A Comparative Study on Mental Disorder Conceptualization: A Cross-Disciplinary Analysis

The conceptualization of mental disorders varies among professionals, impacting diagnosis, treatment, and research. This cross-disciplinary study aimed to understand how various professionals, including psychiatrists, psychologists, medical students, philosophers, and social sciences experts, perceive mental disorders, their attitudes towards the disease status of certain mental states, and their emphasis on biological versus social explanatory attributions. A survey of 371 participants assessed their agreement on a variety of conceptual statements and the relative influence of biological or social explanatory attribution for different mental states. Our findings revealed a consensus on the need for multiple explanatory perspectives in understanding psychiatric conditions and the influence of social, cultural, moral, and political values on diagnosis and classification. Psychiatrists demonstrated balanced bio-social explanatory attributions for various mental conditions, indicating a potential shift from the biological attribution predominantly observed among medical students and residents in psychiatry. Further research into factors influencing these differing perspectives is necessary.

Arterial supply and morphological characteristics of sympathetic neurons in the human superior cervical ganglion

The aim of this study was the micromorphological analysis of the distribution of microvessels, mast cells and ganglionic neurons in two parts, proximal and distal of the human superior cervical sympathetic ganglions (SCSGs). Statistical analyses were applied to detect the possible metric regional differences in their densities. Five injected human SCSGs with colored India ink and gelatin were microdissected and examined. Second group of five human SCSGs was prepared and serially sliced for CD34 and mast cell tryptase immunostaining. The microscopic fields of two parts of the SCSGs were analyzed for the following quantifications: microvessel density (MVD), mast cell density (MCD), and ganglionic cell count and measurements. The mean number of CD34-positive microvessels in microscopic fields, the MVD, had a value of 83 for the upper parts, and 82.7 for the lower parts of SCSGs. The mean number of tryptase-positive mast cells in microscopic fields, the MCD, was 4.5 in the proximal parts, and 4.7 in the distal parts of SCSGs. The mean number of ganglionic neurons in microscopic fields was 19.5 in the proximal parts, and 19.8 in the distal parts of SCSGs. The density of CD34-positive microvessels, the density of tryptase-positive mast cells, and the density, mean diameters and mean areas of ganglionic neurons were not significantly different in two observed parts, upper and lower of the SCSGs. In conclusion, the distributions of microvessels, mast cells, and neurons in two parts of the SCSGs were uniform with no specific micromorphological variations, there is a homogenous vascular and cellular pattern within the SCSGs.

The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

Diagnostic psychiatric and somatic comorbidity in patients with depression in the Western Balkan countries

INTRODUCTION

This paper aims to examine the frequency and significance of diagnostic comorbidity of psychiatric disorders and somatic diseases in a sample of patients with depression as well as present current psychopharmacological treatment of the patients in the sample.

METHODS

The subjects in this study sample were 489 patients from the four Western Balkan countries with current primary diagnosis of major depression according to ICD 10. Comorbid psychiatric disorders and non-psychiatric illnesses were noted according to ICD 10 criteria during the diagnostic interview and analysed later. Additionally, the pharmacological treatment (existing and newly introduced) for each patient was noted and analysed later.

RESULTS

At least one comorbid psychiatric disorder was present in 72.5% of patients. The most frequent were anxiety disorders (53.6%), specifically generalized anxiety disorder (20.2%); non-organic sleep disorders (50.7%), specifically insomnia (48.4%); and sexual dysfunctions (21.4%), specifically lack of sexual desire (20.2%). Comorbidity with any non-psychiatric illness was present in 80.3% of patients. The most frequent were circulatory system diseases (55.9%), specifically hypertension (45.9%); endocrine, nutritional and metabolic disorders (51.3%), specifically hyperlipidaemia (24.0%); and other non-psychiatric disorders (60.7%), specifically low back pain (22.7%). All patients received pharmacological treatment with different medications. Most patients received monotherapy or combination therapy of antidepressants, anxiolytics, antipsychotics and antiepileptics. The most frequently used antidepressants were escitalopram, sertraline, and duloxetine. The most frequently used anxiolytics were alprazolam and diazepam, the most used antiepileptic was pregabalin, and the most used antipsychotics were olanzapine, quetiapine, and aripiprazole.

CONCLUSION

The results of the study confirm the results of previous research studies about the high prevalence of psychiatric and non-psychiatric comorbidities in patients with depression that were conducted in the past. It would be important if future studies could prove the importance of those comorbidities on clinical severity, choice of treatment, and its outcome in patients with depression.

Are Cyberchondria and Intolerance of Uncertainty Related to Smartphone Addiction?

Smartphones are a medium for performing online activities, and one such activity could be the compulsive online health information search - cyberchondria. This study aimed to test whether cyberchondria and intolerance of uncertainty (IU) positively predict smartphone addiction (SA), adjusted for age, gender, daily use duration, the reason for using smartphones, and symptoms of anxiety and depression. The sample consisted of 471 adults (55.2% women) from the general population without chronic diseases (Mage = 38.67). Regression analysis showed that IU was a positive predictor of SA (β = .17, p < .001), as well as cyberchondria (β = .14, p < .001), which had a unique contribution to the explanation of SA, relative to IU. Other significant predictors were average daily smartphone use and entertainment use, the latter being the strongest predictor in the model. These results revealed cyberchondria as a unique predictor of SA.

Psychometric Properties of the Serbian Smartphone Application-Based Addiction Scale (SABAS) and Validation of the English Version Among Non-native English Speakers

The present study evaluated the psychometric properties of the Serbian Smartphone Application-Based Addiction Scale (SABAS) and the original English version of the same scale administered to a Serbian-speaking sample. In Study 1, 599 participants completed Serbian SABAS, with 189 having both test and retest data. Results suggested good internal consistency (α = .81) and test–retest reliability (ICC = .795, p < .001, 95% CI [.731, .844], rtest-retest = .803) of the scale. Convergent validity of the SABAS was evaluated through correlations with the Smartphone Addiction Scale–Short Version (SAS-SV), as well as with anxiety, depression, worry, duration, and purpose of smartphone use. Divergent validity of the SABAS was evaluated through comparing the correlations with entertainment and productive smartphone use. The modified CFA model showed an acceptable fit (χ2(8) = 25.53, p = .001, CFI = .961, TLI = .926, RMSEA = .096, SRMR = .042), confirming the unidimensionality of the SABAS. In the second study, the English SABAS, completed by 335 non-native speakers from Serbia, also showed a good fit of the single-factor model (χ2(9) = 12.56, p = .184, CFI = .990, TLI = .984, RMSEA = .036, SRMR = 0.026), and good psychometric features. Based on the study’s findings, the Serbian version of SABAS is a reliable and valid measure for screening the risk of smartphone addiction. Moreover, the English version can be used among non-native Serbian English speakers.

Correlation of Ionized Magnesium with the Parameters of Oxidative Stress as Potential Biomarkers in Patients with Anxiety and Depression: A Pilot Study

Background

Magnesium (Mg) is the second most abundant intracellular cation. Ionized Mg is the only active form of Mg. The concentration of ionized Mg could be a potentially novel biomarker for anxiety and depression.

Aim

The aim of this study was to assess the serum concentration of ionized Mg and its correlation with biomarkers of oxidative stress and inflammation in patients with anxiety and depression.

Methods

In this study included 93 respondents were divided into 3 groups: C (control group—18 respondents); A (patients with anxiety disorder, dissociative/conversion disorders and somatoform disorders—36 patients); D (patients with depression—39 patients). Clinical diagnosis was based on ICD-10 criteria. Blood samples were used for standard laboratory analysis, ionized Mg analysis, oxidative stress, and inflammatory parameters.

Results

Statistical significance was recorded between healthy volunteers and patients (anxiety/depression) in ionized Mg values. In anxious patients, malondialdehyde (MDA) had a positive correlation between the parameters of oxidative stress with ionized Mg. In depressive patients, MDA had a positive correlation, and glutathione peroxidase 1 (GPX1) a negative correlation with the concentration of ionized Mg.

Conclusion

Ionized Mg and its correlation with parameters of oxidative stress could be potential biomarkers in anxious and depressive patients.

The Role of Psychotherapy in the Treatment of Patients with Non- alcoholic Fatty Liver Disease and Obstructive Sleep Apnea

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is a metabolic disease with extensive multi- organ involvement, whose extra-hepatic manifestations include diabetes mellitus type 2, cardiovascular disease, obstructive sleep apnea (OSA), chronic kidney disease, and polycystic ovary syndrome. Our hypothesis was that there was a strong psychological component in NAFLD and OSA suffering patients and that psychotherapy would be helpful in the treatment of the mentioned diseases.

METHODS

Of 144 initially selected patients (with NAFLD, obesity and OSA), 32 patients agreed to undergo psychotherapy, and 31 therapy-naive NAFLD and OSA patients agreed to participate as controls.

RESULTS

Psychological evaluation revealed that self-esteem rose significantly after one-year psychotherapy (p=0.005). Body mass index (BMI) was significantly lower after psychotherapy, followed by the changes in laboratory results. Binomial logistic regression revealed that the reduction of BMI in high probability led to self-esteem improvement (p=0.03).

CONCLUSIONS

Psychotherapy was an efficient supporting method in the treatment of patients with NAFLD, obesity and OSA. It raised self-esteem and stimulated the motivation for further treatment of obesity, as one of the important factors for NAFLD and OSA. Still, it is advisable to use psychotherapy in combination with other clinical methods of treatment.

Gender differences in depression, anxiety, and stress during the first wave of the COVID-19 pandemic in serbia - results from an online survey

Introduction

COVID-19 outbreak has significantly affected the mental health of people worldwide. The first wave of the pandemic began during the beginning of March 2020, and included significant preventative measures. Previous research on mental health differences between the genders has found that women were more likely to exhibit symptoms of anxiety during the COVID-19 outbreak.

Objectives

The aim of our study was to assess the differences between the genders in depression, anxiety, and stress.

Methods

An online survey designed for the purposes of this study was distributed using the snowballing method during April and May of 2020. The survey consisted of two parts: sociodemographic and clinical data, and COVID-19 related data. Participants also filled out the Depression, Anxiety and Stress Scale (DASS-21) - a well validated, self-questionnaire instrument. T-test for independent samples was used to evaluate the differences between the genders.

Results

Out of the initially sent 563 surveys, a total of 161 were included in further analyses (28.6% response rate). Mean age of the sample was 42.2±10.2 and 65.2% of the participants were female. Mean scores on DASS-21 were as follows: 8.78±6.66 on depression, 9.78±7.39 on anxiety and 7.76±7.14 on stress. Females scored significantly higher on depression (t=-2.25, p=0.029), anxiety (t=-2.25, p=0.028), stress (t=-2.44, p=0.017), and total DASS-21 score (t=-2.44, p=0.016).

Conclusions

The results of our study imply that female participants exhibit higher levels of depression, anxiety, and stress during the COVID-19 pandemic. Larger, population-based studies could provide a mroe in-depth answer to the importance of these differences for the general population.

The Sexuality of Sex Workers: Sexual Arousability and the Sexual Profile of Women Engaged in Prostitution in Serbia

BACKGROUND

In a view of sex work being a sexual behavioural activity, the main objective of our research was to explore the sexuality of sex workers in Serbia regarding to intensity of their sexual arousability.

SUBJECTS AND METHODS

The research was conducted on 30 sex workers and 30 controls of randomly selected social and demographic characteristics, without any signs of psychiatric morbidity. For the evaluation of the intensity of sexual arousability, SAI (Sexual Arousability Index) questionnaire was used.

RESULTS

The analysis of the main total scores of the SAI for the sex workers and control participants showed no statistically significant difference in the overall intensity of arousability (p>0.05). However, item by item analysis of the questionnaire showed qualitative difference in sexuality between sex workers and controls, related to certain aspects of sexuality.

CONCLUSIONS

These findings allow the space for further research in the way of identifying origins of qualitative issues in the sexual profile of sex workers, in correlation to women who are not sex workers, i.e. whether they had been result of potential biological, specific psychodynamic factors, or have been formed as a result of the direct influence of the sex work.

Internet use during coronavirus disease of 2019 pandemic: Psychiatric history and sociodemographics as predictors

Coronavirus disease of 2019 (COVID-19) pandemic and related containment measures have grossly affected the daily living and created a need for alternative ways of social communication and entertainment. The aim of this study was to explore the use of various Internet contents depending on sociodemographics and on psychiatric history of participants. This cross-sectional, population-based study is a part of a wider international multicenter study. A total of 1275 participants across Serbia (71.1% of females; average age = 41.81 ± 12.52 years) were recruited using two-level chain-referral sampling method. The participants filled in an anonymous online questionnaire that included questions on sociodemographic data, psychiatric history, and various aspects of increased Internet use since the pandemic. The data were analyzed using a series of multiple logistic regressions. About two-thirds of the sample reported using Internet more during the pandemic. All of the tested regression models, apart from models predicting browsing religion and travel/tourism, were significant, explaining from about 2% (for the contents specific for COVID-19) up to 34.4% (for the sexual content) of variance of use. Reporting a previously diagnosed psychiatric disorder was a significant predictor of greater Instagram use and browsing sexual and sport-related content since the pandemic. To the best of our knowledge, the study is the first to report on the relationship between Internet using and mental health, during COVID-19 pandemic, in the Balkan region. The findings showed various patterns of the increased use of Internet contents since the pandemic referring to both potentially positive and negative Internet influences.

Predictors of work disabilities in patients with panic disorder with agoraphobia

Objective

The aim of this study was to ascertain predictors of work insufficiency in patients with panic disorder (PD) with agoraphobia (AG).

Method

Linear regression was used to identify predictors of work insufficiency in a sample of 72 consecutive outpatients with PD with AG. Intensity of work insufficiency was ascertained from modified National Institute of Mental Health Panic Questionnaire (NIMH PQ). That represented dependent variable. Independent variables were demographic data, duration of illness, presence of comorbid current major depression episode, presence of any personality disorder and scores on the Panic and Agoraphobia Scale (PAS) subscales: panic attacks, AG (avoidance behavior), anticipatory anxiety and worries about health.

Results

Patients reported severe work insufficiency. The best predict variable for the work insufficiency in patients with PD with AG was high score on the PAS dimension of AG.

Conclusion

Patients generally reported severe effects of PD with AG on work efficacy and the results suggested that the impaired work efficacy was the most associated with avoidance behavior. These results recommend that the treatment of PD with AG patients should be related to decreasing avoidance behavior in order to establish adequate work performance in patients.

Reliability of the bicaudate parameter in the revealing of the enlarged lateral Ventricles in schizophrenia patients

INTRODUCTION

In schizophrenia patients the lateral ventricle enlargement has mostly been reported in relationship with smaller cortical and/or subcortical brain volumes; and it has been observed that ventricular system growth may be a consequence of the smaller caudate nucleus volume. Bicaudate parameters have been used in the Alzheimer dementia and Huntington's chorea diagnosing in order to evaluate brain changes and the enlargement of the lateral ventricles.

SUBJECTS AND METHODS

This study has been carried out on 140 patients out of which 70 patients (30 men and 40 women) who met the ICD 10 criteria for schizophrenia and 70 healthy controls (30 men and 40 women) matched on sex and age with the studied group. All of them underwent direct caudatometry and volume computation based on MRI scans.

RESULTS

Except for the bicorporal line, for all the parameters were obtained the statistically highly significant differences between the examined and control groups. Significant correlation was established for the majority of bicaudate parameters and volumes of the caudate nuclei and lateral ventricles.

DISCUSSION

Enlargement of the lateral ventricles is one of the most frequent MRI finding in schizophrenia patients. Ventricles are enlarging gradually and frontal horns are more affected than other parts. The increased volumes of the caudate nuclei signalized that ventricular enlargement is not the consequence of the caudate atrophy.

CONCLUSION

Bicaudate parameters are reliable parameters for the quick orientation in order to assess the enlarged ventricles in schizophrenia patients.

Is Balint training associated with the reduced burnout among primary health care doctors?

The aim of our study was to examine whether the participation in Balint group is associated with the reducing burnout syndrome among primary health care doctors. This investigation was conducted on a population of 210 doctors employed in primary health centers in Belgrade. Out of 210 doctors, 70 have completed Balint training for a period of at least 1 year, whereas 140 doctors have never attended this training (the Non-Balint group). The level of burnout among physicians was assessed with the Serbian translation of the original 22-item version of the Maslach Burnout Inventory - Human Services Survey which defines burnout in relation to emotional exhaustion, depersonalization and personal accomplishment. We found that 45.0% of the Non-Balint participants and 7.1% of the Balint-trained participants responded with symptoms of high level of emotional exhaustion, with a statistically significant difference (p < 0.001). In relation to depersonalization, 20% of the Non-Balint subjects were highly depersonalized compared to 4.4% of the Balint-trained subjects, with a statistically significant difference (p < 0.001). Regarding the personal accomplishment, 21.4% of the Non-Balint subjects and 7.1% of the Balint-trained subjects had a perception of low personal accomplishment, with a statistical significance (p < 0.001). In the multiple ordinal logistic model, with emotional exhaustion as a dependent variable, statistically significant predictor was female gender (OR = 2.51; p = 0.021), while Balint training was obtained as a protective factor (OR = 0.12; p < 0.001). Non-specialists were detected as a risk factor for depersonalization (OR = 2.14; p = 0.026) while Balint group was found as a protective factor (OR = 0.10; p < 0.001), according to the multiple ordinal logistic regression analysis. Regarding the reduced personal accomplishment, our results indicated that nonspecialists were at risk for this subdimension (OR = 2.09; p = 0.025), whereas Balint participants were protected (OR = 0.18; p < 0.001). Participation in Balint groups is associated with the reduced burnout syndrome among primary health care doctors.

Psychiatrists' treatment preferences for generalized anxiety disorder

OBJECTIVE

The objective of this study is to ascertain psychiatrists' treatment preferences for generalized anxiety disorder (GAD) and compare them to the same psychiatrists' treatment preferences in the hypothetical scenario that treatment is to be administered to themselves as patients.

METHODS

A questionnaire was completed by 221 psychiatrists from 3 Balkan countries. They were asked to indicate their treatment preferences for patients with GAD and for themselves as patients.

RESULTS

A large majority of psychiatrists chose selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors as preferred treatment option for GAD patients. Fewer psychiatrists selected benzodiazepines and pregabalin and about one third chose psychotherapy. The majority of psychiatrists chose the same treatments for their patients and for themselves, with main differences being in terms of pharmacotherapy (especially benzodiazepines) being less frequently recommended and psychotherapy being more frequently recommended as preferred treatment option for psychiatrists as patients.

CONCLUSIONS

Treatment preferences for GAD by psychiatrists in the 3 West Balkan countries were mostly in accordance with treatment guidelines and treatment preferences for patients and for psychiatrists as patients were mostly concordant. However, some psychiatrists were more likely to choose pharmacotherapy for patients and psychotherapy for themselves as patients. These findings have implications for education of psychiatrists and for efforts to improve treatment guidelines and mental health services.

The Balkan region preferences for the treatment of anxiety disorders

The most countries from West Balkan region do not have the official guidelines for the treatment of patients with anxiety disorders (AD).

We have done the survey on preferences of treatment of patients with AD. We have collected data from sample of 221 psychiatrists from Croatia (41 psychiatrists), Macedonia (81 psychiatrists) and Serbia (99 psychiatrists). They give as information about their preferences for treating patients with AD.

The results indicate that the vast majority of psychiatrists report that almost all patients with AD receive benzodiazepines prior to first psychiatric visit. The majority of psychiatrist would opt for SSRI/SNRI antidepressants (91–97%) as the monotherapy or in combination with benzodiazepines (53–59%) or in combination with cognitive-behavior (25–35%) or psychodynamic psychotherapy (12–16%).

The most indicative difference between psychiatrists from different countries is result about the use of pregabalin – almost half of Serbian subsample would opt for pregabalin, but only a quarter of Croatian subsample and no psychiatrist from Macedonian subsample would choose pregabalin. Also, much more Macedonian and Serbian psychiatrist would opt for CBT treatment, but, in contrast, much more Croatian psychiatrist would opt for psychodynamic psychotherapy versus CBT. There is the dissimilarity between preferences for patients’ treatment and preferences for psychiatrists himself/herself treatment:

– more than half of the sample would opt for benzodiazepines in their patients but only the third of the sample would prefer benzodiazepines for himself/herself treatment;

– more psychiatrists would prefer to receive psychotherapy treatment than they would prefer to give it to their patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Personality disorders and anxiety disorders: what is the relationship?

PURPOSE OF REVIEW

To systematically review the recent studies which examined the co-occurrence and relationships between anxiety disorders and personality disorders.

RECENT FINDINGS

The prevalence rates of personality disorders in patients with anxiety disorders are high, with 35% in posttraumatic stress disorder, 47% in panic disorder with agoraphobia and generalized anxiety disorder, 48% in social phobia, and 52% in obsessive-compulsive disorder. There is a high rate (39%) of the DSM cluster C personality disorders among individuals with anxiety disorders. Moreover, anxiety disorders are highly prevalent in samples of people with personality disorders, especially borderline personality disorder (80-84.8%). Personality disorders co-occurring with anxiety disorders have a number of clinical implications, including an increased risk of suicide, greater severity of anxiety disorders, and negative impact on the treatment outcome of anxiety disorders.

SUMMARY

It is important for the clinicians to look for possible personality disorders among patients with anxiety disorders. Further studies need to ascertain how best to treat individuals suffering from both anxiety disorders and personality disorders and focus on the issue of causality when these conditions co-occur.

Psychiatrists' psychotropic drug prescription preferences for themselves or their family members

BACKGROUND

Psychiatrists' preference for certain medications is not only determined by their efficacy and side effect profile but may also depend on the psychiatrists' beliefs about specific therapeutic effects based on their own observation and experience. We aimed to evaluate which antipsychotic or antidepressant drugs psychiatrists would prefer for themselves, their partners and children in case of a mental illness.

SUBJECTS AND METHODS

The study was conducted among psychiatrists in Serbia. The sample consisted of 90 psychiatrists who were asked to complete the questionnaire about their drug selection in hypothetical situations of becoming ill with schizophrenia or depression or these conditions occurring in their partners and children.

RESULTS

In case of schizophrenia, risperidone was the first choice made by most psychiatrists for themselves, their partners or children, followed by clozapine, haloperidol and olanzapine. In case of depression, SSRIs and SNRIs were generally favored, with sertraline and escitalopram being the preferred medications for psychiatrists, partners and their children. With regards to depression, 82.3% of participants would opt for an antidepressant as monotherapy or in combination, but 13.3% would opt for anxiolytic monotherapy. The preferred doses were slightly lower than the recommended ones, especially for antipsychotic agents.

CONCLUSIONS

Most psychiatrists would take or administer atypical antipsychotics or SSRIs as the first choice for themselves, their partners or children. These preferences are mostly in accordance with current treatment guidelines, but there is still room to narrow the gap between guideline recommendations and psychiatrists' medication choices in personally meaningful situations.

Reliability of the Hamilton Rating Scale for Depression: a meta-analysis over a period of 49 years

The aim of this study was to provide a comprehensive meta-analytic review of the reliability of the Hamilton Rating Scale for Depression (HRSD) for the period 1960-2008, taking into consideration all three types of reliability: internal consistency, inter-rater, and test-retest reliability. This is the first such meta-analytic study of a clinician-administered psychiatric scale. A thorough literature search was conducted using MEDLINE and PsycINFO. The total number of collected articles was 5548, of which 409 reported one or more reliability coefficients. The effect size was obtained by the z-transformation of reliability coefficients. The meta-analysis was performed separately for internal consistency, inter-rater and test-retest reliability. A pooled mean for alpha coefficient in random effects model was 0.789 (95%CI 0.766-0.810). The meta-regression analysis revealed that higher alpha coefficients were associated with higher variability of the HRSD total scores. With regard to inter-rater reliability, pooled means in random effects model were 0.937 (95%CI 0.914-0.954) for the intraclass correlation coefficient, 0.81 (95%CI 0.72-0.88) for the kappa coefficient, 0.94 (95%CI 0.90-0.97) for the Pearson correlation coefficient, and 0.91 (95%CI 0.78-0.96) for the Spearman rank correlation coefficient. A meta-regression analysis showed positive association between inter-rater reliability and publication year. Test-retest reliability of HRSD ranged between 0.65 and 0.98 and generally decreased with extending the interval between two measurements (Spearman r between the duration of interval and test-retest reliability figures=-0.74). Results suggest that HRSD provides a reliable assessment of depression. Figures indicate good overall levels of internal consistency, inter-rater and test-retest reliability, but some HRSD items (e.g., "loss of insight") do not appear to possess a satisfactory reliability.

Oral health status of psychiatric in-patients in Serbia and implications for their dental care

AIM

To determine oral health status and identify predictors of oral health in a representative sample of psychiatric in-patients in Serbia.

METHODS

The study included 186 psychiatric in-patients and 186 control participants without psychiatric illness matched to the study group by age, sex, marital status, education level, employment, and monthly income. Dental examinations were done in both groups to measure the following indices of oral health: decayed, missing, and filled teeth (DMFT) index; community periodontal index; and plaque index. Participants were also interviewed about their dental health behavior and their medical records were examined.

RESULTS

Psychiatric in-patients had higher caries prevalence, poorer periodontal health, and poorer oral hygiene than controls. The average DMFT score in the patient group was 24.4 and 16.1 in the control group (P<0.001). Periodontal diseases were significantly more prevalent among psychiatric in-patients than among controls (P<0.001). The average plaque index for patients was 2.78 and 1.40 for controls (P<0.001). Multiple regression analysis demonstrated that 1) DMFT index was associated with age, male sex, duration of mental illness, use of antidepressants, time since the last visit to the dentist, and snacking frequency; 2) community periodontal index was associated with male sex; and 3) plaque index was associated with age, male sex, education level, employment, monthly income, tooth brushing technique, and snacking frequency.

CONCLUSION

Psychiatric in-patients in Serbia have poorer oral health than healthy controls. It is necessary to intensify preventive dental care in this vulnerable population.

[Panic attacks simulate presence of somatic illnesses]

INTRODUCTION

Panic attacks are characterized with sudden attacks of anxiety with numerous somatic symptoms, such as palpitations, tachycardia, tachypnea, nausea, vertigo. The objective of this study was to analyze symptoms of panic attacks in patients with panic disorder, especially, to determine the specific relationship of somatic and neurological symptoms of panic attacks in boundaries of somatic systems.

MATERIAL AND METHODS

The study sample consisted of 97 patients with primary diagnosis of panic disorder, without any acute, severe and unstable somatic illness. The presence and frequency of symptoms of panic attacks were estimated by the Panic Disorder Questionnaire.

RESULTS

The study results indicate that the most frequent symptoms of panic attacks were cardiological signs (heart pounding or racing) and trembling, followed by unsteady and fainting feeling symptoms, sweating, respiratory symptoms and gastroenterological symptoms. The results of correlation analyses indicate that symptoms of panic attacks classified into cardiovascular, gastro-enterological, respiratory and neurootological systems show statistically significant correlations.

CONCLUSION

The results of analyses of symptoms of panic attacks point to their intercorrelation. This specific association of the symptoms, if they are examined on their own in the patients, could lead to false clinical manifestation of some somatic illness. Therefore, it is necessary to analyze adequately and make the proper differential diagnosis of patients with panic disorder.

Co-occurrence of Axis I and Axis II disorders in female and male patients with panic disorder with agoraphobia

OBJECTIVE

The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA.

METHODS

The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders.

RESULTS

Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women.

CONCLUSIONS

The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.

Are there gender differences in catastrophic appraisals in panic disorder with agoraphobia?

Our aim in this study was to compare panic-related catastrophic appraisals between women and men with panic disorder with agoraphobia (PDA). One hundred two outpatients with PDA (75 women and 27 men) participated. Two instruments for the assessment of catastrophic appraisals, Agoraphobic Cognitions Questionnaire and Panic Appraisal Inventory, were administered before and after cognitive-behavioral therapy (CBT) that also included pharmacotherapy in three-fourths of the patients. Female and male patients did not differ significantly in terms of their tendency to anticipate catastrophic consequences of panic, before or after CBT-based treatment. For both females and males, the tendency to make catastrophic appraisals decreased significantly with treatment. We conclude that among patients with PDA there are no gender differences in catastrophic appraisals of panic sensations and symptoms. The apparently higher risk of panic recurrence in women does not seem to be related to their panic-related catastrophic appraisals. These findings also support a notion that there is no gender difference in response to CBT-based treatment of PDA.

Gender differences in psychopathologic features of agoraphobia with panic disorder

Background/Aim. To examine gender differences in the major psychopathologic features in agoraphobia with panic disorder. Method. The study was conducted as a clinical study. The sample consisted of 119 patients, 32 men (26.9%) and 87 women (73.1%) with the basic diagnosis of agoraphobia with panic disorder. All the patients were evaluated with the clinical instruments suitable for the assessment of various clinical features associated with agoraphobia with panic disorder - questionnaires (the Hopkins Symptom Checklist 90, the Panic Appraisal Inventory, the Fear Questionnaire, the Beck Anxiety Inventory, and the Beck Depression Inventory), and the clinical rating scale (the Panic and Agoraphobia Scale). After the data collection, the sample was divided into two groups by the gender. Then the groups were compared. Results. There were no differences between the genders in the global psychopathologic features (the age at the onset of a disorder, duration of a disorder, severity and frequency of panic attacks, intensity of general psychiatric symptoms, intensity of general anxiety and depression). The women, however, reported a subjective perception of a more severe agoraphobic avoidance and males were significantly more likely than the females to anticipate the serious somatic consequences of panic attacks and worry about somatic health. Conclusion. There were a few gender specific psychopathologic features in patients with agoraphobia with panic disorder, so further studies would be necessary to come to a more precise conclusion.

Relationship of psychiatric comorbidity and treatment of panic disorder and agoraphobia

Introduction. Besides numerous studies that examined various aspects of comorbidity in patients with panic disorder and agoraphobia and numerous studies that examined efficacy of different treatment modalities in these patients, there was no study that examined relationship of overall psychiatric comorbidity and treatment of patients with panic disorder and agoraphobia. Objective. The objective of the study was to establish the effect of psychiatric comorbidity on treatment efficiency of patients with panic disorder and agoraphobia. Method. The sample of the study consisted of 119 patients with primary diagnosis of panic disorder and agoraphobia. The therapy of patients was based on the use of individual integrative model of treatment, which incorporated psycho-pharmaceuticals (benzodiazepines and antidepressants) and cognitive- behavior therapy. Symptom severity was estimated by Panic and Agoraphobia Scale before and after the completion of treatment. Patients with comorbidity and patients without any comorbidity were compared by MANOVA and ANOVA with repeated measures. Results. The results of the study showed that 91% of patients met diagnostic criteria of comorbid psychiatric disorder and these patients had more severe clinical picture than patients without any comorbid disorder before the treatment. The results also showed that, after the completion of treatment, there was a significant reduction of all analyzed symptoms, that the effects of treatment were significantly better in patients with psychiatric comorbidity and that comorbid psychiatric disorders had no negative effect on the main goals of the treatment. Conclusion. Based on these results, it may be concluded that: in patients with panic disorder and agoraphobia and comorbid psychiatric disorders, the pharmacotherapy must be based on simultaneous use of antidepressants and benzodiazepines, while standard cognitive-behavior therapy of patients with panic disorder and agoraphobia must be modified in case of the existing comorbid psychiatric disorders.

Treatment of panic disorder with agoraphobia in an anxiety disorders clinic: factors influencing psychiatrists' treatment choices

The main objective of this report was to identify patient characteristics that led psychiatrists in an academic anxiety disorders clinic to make a decision about intensive treatment of patients with panic disorder with agoraphobia (PDA) with cognitive-behavioral therapy (CBT) alone, CBT plus a high-potency benzodiazepine (CBT+BZ) or CBT combined with BZ and an antidepressant, fluoxetine (CBT+BZ+AD). On the basis of their clinical judgment and collaborative negotiation with the patient, psychiatrists chose one of the three treatment modalities for 102 PDA outpatients. Two stepwise logistic regressions were performed to explore pre-treatment patient characteristics the psychiatrists may have considered in choosing among these treatments. One regression examined the decision to add BZ to CBT, while the other examined the decision to add AD to CBT+BZ. Psychiatrists generally used combination treatments in patients with more severe PDA. CBT alone was a more likely choice for dominant anxiety-related cognitive phenomena. Patients with prominent panic attacks and somatic symptoms were more likely to be treated with CBT+BZ, while those who also had significant depressive symptoms and higher disability levels were more likely to receive CBT+BZ+AD. Patients in all three treatment groups showed significant reduction in symptoms during intensive treatment and reached similar end states. In a clinic setting where CBT is accepted as the basic treatment for PDA, psychiatrists added BZ to control prominent panic symptoms and added AD to elevate depressed mood and help cope with marked disability. These choices appear rational and resulted in substantial clinical improvement at the end of intensive treatment in the clinic.

Panic disorder patients at the time of air strikes

We assessed the impact of real danger on several aspects of the panic disorder (PD) patients' psychopathology and level of disability. At the time of the NATO air strikes on Belgrade, 84 PD patients who were in partial or complete remission were administered the Panic and Agoraphobia Scale (PAS). All had been treated previously, and the majority (58.3%) were taking antipanic medications. The PAS, which was used as part of the regular follow-up assessment battery for PD patients, measures the overall severity of PD and the severity of key aspects and components of PD. Compared to the PAS assessments made before the onset of air strikes, the PAS assessments made at the time of air strikes showed significant differences in terms of decreased overall severity of PD, fewer health concerns, decrease in the level of disability, and greater intensity and frequency of anticipatory anxiety. Differences on the measures of panic attacks and agoraphobic avoidance were negligible. These results suggest that there is no relationship between panic attacks and real danger and lend support to the notion that panic attacks and fear induced by real danger are different phenomena. Contrary to the expectations of many PD patients, the presence of real danger does not seem to be associated with deterioration in their functioning, and PD patients can be reassured that they are not likely to cope worse under conditions of danger.

Characteristics of agoraphobia in women and men with panic disorder with agoraphobia

We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall "profile" of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings.

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.