core feature of schizophrenia, yet how specific EF dimensions differ across illness stages remains poorly understood. This study aimed to characterize the differential profiles of three EF dimensions between first-episode schizophrenia (FES) and chronic schizophrenia (ChSz) patients, and to identify which dimensions most strongly differentiate between these illness stages. Methods A total of 182 schizophrenia patients (85 FES, illness duration <= 2 years; 97 ChSz, illness duration >= 5 years) completed five behavioral paradigms assessing inhibitory control, working memory, and cognitive flexibility. Mixed-model ANCOVA examined differential EF impairment patterns between groups. Random forest classifiers with nested cross-validation and Shapley Additive Explanations (SHAP) were employed to determine the relative multivariate importance of EF dimensions in distinguishing between illness stages. Results Mixed-model ANCOVA revealed a significant group-by-dimension interaction. FES patients exhibited milder deficits in inhibitory control and working memory updating compared to ChSz patients (all p(fdr) < 0.05), with the largest effect size for interference inhibition (eta & sup2; = 0.140). Correlation analyses linked EF impairments to illness duration, symptom severity, and antipsychotic dosage. SHAP analysis identified interference inhibition and working memory updating as the dimensions most strongly associated with illness stage. Conclusions This study revealed stage-specific EF impairment profiles in schizophrenia, with inhibitory control and working memory updating showing the greatest differences between FES and ChSz patients. These dimensions may serve as sensitive markers for differentiating illness stages and represent potential targets for stage-specific cognitive interventions.
Background and Objectives: Intranasal esketamine represents a novel therapeutic option for Treatment-Resistant Depression (TRD). However, its medium-to-long-term risk-benefit profile in real-world clinical practice remains controversial. Limited data is available regarding its effectiveness, particularly in patients who have not responded to electroconvulsive therapy (ECT), which is the focus of this study. Methods: We conducted a 6-month observational study investigating intranasal esketamine treatment in the first TRD patients managed at our care centers. We compared outcomes between patients who had not responded to prior ECT and those for whom ECT had not been attempted. Results: The sample comprised 60 patients exhibiting high chronicity (mean episode duration: 41.2 +/- 54.7 months) and complexity, with psychiatric comorbidity observed in 37 cases (61.6%). The mean Montgomery & Aring;sberg Depression Rating Scale (MADRS) score decreased from a baseline of 33.9 +/- 7.8 to 15.7 +/- 9.6 at 6 months. No significant differences in therapeutic responses were observed in patients who had not responded to ECT during the current episode. Conclusions: This real-world study suggests the opportunity to promptly test intranasal esketamine in ECT refractory subtype of TDR patients.
Background and objectives Functional Neurological Disorder (FND) is a relatively common neuropsychiatric condition characterised by disabling or distressing, but potentially reversible, neurological symptoms. There are no well-validated treatments, despite emerging evidence for several psychotherapies. A formulation is a set of explanatory hypotheses answering the question ‘why does this patient suffer from this problem at this time?’ This study examined the formulations of adults with FND who were treated with Shared Individual Formulation Therapy (SIFT). SIFT uses clinical history-taking and hypothesis-refinement over several sessions to collaboratively formulate how symptoms have emerged in the context of the patient’s life experience, to identify relevant vulnerabilities and coping strategies. A shared individual formulation is co-written and verified with each participant to ensure it represents their experience accurately. Our objective was to explore the patterns and associations in these formulations. Methods We extracted the formulations from twenty-four letters generated during a prospective, open-label trial of SIFT for FND. Framework analysis was used to identify the key features (‘exposures’, ‘schemas’, ‘activations’ and ‘mechanisms’) within each formulation. Subgroups identified using hierarchical clustering were compared statistically across characteristics, therapy ratings and outcome scores. Results Three clusters were identified. Two were characterised by overvigilance and body focus (n = 10), and one was characterised by dissociation and other directedness (n = 14). There was some indication of possible differences in treatment response, but numbers were too small to draw firm conclusions. Conclusion Findings support the psychological heterogeneity of adults with FND. Analysis of formulations can be used to identify clinically distinct subgroups.
Background and objectives: Cognitive Behavioral Therapy (CBT) is an effective adjunctive treatment for Attention-Deficit/Hyperactivity Disorder (ADHD). This study examined sex differences in the efficacy of a brief 6-session CBT program versus a traditional 12-session format, combined with stable pharmacotherapy, in adults with ADHD. Method: A total of 81 adults (58 % male; 41.27 +/- 9.26 years) were randomly assigned to 6- or 12-session CBT. ADHD symptoms, psychopathology, and functioning were assessed at baseline, post-treatment, and 3- and 6-month follow-up. Mixed-effects models analyzed interactions between time, treatment group, and sex. Results: At baseline, females exhibited greater symptom severity (p = 0.019), higher inattention (p < 0.001), and more pronounced impairments (p = 0.004). CBT led to significant clinical improvements regardless of sex. A significant time-by-sex interaction emerged for inattention (CAARS:O:L, p = 0.043), although it did not remain significant after adjusting for baseline severity. Regarding time & times; group & times; sex interactions, females in the 6-session group showed smaller reductions in clinical severity during follow-up (CGI-S, p = 0.047); however, this effect was no longer statistically significant after controlling for baseline ADHD severity. Findings should be interpreted with caution given the limited female sample at follow-up and the significant influence of initial symptom burden on long-term trajectories. Conclusions: CBT improves ADHD symptoms and related impairments in adults, with comparable overall benefits across sexes. Treatment response follow-up differences were better explained by baseline severity and treatment intensity rather than sex-specific differences.
