A Randomized Controlled Trial on the Efficacy of a Psychosocial Behavioral Intervention to Improve the Lifestyle of Patients With Severe Mental Disorders: Study Protocol

One-year efficacy of a lifestyle behavioural intervention on physical and mental health in people with severe mental disorders: results from a randomized controlled trial

This multicentric randomized controlled trial (RCT), carried out in six Italian University mental health sites, aims to test the efficacy of a six-month psychosocial intervention (LYFESTYLE) on Body Mass Index (BMI), body weight, waist circumference, fasting glucose, triglycerides, cholesterol, Framingham and HOmeostasis Model Assessment of insulin resistance (HOMA-IR) indexes in patients with schizophrenia, bipolar disorder, and major depression. Moreover, the efficacy of the intervention has also been tested on several other physical and mental health domains. Patients were randomly allocated to receive the six-month experimental intervention (LIFESTYLE) or a behavioural control intervention. All enrolled patients were assessed at baseline and after one year. We recruited 401 patients (206 in the experimental and 195 in the control group) with a diagnosis of schizophrenia or other psychotic disorder (29.9%), bipolar disorder (43.3%), or major depression (26.9%). At one year, patients receiving the experimental intervention reported an improvement in body mass index, body weight, waist circumference, HOMA-IR index, anxiety and depressive symptoms and in quality of life. Our findings confirm the efficacy of the LIFESTYLE intervention in improving physical and mental health-related outcomes in patients with severe mental illnesses after one year.

Combination of Two Long-Acting Antipsychotics in Schizophrenia Spectrum Disorders: A Systematic Review

BACKGROUND

Up to 34% of patients with schizophrenia are resistant to several treatment trials. Lack of continuous and adequate treatment is associated with relapse, rehospitalization, a lower effect of antipsychotic therapy, and higher risk of side effects. Long-acting injectables antipsychotics (LAI APs) enhance compliance and improve clinical outcomes and quality of life in patients with schizophrenia, and thus it may be advisable to administer two LAI APs at the same time in cases of treatment-resistant schizophrenia. The purpose of this review is to summarize the available literature regarding the combined use of two LAI APs in patients with schizophrenia or other psychotic spectrum disorders.

METHODS

An extensive literature search for relevant articles regarding any combination of two long-acting injectable antipsychotics has been performed from inception up to 9 February 2024, on PubMed, Scopus and APA PsycInfo, according to the PRISMA statement. Only studies reporting combination of two LAI APs and its clinical outcome in patients with schizophrenia and related disorders were selected.

RESULTS

After the selection process, nine case reports, four case series and two observational retrospective studies were included in the final analysis. All patients treated with dual LAI APs reported a good response, and no new or unexpected adverse effects due to the combination of two LAIs were reported. Different drug combinations were used, and the most frequent association resulted in aripiprazole monohydrate + paliperidone palmitate once monthly (32 times).

CONCLUSIONS

Our review highlights that the treatment regimen with two concurrent LAI APs is already widely used in clinical practice and is recognized as providing a promising, effective, and relatively safe therapeutic strategy for treating the schizophrenia spectrum disorders.

Physical activity influences adherence to pharmacological treatments in patients with severe mental disorders: results from the multicentric, randomized controlled LIFESTYLE trial

Introduction: Poor adherence to pharmacological treatment is frequent in people with severe mental disorders and it often causes lack of effectiveness of many psychotropic drugs. Thus, efforts should be made to improve adherence to pharmacological treatments in patients with these disorders. Methods: In this paper, based on the LIFESTYLE randomized, controlled multicentric trial, we aim to: 1) assess the level of adherence in a real-world sample of patients with severe mental disorders; 2) evaluate differences in treatment adherence according to patients' socio-demographic and clinical characteristics; 3) evaluate the impact of an innovative psychosocial intervention, on patients' adherence to treatments. The Lifestyle Psychosocial Group Intervention consists of group sessions, focused on different lifestyle behaviours, including healthy diet; physical activity; smoking habits; medication adherence; risky behaviours; and regular circadian rhythms. At end of each session a 20-min moderate physical activity is performed by the whole group. Results: The sample consists of 402 patients, mainly female (57.1%, N = 229), with a mean age of 45.6 years (±11.8). Less than 40% of patients reported a good adherence to pharmacological treatments. Adherence to treatments was not influenced by gender, age, diagnosis and duration of illness. At the end of the intervention, patients receiving the experimental intervention reported a significant improvement in the levels of adherence to treatments (T0: 35.8% vs. T3: 47.6%, p < 0.005). Patients practicing moderate physical activity reported a two-point improvement in the levels of adherence [odds ratio (OR): 1,542; 95% confidence intervals (CI): 1,157-2,055; p < 0.001], even after controlling for several confounding factors. Discussion: The experimental lifestyle intervention, which can be easily implemented in the routine clinical practice of mental health centres, was effective in improving adherence to pharmacological treatments.

Associations between overweight, obesity, and mental health: a retrospective study among European adults aged 50

Background

The comorbidities associated with overweight and obesity have been well researched and scientifically proven while their relationship to mental health is still not verified.

Methods

This study is aimed at investigating reciprocal associations between obesity and mental health, and is intended to further analyze possible long-term effects using data from the Survey of Health, Ageing and Retirement in Europe (SHARE). In order to do that, waves 4 and 8, conducted in 2010 and 2019/20 of this survey, were analyzed in a cross-lagged panel approach including 16,184 adult Europeans (50+) using multiple linear regression analysis focusing on the Body Mass Index (BMI), depression status and quality of life (QoL).

Results

Findings yield significant cross-lagged effects in one direction regarding BMI predicting QoL and depression state, whereas depression state and QoL do not significantly predict BMI. Findings include people living with obesity, overweight, and underweight showing significantly decreased levels of QoL as well as increased depression scores compared to people of normal weight over a lag time of 10 years, where people living with obesity indicate the strongest effect.

Conclusions

However, results do not confirm reciprocal associations in the long term. Hence, there is a strong need to carry out further research on this issue.

Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial

Aims of the present study are to test the efficacy of a lifestyle group intervention, compared to a brief psychoeducational intervention, on levels of physical activity and dietary habits in a real-world sample of patients with severe mental disorders. The study, funded by the Italian Ministry of Education, has been carried out in six Italian University psychiatric outpatient units. All patients were randomly assigned to the experimental or control group and were assessed through standardized assessment instruments at baseline and six months after randomization. Of the 401 recruited patients, 43.3% had a diagnosis of bipolar disorder, 29.9% of psychosis and 26.9% of major depression. Patients were mainly female (57%), with a mean age of 45.6±11.8 years. Treated patients have almost 8 times the likelihood to show an increase of the total MET (OR: 8.02; p < .001) and of the walking MET (OR: 7.68; p < .001) and are more likely to increase the weekly consumption of vegetables (OR= 1.98, p < .05) and to reduce that of junk food (OR:0.23; p < .05). The present study support the notion that patients with severe mental disorders can improve their lifestyle behaviours and that, with appropriate support, they can achieve a healthy living.

Using sport-based interventions for people with severe mental disorders: results from the European EASMH study

People with severe mental disorders report significantly poorer physical health and a higher mortality rate compared with the general population. Several interventions have been proposed in order to challenge this mortality gap, the promotion of physical activities represents one of the most important strategies. In fact, in people with severe mental disorders, physical activity can improve body composition, quality of life, personal functioning, self-esteem, cognition, and cardiorespiratory fitness, as well as reducing affective, psychotic and anxiety symptoms, cardiometabolic burden and increase the global recovery. While sport-based programs are consistently being proposed as an integral part of effective personalized treatment approaches for people with severe mental disorders, their routine implementation is hampered by poor working task integration among different professionals and the lack of training programmes for sport professionals focused on people with severe mental disorders. In this paper, we will: (a) review the efficacy of exercise/sport-based interventions for people with severe mental disorders; (b) describe the main difficulties in engaging patients with severe mental disorders in these interventions; and (c) report the results of the first study on the best practices available in Europe in the field of sport and mental health carried out in the context of the European Alliance for Sport and Mental Health (EASMH) project. According to the EASMH survey, sport-based psychosocial interventions are not frequently available in mental health services, with significant differences at the European level. In the near future, it would be advisable to promote the integration and collaboration between mental health professionals and sport professionals, in order to improve the dissemination and availability of sport-based interventions in routine clinical practice. The EASMH project aims to fill this gap by creating a network of collaborators, researchers and stakeholders with different backgrounds in order to improve the dissemination of sport-based rehabilitation interventions and by developing an innovative training programme for sport coaches in order to improve their skills in interacting and building an effective relationship with people with severe mental disorders.

Clinical and psychopathological correlates of duration of untreated illness (DUI) in affective spectrum disorders

Affective disorders represent psychopathological entities lying on a continuum, characterized by high prevalence and functional impairment. A delay in treatment initiation might increase the burden associated with affective spectrum disorders. The present study was aimed at analyzing the correlates of a long duration of untreated illness (DUI) in these conditions. We recruited subjects diagnosed with affective disorders, both in- and outpatients, and collected information concerning socio-demographic, clinical, and psychopathological characteristics. Long DUI was defined according to previous research criteria as >2 years for Bipolar Disorders or >1 year for Depressive Disorders. Bivariate analyses were performed to compare subjects with a long and short DUI (p<0.05). A logistic regression was operated to evaluate the correlates of long DUI. In the present sample (n=135), 34.1% (n=46) subjects showed a long DUI. This subgroup presented with more physical comorbidities (p=0.003), higher body mass index (BMI) (p<0.001), more frequent anxiety onset (p=0.018), younger onset age (p=0.042), and more severe depressive symptoms (Hamilton Depression Rating Scale item 1-depressed mood (p=0.032) and item 2-guilt feelings (p=0.018)). At the logistic regression, higher severity of depressed mood (OR 1.568), higher BMI (OR 1.264), and younger age at onset (OR 0.935) were associated with long DUI. The present study confirmed a possible role of DUI as a construct underpinning higher clinical severity in affective spectrum disorders, possibly linked to worse illness course and unfavorable outcomes. Intervention strategies targeting physical comorbidities and depressive symptoms severity may decrease disease burden in subjects with a long DUI.

Efficacy of family psychoeducation on drug compliance, self-esteem and caregivers' burden among selected psychiatric inpatients from a tertiary care centre, North India

BACKGROUND

Lack of awareness has alarmingly raised the proportion of drug noncompliance among psychiatric patients, which are proven worrisome not only to the patients but also to their caregivers. An individually tailored family psychoeducation will address the issue by enhancing the knowledge among patients and their caregivers.

AIM

The aim of this study is to assess the efficacy of family psychoeducation on drug compliance, self-esteem, and caregiver's burden among psychotic and mood disorder patients in a selected tertiary care center, Uttarakhand, India.

METHODS

A quasi-experimental study was performed among 120 participants using total enumerative sampling in a general hospital psychiatric ward. Data were collected from patients and caregivers using the Medication Adherence Rating Scale, Rosenberg Self-esteem Scale, and Zarit burden interview-22. The outcome measures were evaluated in the 2 and 4^th weeks, and data were analyzed using the descriptive (frequency, percentage) and inferential statistics (Friedman analysis of variance, Wilcoxon signed-rank test) using the SPSS software version 23.0.

RESULTS

The present study showed that almost 30% of patients were noncompliant with their drug regime (mean ± standard deviation, 4.23 ± 1.57), and a majority (63.33%) of them presented with a low level of self-esteem. Furthermore, 71.7% and 13.3% of caregivers experienced a moderate and severe burden. An increase in drug compliance (35%) and self-esteem (31%) and a decrease in caregivers' burden (13%) were observed after the administration of family psychoeducation (P = 0.00).

CONCLUSION

There is a great need to provide family psychoeducation on a routine basis in general hospitals. Patients with higher self-esteem will ultimately show improved social and occupational functionality resulting in satisfactory treatment compliance and decreased caregivers' burden.

The Complex Interplay Between Physical Activity and Recovery Styles in Patients With Severe Mental Disorders in a Real-World Multicentric Study

Compared with the general population, people with severe mental disorders have significantly worse physical health and a higher mortality rate, which is partially due to the adoption of unhealthy lifestyle behaviors, such as heavy smoking, use of alcohol or illicit drugs, unbalanced diet, and physical inactivity. These unhealthy behaviors may also play a significant role in the personal and functional recovery of patients with severe mental disorders, although this relationship has been rarely investigated in methodologically robust studies. In this paper, we aim to: a) describe the levels of physical activity and recovery style in a sample of patients with severe mental disorders; b) identify the clinical, social, and illness-related factors that predict the likelihood of patients performing physical activity. The global sample consists of 401 patients, with a main psychiatric diagnosis of bipolar disorder (43.4%, N = 174), psychosis spectrum disorder (29.7%; N = 119), or major depression (26.9%; N = 118). 29.4% (N = 119) of patients reported performing physical activity regularly, most frequently walking (52.1%, N = 62), going to the gym (21.8%, N = 26), and running (10.9%, N = 13). Only 15 patients (3.7%) performed at least 75 min of vigorous physical activity per week. 46.8% of patients adopted sealing over as a recovery style and 37.9% used a mixed style toward integration. Recovery style is influenced by gender (p < 0.05) and age (p < 0.05). The probability to practice regular physical activity is higher in patients with metabolic syndrome (Odds Ratio - OR: 2.1; Confidence Interval - CI 95%: 1.2-3.5; p < 0.050), and significantly lower in those with higher levels of anxiety/depressive symptoms (OR: 0.877; CI 95%: 0.771-0.998; p < 0.01). Globally, patients with severe mental disorders report low levels of physical activities, which are associated with poor recovery styles. Psychoeducational interventions aimed at increasing patients' motivation to adopt healthy lifestyle behaviors and modifying recovery styles may improve the physical health of people with severe mental disorders thus reducing the mortality rates.

How to improve the physical health of people with severe mental illness? A multicentric randomized controlled trial on the efficacy of a lifestyle group intervention

Background

People with severe mental illnesses (SMI) have a mortality rate two times higher compared to the general population, with a decade of years of life lost. In this randomized controlled trial (RCT), we assessed in a sample of people with bipolar disorder, major depressive disorder, and schizophrenia spectrum disorder, the efficacy of an innovative psychosocial group intervention compared to a brief psychoeducational group intervention on patients’ body mass index (BMI), body weight, waist circumference, Framingham and HOMA-IR indexes.

Methods

This is a multicentric RCT with blinded outcome assessments carried out in six Italian university centers. After recruitment patients were randomized to receive a 6-month psychosocial intervention to improve patients’ physical health or a brief psychoeducational intervention. All recruited patients were assessed with standardized assessment instruments at baseline and after 6 months. Anthropometric parameters and blood samples have also been collected.

Results

Four-hundred and two patients with a diagnosis of bipolar disorder (43.3%), schizophrenia or other psychotic disorder (29.9%), or major depression (26.9%) were randomly allocated to the experimental (N = 206) or the control group (N = 195). After 6 months, patients from the experimental group reported a significant reduction in BMI (odds ratio [OR]: 1.93, 95% confidence intervals [CI]: 1.31–2.84; p < 0.001), body weight (OR = 4.78, 95% CI: 0.80–28.27, p < 0.05), and waist circumference (OR = 5.43, 95% CI: 1.45–20.30, p < 0.05). Participants with impaired cognitive and psychosocial functioning had a worse response to the intervention.

Conclusions

The experimental group intervention was effective in improving the physical health in SMI patients. Further studies are needed to evaluate the feasibility of this intervention in real-world settings.

Assessing psychopathology in bariatric surgery candidates: discriminant validity of the SCL-90-R and SCL-K-9 in a large sample of patients

PURPOSE

Pre-surgical psychosocial evaluation of bariatric surgery (BS) patients should identify psychiatric issues that could worsen after surgery and those requiring additional ongoing intervention. In this view, the use of reliable, appropriate and concise evaluating instruments is of critical importance. The aim of the present study was to investigate the clinical utility of both the Symptom Checklist 90-Revised (SCL-90-R) and its brief unidimensional version, the so-called Symptom-Checklist-K-9 (SCL-K-9) in detecting the presence of psychiatric disorders among bariatric surgery (BS) candidates.

METHODS

Seven-hundred-and-ninety-eight BS candidates (563 women and 235 men; mean age: 44.15 ± 11.45) were enrolled in the present study. All participants underwent a full psychiatric interview and were administered the SCL-90-R.

RESULTS

Three-hundred-and-sixty-two patients (45.4%) met the criteria for a diagnosis of at least one psychiatric disorder and ninety-nine patients (12.4%) had psychiatric comorbidities. In the current sample, 219 patients (27.4%) met the criteria for binge eating disorders (BED), 158 (19.8%) met the criteria for major depressive disorder (MDD), and 67 (8.4%) met both criteria. A receiver operating characteristic (ROC) curves procedure showed that both the SCL-90-R and the SCL-K-9 satisfactorily categorize patients with any psychiatric disorder, both BED and MDD (area under the ROC curve ≥ 0.70, p < 0.001).

CONCLUSION

Our results suggest that the SCL-90-R and the SCL-K-9 may represent first-level screening tests identifying at-risk patients, eligible for a more expensive or time-consuming clinical assessment.

LEVEL OF EVIDENCE

Level V, cross-sectional, descriptive study.

The impact of clinical and social factors on the physical health of people with severe mental illness: Results from an Italian multicentre study

Our manuscript aims to: 1) assess physical health in a sample of patients with severe mental disorders; and 2) identify the psychopathological and psychosocial characteristics associated with an increased likelihood of having a poor physical health. The study, funded by the Italian Ministry of Education, has been carried out in psychiatric outpatient units of six Italian University sites. All recruited patients have been assessed through standardized assessment instruments. Moreover, anthropometric parameters have been obtained at recruitment and a blood samples have been collected to assess cardiometabolic parameters. Four-hundred and two patients with a primary diagnosis of bipolar disorder (43.3%), schizophrenia or other psychotic disorder (29.9%), or major depression (26.9%) were recruited. Internalized stigma, psychosocial functioning, quality of life, psychiatric hospitalizations, depressive/anxiety and manic symptoms and cognition were those domains more strongly associated with poor metabolic parameters, including high body mass index, HOMA and Framingham indexes and waist circumference. There were no statistically significant differences among the three diagnostic groups. Our findings highlight the importance of perceived stigma and quality of life on patients' physical health. This should be taken into account when developing plans for reducing the mortality rate in patients with severe mental disorders.

The burden of depressive disorders in musculoskeletal diseases: is there an association between mood and inflammation?

IMPORTANCE

Evidence emerged concerning how inflammatory arthritis and mood disorders can often occur in the same patient and show a similar clinical pattern. An overview of the rheumatological and psychiatric aspects of these diseases can certainly be useful for the improvement of patients' clinical and therapeutic management.

OBJECTIVE

The aim of this narrative review was to summarize existing literature about common pathogenetic and clinical aspects as a means of improving management and therapeutic approach in patients affected by rheumatoid arthritis, psoriatic arthritis and spondyloarthritis. Outcomes such as disease activity indexes and patient reported outcomes (PROs) were considered.

FINDINGS

Common pathogenetic pathways emerged between inflammatory arthritis and mood disorders. Pro-inflammatory mechanisms, such as TNFα, IL-6, IL-17 and oxidative stress factors as well as neurotransmitter alterations at the level of CNS and blood-brain barrier (BBB) cells are involved. The activation of these common pathogenetic pathways is, also, affected by the same triggers, such as smoking, stress, lifestyle, and evidence has emerged concerning the possibility of the clinical efficacy of using the same therapeutic approaches.

CONCLUSIONS

The main causes of the variability in clinical studies outcomes are the rheumatological diseases considered, the prevalence of depression in the general population and in patients with rheumatological diseases and the type of depressive symptom examined. Patients affected by inflammatory arthritis can present symptoms and signs in common with mood disorders, leading to possible clinical overlap. There are still few studies analyzing this concept: they are extremely heterogeneous, both in the characteristics of the population taken into consideration and in the methods used for the definition of depressive disorder, but the suggestions of the data obtained so far are promising and deserve to be pursued.

Cardiovascular risk in patients with severe mental illness in Italy

BACKGROUND

Patients with severe mental illness (SMI), such as schizophrenia or bipolar disorders, are more frequently affected by metabolic syndrome and cardiovascular (CV) diseases than the general population, with a significant reduction in life expectancy. Beyond metabolic syndrome, quantifying the risk of CV morbidity in the long-term may help clinicians to put in place preventive strategies. In this study, we assessed 10-year CV risk in patients with SMI and healthy individuals using an algorithm validated on the Italian general population.

METHODS

Patients aged 35-69 years diagnosed with SMI were consecutively recruited from psychiatric acute care units. Single CV risk factors were assessed, and 10-year CV risk calculated by means of the CUORE Project 10-year CV risk algorithm, based on the combination of the following risk factors: age, systolic blood pressure, total and high-density lipoprotein cholesterol, diabetes, smoking habit, and hypertensive treatment. Patients' data were compared with those from the general population. The 10-year CV risk was log-transformed, and multivariable linear regression was used to estimate mean ratios, adjusting for age, and education.

RESULTS

Three hundred patients and 3,052 controls were included in the analysis. Among men, the 10-year CV risk score was very similar between patients with SMI and the general population (mean ratio [MR]: 1.02; 95%CI 0.77-1.37), whereas a 39% increase in 10-year CV risk was observed in women with SMI compared to the general population (MR: 1.39; 95%CI 1.16-1.66).

CONCLUSIONS

In our study, women with SMI were consistently more at risk than the general population counterpart, even at younger age.

The Impact of Quarantine and Physical Distancing Following COVID-19 on Mental Health: Study Protocol of a Multicentric Italian Population Trial

The COVID-19 pandemic and its related containment measures-mainly physical distancing and isolation-are having detrimental consequences on the mental health of the general population worldwide. In particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. The vast majority of available studies have been conducted in China, where the pandemic started. Italy has been severely hit by the pandemic, and the socio-cultural context is completely different from Eastern countries. Therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of COVID-19 and quarantine measures on the mental health of the Italian population. In fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. The "COVID-IT-mental health trial" is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of COVID-19 pandemic and its containment measures on mental health of the Italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. Data will be collected through a web-platform using validated assessment tools. Participants will be subdivided into four groups: a) Group 1-COVID-19 quarantine group. This group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with COVID-19+ individuals; b) Group 2-COVID-19+ group, which includes isolated people directly/indirectly exposed to the virus; c) Group 3-COVID-19 healthcare staff group, which includes first- and second-line healthcare professionals; d) Group 4-COVID-19 mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. Mental health services worldwide are not prepared yet to manage the short- and long-term consequences of the pandemic. It is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups.

Efficacy of the interpersonal and social rhythm therapy (IPSRT) in patients with bipolar disorder: results from a real-world, controlled trial

BACKGROUND

Bipolar disorder (BD) is one of the most burdensome mental disorders, with a lifetime prevalence of 2.4%, with a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type II. Several interventions have been developed to implement the treatment strategy of bipolar disorder, including the Interpersonal and Social Rhythm Therapy (IPSRT). This intervention has been specifically developed to manage patients' stressful life events, improve the disruptions of social and circadian rhythms and increase adherence to medications. The aim of the present study is to assess the efficacy of IPSRT on affective and anxiety psychopathology, social functioning, response to pharmacological treatment and affective morbidity index (AMI) in BD patients.

METHODS

BD patients were consecutively recruited at the Mood Disorder Unit of the University of Campania "Luigi Vanvitelli" and randomly assigned to the experimental group receiving the IPSRT or to the Treatment as Usual (TAU) group. Patients were assessed at baseline, after 3 and 6 months with several validated assessment tools and with the affective morbidity index.

RESULTS

At the end of the intervention, compared to controls, patients from the experimental group reported a significant improvement in anxious depressive and manic symptomatology, global functioning; and response to mood stabilizers. Patients in the IPSRT group reported a reduction at the AMI score.

CONCLUSIONS

IPSRT has been confirmed to be effective in improving the clinical symptomology of BD patients and in improving the affective morbidity index. Further studies with longer follow-up are needed in order to assess the stability of the results.Trial registration The study was approved by the local ethical review board (N001567/28.01.2018).

Attitudes of Italian Psychiatrists Toward the Evaluation of Physical Comorbidities and Sexual Dysfunction in Patients With Schizophrenia. Implications for Clinical Practice

Treatment guidelines for patients with schizophrenia recommend evaluating their risk of physical comorbidities, especially since these patients are known to have decreased life expectancy due to comorbidities. Therefore, to the authors' knowledge, this is the first national survey conducted to investigate how Italian psychiatrists deal with the risk of physical comorbidities and sexual dysfunction in patients with schizophrenia. A sample of 750 psychiatrists completed an ad hoc online survey investigating their decision making about performing blood tests, clinical and instrumental examinations, and scheduling follow-up appointments in relation to the different phases of the illness and possible pharmacological side effects. Compared to patients in therapeutic continuation, those diagnosed for the first time and those who received a therapeutic change were visited more frequently (every 15 to 17 days vs. every 40 days, respectively), and were more regularly prescribed blood tests and instrumental examinations (every 4.2 to 4.4 months vs. every 9 months, respectively). There was a high interest in the surveillance of cardiometabolic risk. In 54% of patients, prolactin testing was not requested before starting an antipsychotic. In terms of specialist referrals, only 5% of surveyed psychiatrists "never" sought for additional counseling. There was little attention given to sexual functioning assessment based on the survey results about patients' daily life and with regard to deciding to prescribe additional examinations. In fact, only up to 3% of psychiatrists reported assessing sexual functioning using specific psychometric tests. In summary, Italian psychiatrists describes themselves as careful healthcare providers for the physical illnesses of patients with schizophrenia but with several shortcomings. For instance, clinical attention toward patients' sexual and reproductive healthcare needs remains a challenge. Psychiatrists should take the lead for the integrated education, assessment, and care of medical needs of their patients with mental illness. Based on the results of this survey, the authors also believe that a future challenge for the management of patients with mental illness will be the classification of patients based on their risk of comorbidities, to help ensure optimal healthcare provision for those at greater risk of other illnesses.

Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes

Major depression shortens life while the effectiveness of frontline treatments remains modest. Exercise has been shown to be effective both in reducing mortality and in treating symptoms of major depression, but it is still underutilized in clinical practice, possibly due to prevalent misperceptions. For instance, a common misperception is that exercise is beneficial for depression mostly because of its positive effects on the body ("from the neck down"), whereas its effectiveness in treating core features of depression ("from the neck up") is underappreciated. Other long-held misperceptions are that patients suffering from depression will not engage in exercise even if physicians prescribe it, and that only vigorous exercise is effective. Lastly, a false assumption is that exercise may be more harmful than beneficial in old age, and therefore should only be recommended to younger patients. This narrative review summarizes relevant literature to address the aforementioned misperceptions and to provide practical recommendations for prescribing exercise to individuals with major depression.

Stop Turning a Blind Eye: Tobacco Smoking Among Egyptian Patients With Schizophrenia

Background: Patients with schizophrenia have considerably higher rates of mortality than general population. Multiple factors may play a role in this. Despite being a major preventable cause of death, smoking is usually overlooked when dealing with patients with schizophrenia. Understanding the pattern of smoking, its severity, and the reasons to quit might be helpful in managing patients with schizophrenia and decreasing the mortality gap. Subjects and Methods: The study included smokers divided into two groups; the first included 346 patients with schizophrenia while the second group had 150 smokers with no mental illness. Both groups were assessed and compared regarding sociodemographic variables, pattern of smoking, severity of nicotine dependence, and motivation to quit smoking. Results: Earlier age of starting to smoke, higher number of cigarettes per day, and lower dependency scores were noted in patients with Schizophrenia. Positive correlation was found between positive symptoms and severity of dependence. Specific positive symptoms were correlated to number of cigarettes per day and time before first cigarette. Patients with Schizophrenia showed a significant difference in intrinsic reasons to quit (health concerns and self-control), which were also positively correlated to their positive symptoms score. Linear regression analysis for predictors of FTND score revealed that only age, sex, and schizophrenia were significant predictors of FTND score. Conclusion: Patients with schizophrenia smoke at earlier ages and smoke more cigarettes per day, yet, have less severe dependence than non-schizophrenic counterparts. Positive symptoms play a role in their smoking pattern and severity. Health concerns and self-control are their main motives to quit smoking.