Exploring clozapine pharmacokinetics in Tunisian schizophrenic patients: A population-based modelling approach investigating the impact of genetic and non-genetic variables

Clozapine is characterized by a large within- and between-patient variability in its pharmacokinetics, attributed to non-genetic and genetic factors. A cross-sectional analysis of clozapine trough concentration (Clz C0) issued from Tunisian schizophrenic patients was collected and analysed using a nonparametric modelling approach. We assessed the impact of demographic covariates (age, weight and sex), patient's habits (smoking status, alcohol and caffeine intake) and the genetic factors (CYP1A2*1C, CYP1A2*1F and CYP2C19*2 polymorphisms) on each pharmacokinetic parameter. An external validation of this pharmacokinetic model using an independent data set was performed. Fit goodness between observed- and individual-predicted data was evaluated using the mean prediction error (% MPE), the mean absolute prediction error (% MAPE) as a measure of bias, and the root mean squared error (% RMSE) as a measure of precision. Sixty-three CLz C0 values issued from 51 schizophrenic patients were assessed in this study and divided into building and validation groups. CYP1A2*1F polymorphism and smoking status were the only covariates significantly associated with clozapine clearance. Precision parameters were as follows: 1.02%, 0.95% and 22.4%, respectively, for % MPE, % MAPE and % RMSE. We developed and validated an accurate pharmacokinetic model able to predict Clz C0 in Tunisian schizophrenic patients using the two parameters CYP1A2*1F polymorphism and smoking.

Depression among medical students in Tunisia: Prevalence and associated factors

BACKGROUND

Medical school is known for its lengthy process, which is both physically and emotionally draining. Students' mental balance would shrink as they progress in their medical training. A systematic review and meta-analysis reported that the prevalence of depressive symptoms among medical students remained relatively constant at 27.2%.

AIM

To assess the prevalence of depressive symptoms among Tunisian medical students and evaluate its associated factors.

METHODS

This is a descriptive cross-sectional study that was carried out in the second semester of the academic year 2017/2018, between April 2018 and July 2018 among 1138 medical students. Data were collected using a socio-demographic questionnaire and the Beck Depression Inventory-II (BDI-II).

RESULTS

Sixty-four percent (n = 728) of the participants had depressive symptoms, of which 266 (23.4%) met the criteria for mild, 271 (23.8%) for moderate, and 191 (16.8%) for severe depressive symptoms. Female gender, low socio-economic level, smoking habits and history of mental disorder, performing leisure and physical activities, satisfaction toward a career choice, and happiness perception were the main prognostic factors for depression among medical students. Although academic grades may not be considered a prognostic factor, final-year students appeared to be less depressive than their colleagues.

CONCLUSION

These findings give insight into mental health issues and comorbidities among Tunisian medical students. It is a hopeful request for decision-makers and academic authorities to set serious measures and draw effective interventions to minimize the currency of psychological distress among this subpopulation.

Eating disorder and anxiety during Covid19 pandemic: the Maghrebian experience

The coronavirus pandemic is considered the worst-hit that the world had witnessed in the current century. The impact of the pandemic, especially during the lockdown, was not only diverse but also worldwide. The African continent, including the Maghreb, was no exception. The aim of this study was to assess the levels of anxiety and eating behaviors and their correlations in three Maghrebian countries following the official outbreak of the COVID19 pandemic. It is a cross-sectional study of 754 participants from Tunisia, Algeria and Morocco. It took place between 30 April and 2 July 2020. The survey showed that eating disorders represented 45.9% of the sample while 26.8% (202 participants) matched the anxiety criteria. Statistical significant factors for eating disorders were gender (p = 0.002; OR = 1.760), underweight (p = 0.021; OR = 0.306), anxiety (p = 0.001; OR = 0.470), bulimia (p = 0.000; OR = 0.794) and body dissatisfaction (p = 0.000; OR = 0.920). This rise goes along with other surveys in different parts of the world. These results can be explained by multiple reasons such as the 'food insecurity' mechanism, the excessive feeling of boredom and loneliness resulting from social distancing and the overwhelming overthinking about the onset of a serious economic crisis.

An international research agenda for clozapine-resistant schizophrenia

Treatment-resistant symptoms occur in about a third of patients with schizophrenia and are associated with a substantial reduction in their quality of life. The development of new treatment options for clozapine-resistant schizophrenia constitutes a crucial, unmet need in psychiatry. Additionally, an overview of past and possible future research avenues to optimise the early detection, diagnosis, and management of clozapine-resistant schizophrenia is unavailable. In this Health Policy, we discuss the ongoing challenges associated with clozapine-resistant schizophrenia faced by patients and health-care providers worldwide to improve the understanding of this condition. We then revisit several clozapine guidelines, the diagnostic tests and treatment options for clozapine-resistant schizophrenia, and currently applied research approaches in clozapine-resistant schizophrenia. We also suggest methodologies and targets for future research, divided into innovative nosology-oriented field trials (eg, examining dimensional symptom staging), translational approaches (eg, genetics), epidemiological research (eg, real-world studies), and interventional studies (eg, non-traditional trial designs incorporating lived experiences and caregivers' perspectives). Finally, we note that low-income and middle-income countries are under-represented in studies on clozapine-resistant schizophrenia and propose an agenda to guide multinational research on the cause and treatment of clozapine-resistant schizophrenia. We hope that this research agenda will empower better global representation of patients living with clozapine-resistant schizophrenia and ultimately improve their functional outcomes and quality of life.

Attitudes toward mental illness among medical students and impact of temperament

BACKGROUND

Mental health-related stigma is a serious problem that has undesirable consequences for individuals with mental disorders including physical health disparities, increasing mortality, and social dysfunction. Besides, these individuals frequently report feeling 'devalued, dismissed, and dehumanized' when encountering health professionals who are also perpetrators of stigmatizing attitudes and discriminatory behaviors.

AIMS

The present study concentrates on attitudes, and behavioral responses of medical students and junior doctors toward individuals with a mental illness and explores factors associated with stigma including temperament.

METHODS

A cross-sectional study was conducted among medical students and junior doctors from medical schools of universities in Tunisia. All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform. Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians' Attitudes (MICA), Assessment of Affective Temperament, TEMPS-A scale.

RESULTS

A total of 1,028 medical students and junior doctors were recruited. The completion of a psychiatry clerkship for medical students didn't improve significantly the level of stigma toward people with a mental illness. Students in the fourth year had significantly the lowest MICA scores comparing to other students. Psychiatrists had significantly lower scores of explicit stigma attitudes than the other groups (Mean score = 0.42). As for other specialties, surgical residents had more stigmatizing attitudes than those who had medical specialties. 70% of participants believed that people with a mental illness are more dangerous than the other patients. Hyperthymic temperament was significantly associated with decreased stigma attitudes toward patients with mental illness.

CONCLUSION

A combination of medical school experiences of psychiatry's theoretical learning and clerkship and wider societal beliefs are important factors that shape students. Awareness of this will enable educators to develop locally relevant anti-stigma teaching resources throughout the psychiatry curriculum to improve students' attitudes toward mental illnesses.

Factors Associated with Mental Health Outcomes and the Level of Work Engagement Among Health Care Workers Exposed to Coronavirus Disease 2019 in Tunisia

Introduction

Heath workers especiallyin the emergency rooms and emergency medical services are exposed to sustained stress which had increased due to the Pandemic situation

Objectives

To search for factors associated with mental disorders among health workers during the Covid 19 pandemic

Methods

Data were collected through a questionnaire,with demographic variables anddifferentscales to evaluate the degree of symptoms of depression, anxiety, insomnia, distress, and the level of work engagement(PHQ-9,GAD-7,ISI,IES-R,UWES-9).

Results

Of the 217 participants, 46% were physicians, 42% were nurses and 12% were emergency medical technicians. We also found a femalepredominance of 66%, 55% were single and a total of 155 participants of whom 71% were frontline health workers. In our study, 54.8% of the HCWs had symptoms of depression, 68.2% had symptoms of anxiety and insomnia and 71.4% had symptoms of distress. Binarylogisticregressionanalysisshowedthat being married was associated with depression, anxiety, and insomnia, and being a frontlineworkerappeared to be a risk factor for depression and insomnia. Psychiatric support was an independentrisk factor for all psychiatric symptoms.In addition, living in a rural area was associated with depression, and age 31 or older was associated with anxiety. In addition, having a history of psychiatric illness was a risk factor for insomnia. Being a nurse was identified as a risk factor for psychiatric distress. We also found a moderatelevel of professional commitment to be a protective factor.

Conclusions

Protecting healthcare workers is a crucial part of the public health response to the COVID-19 outbreak.

Disclosure

No significant relationships.

Mandatory containment of COVID-19 patients in Monastir: Legislative framework and impact on freedoms

Introduction

Tunisia found itself in an exceptional situation during the covid 19 pandemic requiring a legal regime of exceptionality and sanitary necessity with a double challenge: the fight against the sanitary crisis, and the preservation of democratic gains

Objectives

To describe the legislative framework put in place concerning patients with COVID-19 who stayed at the compulsory containment and to discuss the legality of these emergency decisions

Methods

The authors conducted a descriptive cross-sectional study of patients with COVID-19 staying in the compulsory containment centre of Monastir, with a review of the literature The data were collected through telephone calls. A review of the literature as well as a consultation of the different legislative

Results

The average age was 41.39 ± 1.26 and the sex ratio was 1.17.Imported cases represented 45.3% of the sample and 23% of them expressed a desire to consult a specialist. The duration of mandatory confinement was on average 35.86±1.31 days with extremes ranging from 7 to 86 days. Concerning the legislative framework of the emergency decisions taken during the first wave, the President of the Republic and the Head of Government used Articles 80 and 70 of the Tunisian Constitution, respectively, to issue legislative texts announcing the state of emergency and accompanying. Thus, these legislative measures were restrictive of rights and freedoms and seriously threatened the fragile gains of our democracy

Conclusions

COVID-19 redefined not only the health system but also the economic conditions, as well as the normative and legislative system 2014

Disclosure

No significant relationships.

Trainees between theoreticalknowledge and the initiative takingat the hospital

Introduction

The internshipis a period in which the studentimplements what they have learned from their training to obtain or certification and to promote their professionalintegration, the difficulty of taking initiative and the lack of self-esteemrepresenting an obstacle to their training

Objectives

This is a quantitative descriptive study conducted at the different placement departments among all 2nd-year students in all sections. Our data collection was done using two questionnaires administered, one for the supervisors and the other for the students.

Methods

Theoretical Framework: Theorist Patricia Benner

Results

According to the results found, in oursample, thereis a predominance of females 89.17%, with a sex ratio of 0.121. 88.34% are aged between 20 - 21 years and an averageage of 22.4 years. According to the interpretation of the Rosenberg Self-Esteem Scale scores, 17.5% of the trainees have a “Very Low Self-Esteem”, 47.5% have a “Low Self-Esteem”, 25.83% have an “Average Self-Esteem”, and only 9.17% have a “High Self-Esteem”. In addition, more than half of the respondents, 53.33%, state thatthey “often” have difficultytaking the initiative in the traineeshipenvironment, while 30.83% do not have such difficulty but “rarely”. Indeed, 53.33% of confirmedsupervisorssaythatthey “often” have difficultytaking the initiative in the placement environment

Conclusions

It isnecessary to take into account these obstacles to the trainee’s training through better psychological supervision, which could be the first steptowardssolving the problem

Disclosure

No significant relationships.

The role of academic factors on the development of mental illness stigma

Introduction

Stigma and discrimination can disrupt the lives of individuals with a mental illness, preventing their opportunities to become productive citizens. These Individuals must also face either an avoidant attitude by healthcare professionals or prejudices about their adherence to medications and the psychological nature of their physical symptoms.

Objectives

Assess stigma in terms of explicit and implicit attitudes among medical school students and junior doctors. Evaluate academic factors and interfering with these attitudes.

Methods

A cross-sectional study was conducted among students from medical schools in Tunisia.

All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform.

Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians’ Attitudes (MICA).

Results

The sample consisted of 1028 respondents. The respondents’ mean age was 24.54 years (SD=3.7). Post-clinical students scored higher than pre-clinical students in questions 2, 6, and 12 on the rating scale. A positive significant relationship was identified with specialization in psychiatry. Residents who were specialized in family medicine, emergency, and intensive care had a higher stigma level compared to other residents (Mean score>0.51). The completion of a psychiatry clerkship did not significantly reduce the level of stigma toward people with a mental illness ( p=0.8).

Conclusions

A combination of medical school experiences of psychiatry’s theoretical learning and clerkship are important factors that shape students. Awareness of this will enable educators to develop locally relevant anti-stigma teaching resources throughout the psychiatry curriculum to improve students’ attitudes towards psychiatry as a discipline and mental illness in general.

Disclosure

No significant relationships.

First episode-psychosis: Short- and long-term outcomes and related features predicting the transition to schizophrenia

Introduction

The occurrence of a first episode-psychosis in adolescents or young adults represents a difficult struggle with an uncertain and divergent outcome, since the clinician does not have at his disposal the clinical elements sufficient to predict these different disease trajectories.

Objectives

Our aims are to describe the socio-demographic, clinical characteristics and the short and long-term outcomes of a first episode-psychosis and to identify the predictive factors of the transition to schizophrenia.

Methods

We conducted a retrospective study about 117 patients hospitalized for a first episode-psychosis in the Psychiatric Department of Monastir (Tunisia). Sociodemographic and clinical features were collected using a pre-established form.

Results

First-episode psychosis affected young male subjects with low educational level. Stressors were present in 54.7%. An 8-week prodromal phase preceded the onset of the disorder in 59%. The disorder course included diagnosis of: Brief psychotic disorder (32.5%), schizophrenia (31.6%) and bipolar disorder (18.8%). The short-term outcome was characterized by a complete remission rate of 58.1% at 3 months and 37.6% at 6 months. The long-term outcome was marked by a high rate of lost to follow-up: 70.8% after 5 years. The transition to schizophrenia was linked to the presence of delirium of influence and the absence of favorable course at 3 months.

Conclusions

Our results led to the identification of the profile of patients with a first episode-psychosis and the factors correlated with a diagnosis of schizophrenia. Indeed, the determination of risk factors would make it possible to adapt earlier the care.

Disclosure

No significant relationships.

Impact of temperament on mental illness stigma among medical students

Introduction

Mental illness stigma is the most significant obstacle impeding the wellbeing of individuals with such conditions. Thus, research on determinants of mental illness stigma may be of crucial importance in avoiding these attitudes. Affective temperaments are thought to be present in up to 20% of the healthy general population. However, there are very few studies addressing the relationship between temperament and mental health-related stigma.

Objectives

Evaluate attitudes and behavioral responses of medical students towards individuals with a mental illness. Explore factors associated with stigma including temperament.

Methods

A cross-sectional study was conducted among students in medical universities.

All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform.

Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians’ Attitudes (MICA). Students were also asked to complete the TEMPS-A Scale.

Results

The sample consisted of 1028 respondents (9.3% of the total population). Females represented 78,3% of the study sample. A dominant affective temperament was found in 17% of the cases under study, represented mainly by depressive and irritable temperaments. Bivariate correlations performed to assess the association between temperament and mental illness stigma revealed that a positive relationship was identified between the MICA scale and hyperthymic temperament( p=0,04). There were no significant associations between the other type of temperaments and The MICA scale.

Conclusions

Students’ temperament should be considered in developing anti-stigma programs in undergraduate education. Further researches should be undertaken to disentangle the complex relationship among demographic features, personality traits, and attitudes toward people with a mental illness.

Disclosure

No significant relationships.

prevalence of addictions among students at the High School of The Health Sciences and Techniques of Sousse

Introduction

Addiction isfrequent in youngsubjects, particularly in students, who are in contact with psychoactive substances such as drugs, tobacco, alcohol, and cannabis

Objectives

The objectives of our study were to investigate the prevalence of addictions among ESSTSS students and to determine the factors associated with addictions.

Methods

A descriptive correlational cross-sectional study was conducted at ESSTSS among 122 students for 2 months (March and April 2021). The data was collectedusing a questionnaire administered to the students.

Results

There were 102 women and 20 men with an averageage of 20.96 years. theprevalence of drug use was 56.6% according to DAST-10, with addiction notedin 5.7% of cases. The prevalence of tobacco use was 35.3% according to the Fagerstörm test, with 23.3% of the students being highlyaddicted to tobacco. The prevalence of alcohol use was 29.5%, 35% for men, and 28.43% for womenaccording to the AUDIT, alcoholdependence was notedin 14.3% of men and 6.9% of women. The prevalence of cannabis use was 16.4% according to the CAST test, a high risk of dependence was observedin 20% of cases. The analytical study showedthat the factors associated with addiction were age, gender, year of study, and specialty

Conclusions

The prevalence of substance use among health science students is significant and since the use of these substances has a detrimental effect on health itisbetter to understand the associated factors and this obliges us to establish appropriate preventive interventions

Disclosure

No significant relationships.

Value of psychological counseling for trainees exposed to the death of a patient in emergency and resuscitation departments

Introduction

Trainee emergency and resuscitation technicians are not prepared during their academic training to deal with their psychological reactions to the death of a patient, we wanted to describe their feelings and understand the aggravating factors and highlight the need for intervention.

Objectives

Our study aims to describe the psychological reactions of traineesexposed to the death of a patient on the internship grounds and to demonstrate the usefulness of specific psychological counseling

Methods

It is a prospective interventional study carried out with 2nd and 3rd-year students of the emergency and resuscitation section, our collection was done using a self-administered questionnaire with a validated PDI scale before the training, and a satisfaction questionnaire with the same scale after the training.

Results

Our population isyoung, with an averageage of 20.05 years, and ispredominantlyfemale, with a sex ratio of 0.12. Eighty-seven percent of the population statedthatthey were not prepared to deal with their feelings about the death of a patient, and thiseventharmed the quality of care for 68% of the students. According to the scores of the PDI scale in pre-training 77.33% of the students are at risk of developing PTSD, this percentage decreases to 30.67% according to the same scale in post-training.

Conclusions

it is important to take into consideration the suffering of traineesexposed to traumaticevents such as the death of patients and to prepare them psychologically to deal with these situations

Disclosure

No significant relationships.

Physical and mental health impact of COVID-19 on children, adolescents, and their families: The Collaborative Outcomes study on Health and Functioning during Infection Times - Children and Adolescents (COH-FIT-C&A)

BACKGROUND

The COVID-19 pandemic has altered daily routines and family functioning, led to closing schools, and dramatically limited social interactions worldwide. Measuring its impact on mental health of vulnerable children and adolescents is crucial.

METHODS

The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT - www.coh-fit.com) is an on-line anonymous survey, available in 30 languages, involving >230 investigators from 49 countries supported by national/international professional associations. COH-FIT has thee waves (until the pandemic is declared over by the WHO, and 6-18 months plus 24-36 months after its end). In addition to adults, COH-FIT also includes adolescents (age 14-17 years), and children (age 6-13 years), recruited via non-probability/snowball and representative sampling and assessed via self-rating and parental rating. Non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to promote health and prevent mental and physical illness in children and adolescents will be generated by COH-FIT. Co-primary outcomes are changes in well-being (WHO-5) and a composite psychopathology P-Score. Multiple behavioral, family, coping strategy and service utilization factors are also assessed, including functioning and quality of life.

RESULTS

Up to June 2021, over 13,000 children and adolescents from 59 countries have participated in the COH-FIT project, with representative samples from eleven countries.

LIMITATIONS

Cross-sectional and anonymous design.

CONCLUSIONS

Evidence generated by COH-FIT will provide an international estimate of the COVID-19 effect on children's, adolescents' and families', mental and physical health, well-being, functioning and quality of life, informing the formulation of present and future evidence-based interventions and policies to minimize adverse effects of the present and future pandemics on youth.

The collaborative outcomes study on health and functioning during infection times in adults (COH-FIT-Adults): Design and methods of an international online survey targeting physical and mental health effects of the COVID-19 pandemic

BACKGROUND

. High-quality comprehensive data on short-/long-term physical/mental health effects of the COVID-19 pandemic are needed.

METHODS

. The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT) is an international, multi-language (n=30) project involving >230 investigators from 49 countries/territories/regions, endorsed by national/international professional associations. COH-FIT is a multi-wave, on-line anonymous, cross-sectional survey [wave 1: 04/2020 until the end of the pandemic, 12 months waves 2/3 starting 6/24 months threreafter] for adults, adolescents (14-17), and children (6-13), utilizing non-probability/snowball and representative sampling. COH-FIT aims to identify non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to improve social/health outcomes in the general population/vulnerable subgrous during/after COVID-19. In adults, co-primary outcomes are change from pre-COVID-19 to intra-COVID-19 in well-being (WHO-5) and a composite psychopathology P-Score. Key secondary outcomes are a P-extended score, global mental and physical health. Secondary outcomes include health-service utilization/functioning, treatment adherence, functioning, symptoms/behaviors/emotions, substance use, violence, among others.

RESULTS

. Starting 04/26/2020, up to 14/07/2021 >151,000 people from 155 countries/territories/regions and six continents have participated. Representative samples of ≥1,000 adults have been collected in 15 countries. Overall, 43.0% had prior physical disorders, 16.3% had prior mental disorders, 26.5% were health care workers, 8.2% were aged ≥65 years, 19.3% were exposed to someone infected with COVID-19, 76.1% had been in quarantine, and 2.1% had been COVID 19-positive.

LIMITATIONS

. Cross-sectional survey, preponderance of non-representative participants.

CONCLUSIONS

. Results from COH-FIT will comprehensively quantify the impact of COVID-19, seeking to identify high-risk groups in need for acute and long-term intervention, and inform evidence-based health policies/strategies during this/future pandemics.

Late-Onset Psychiatric Manifestations Revealing Limbic Encephalitis: a Case Report of a 48 Years Old Man

Psychiatric symptoms of late-onset are often atypical and an organic origin that remains to be eliminated at first. Still, many somatic etiologies like encephalitis remains poorly understood and multidisciplinary management is necessary. We present the case of a man hospitalized for the first time in the psychiatric ward of Monastir Tunisia at the age of 48 for behavioral disorders with atypical symptoms, Brain Magnetic resonance imaging showed bilateral signal abnormalities of the internal temporal region and hippocampal left lesions, suggestive of encephalitis. The autoimmune origin has been strongly suspected and the determination of "onco-neuronal" antibodies and specifically the assay of anti Ma1 and anti Ma2 antibodies were positive. These elements lead us to evoke autoimmune encephalitis and immunotherapy was initiated for the patient.

Hashimoto’s Encephalopathy Revealed by Hypochondriacal Delusion: A Case Report Involving a Male Patient

Hashimoto’s encephalopathy (HE) is a rare autoimmune disorder. It associates encephalopathy with autoimmune thyroiditis, presenting abnormal elevations of thyroid antibodies. It is more common in females. It can present with various symptoms, including seizures, myoclonus, psychosis, hallucinations, and mood disturbances. Hypochondriacal delusion is an unusual clinical presentation of this disorder. The authors report a case of HE in a male patient whose clinical presentation was dominated by hypochondriacal delusion. The absence of response to antipsychotics, high serum antithyroid peroxidase antibodiesof about 199 UI/ml, the normality of magnetic resonance imaging, and improvement with corticosteroids confirmed the diagnosis. This neuroendocrine disorder is often misdiagnosed and it represents a diagnostic challenge for clinicians. It should be considered in patients presenting a refractory or an atypical neuropsychiatric disorder and having a family history of autoimmune disease.

Unipolar Mania: A Particular Aspect of Bipolar Disorder in Tunisia

Objective

Unipolar mania is a clinical reality in our daily practice. Many authors suggested that bipolar patients can have only manic episodes without depressions. These findings lead us to explore more this particularity.

Methods

We conduct a retrospective, descriptive and comparative study including 173 patients, followed for bipolar disorder type I, according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria, during the period between January 2008 and December 2015. Two groups were identified. The first one was composed of 98 patients who had presented only manic episodes. The second group contained the rest of the sample. Unipolar mania was defined as the presence of three or more manic states without a depressive episode during the period of the study.

Results

One hundred seventy three patients were included in the study. The average age of the sample was 43 years old. The first episode was manic in 129 patients (74.6%). The dominant polarity was manic in 90.8% of the cases. Seasonal characteristic and psychotic symptoms were observed in respectively 11.0% and 53.2% of the sample. Rapid cycling evolution was observed among 2.3% of patients. The unipolar manic profile accounted for 56.6% of the population. This result is equivalent to an annual incidence of 8%. Comparing the two groups, we did not find a significant difference concerning the sociodemographic and clinical variables except for the number of suicide attempts (p=0.014).

Conclusion

Our study shows that unipolar mania is clinical evidence. More studies should be conducted in order to understand its nosological and psychopathological foundations.

ADHD in Tunisian Adolescents: Prevalence and Associated Factors

OBJECTIVE

The aims of the study were to determine the prevalence of ADHD in a population of high school students and to explore the factors associated with this disorder.

METHOD

This was a cross-sectional study that had included 447 high school students. The diagnosis of ADHD was made by the Adult ADHD Self-Report Scale translated in Arabic language. The sociodemographic and clinical characteristics were evaluated by a preestablished questionnaire. The self-esteem was assessed by the Rosenberg Self-Esteem Scale.

RESULTS

The prevalence of ADHD was 18.1%. The logistic regression analysis showed an association between the diagnosis of ADHD and the bad relationships with parents (odds ratio [OR] = 16.43; p < 10-3), the presence of personal psychiatric antecedents (OR = 12.16; p < 10-3), internet misuse (OR = 2.39; p = .014), and maltreatment antecedents (OR = 3.16; p = .009).

CONCLUSION

The prevalence of ADHD in this study was one of the highest prevalence reported. The factors associated with ADHD may have diagnostic and therapeutic implications.

Lipid profile in schizophrenia: case control study

INTRODUCTION

Cardiovascular diseases are common co morbidities of schizophrenia and constitute the main factors of high mortality in this pathology. Cardiovascular damages are favored by some risk factors, of which one of the most important is dyslipidemia. In this context, a study of lipid profile in schizophrenia is interesting.  The aims of this study were to compare the lipid profile of patients with schizophrenia to healthy controls and to investigate the associations between lipid parameters and demographics, clinical and treatment characteristics of the patients.

METHODS

We conducted a case-control study between April 2013 and March 2014 on 78 patients with schizophrenia and 68 healthy subjects who benefited from the dosage of four serum lipid parameters: total cholesterol (TC), triglycerides (TG), High-density lipoprotein Cholesterol (HDL-C) and Low-density lipoprotein cholesterol (LDL-C). For the socio-demographic and clinical assessments, we used an information sheet and the following psychometric scales: PANSS (Positive And Negative Syndrome Scale), CGI (Clinical Global Impressions), GAF (Global Assessment Functionning) and the Calgary scale for depression.

RESULTS

The comparative study showed that serum concentrations of TC and LDL-C were significantly higher for patients compared to healthy controls respectively with (t=2,83 ; p=0,008) and             (t=9,35; p<0,001), the cholesterol ratio (TC / HDL-C) was also significantly higher for patients           (t=2,23; p=0,033). The patients had significantly higher prevalence of hypercholesterolemia              (OR = 2.96) and low density hyperlipoproteinemia (OR = 18.79). The analytical study in the population of patients showed that the age ≥35 year-old, male gender and alcohol consumption were associated with disturbances in lipid parameters. Cannabis consumption was associated with significantly lower concentrations in TG. Concerning clinical features, paranoid schizophrenia was associated with less dyslipidemia unlike the depressive dimension assessed by the Calgary scale. There was a negative correlation between plasmatic TG concentrations and doses of antipsychotics.

CONCLUSION

The vast majority of the literature confirms that patients with schizophrenia are at greater risk of dyslipidemia. This high risk appears to be more important with the consumption of alcohol and tobacco. It seems also that age and masculine gender are dyslipidemia risk factors for schizophrenic patients. The paranoid type of schizophrenia and positive symptoms seem to be associated with less dyslipidemia while depressive symptoms worsen lipid parameters. It then follows that, clinical and regular monitoring of lipid profile, lifestyle recommendations (smoking cessation, exercise and balanced diet) and appropriate therapeutic choices could help reduce morbidity and mortality among patients with schizophrenia. A special focus should be accorded to patients with high negative and depression symptoms.

[Dyslipidemia and suicidal risk in patients with psychiatric disorders]

The aim of this work is to study the association between dyslipidemia and suicidal risk in patients with psychiatric pathology. Our study has involved 155 patients suffering from major depressive disorder and 124 schizophrenic patients aged 40.58±12.16 and 43.43±10.60 years, respectively. Total cholesterol (TC), triglycerides (TG) and HDL-c were determined by enzymatic methods, LDL-c was calculated by the Friedewald formula. Plasma cholesterol level was significantly lower among suicidal schizophrenic or depressive patients. There were no significant differences in the others lipid levels. The results of our study suggest that total cholesterol values less than 3.59mmol/L could be an indicator of suicide vulnerability in patients with schizophrenia or major depressive disorder.

Neurological soft signs in Tunisian patients with first-episode psychosis and relation with cannabis use

BACKGROUND

Neurological soft signs (NSS) are minor non-localizing neurological abnormalities that are conceptualized as neurodevelopmental markers that mediate the biological risk for psychosis. We aimed to explore the relationship between NSS and cannabis use, an environmental risk factor of psychosis.

METHODS

This was a cross-sectional study in consecutively admitted patients hospitalized for first-episode psychosis. NSS were assessed by the NSS scale (23 items exploring motor coordination, motor integrative function, sensory integration, involuntary movements or posture, quality of lateralization). Presence of NSS was defined as a NSS scale total score ≥9.5. Cannabis use was ascertained with the cannabis subsection in the Composite International Diagnostic Interview.

RESULTS

Among 61 first-episode psychosis patients (mean age = 28.9 ± 9.4 years; male = 86.9%, antipsychotic-naïve = 75.4%), the prevalence of current cannabis use was 14.8% (heavy use = 8.2%, occasional use = 6.6%). NSS were present in 83.6% of the sample (cannabis users = 66.7% versus cannabis non-users = 85.5%, p = 0.16). The mean total NSS score was 15.3 ± 6.7, with a significant lower total NSS score in cannabis users (11.2 ± 5.6 versus 16.0 ± 6.7, p = 0.048). Differences were strongest for the "motor coordination" (p = 0.06) and "involuntary movements" (p = 0.07) sub-scores.

CONCLUSIONS

This study demonstrated a negative association between cannabis use and NSS, especially regarding motor discoordination. This finding supports the hypothesis that a strong environmental risk factor, such as cannabis, may contribute to the onset of psychosis even in the presence of lower biological and genetic vulnerability, as reflected indirectly by lower NSS scores. Nevertheless, additional studies are needed that explore this interaction further in larger samples and considering additional neurobiological and environmental risk factors.

Is low total cholesterol levels associated with suicide attempt in depressive patients?

BACKGROUND

Patients with major depressive disorder (MDD) have a high risk of suicide. Many pathophysiological factors involved in MDD and suicide such us a low cholesterol levels have been associated with MDD and increased vulnerability to suicide. In this study, we investigate the relation between lipid parameters and suicide risk in patients with MDD.

METHODS

Plasma levels of total cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c) were determined in 160 patients meeting the DSM-IV-TR criteria for MDD (110 patients without suicidal behavior and 52 suicidal attempters) and 151 healthy controls.

RESULTS

A significant decrease in plasma cholesterol levels was observed in the group of suicidal depressive patients compared to those without suicidal behavior (p < 0.001). For the other lipid levels (triglycerides, HDL cholesterol, and LDL cholesterol), there were no significant differences between suicidal and non-suicidal patients.

CONCLUSIONS

Our study showed a significant decrease in plasma cholesterol levels in suicidal patients. This result support the hypothesis of the association of low plasma cholesterol level and suicidal behavior in patients with major depressive disorder.

Use of Clozapine for Borderline Personality Disorder: A Case Report

Patients with borderline personality disorder (BPD) show significant impairment in functioning, particularly in the interpersonal and social domains. Prior reports suggest that clozapine may be effective in the management of BPD. We present the case of a patient with BPD who experienced persistent suicidal ideation and was treated with clozapine at a state psychiatric hospital. After treatment failure with other psychotropic medications, clozapine medication was initiated; not only did suicidal ideation cease, but social and professional functioning also greatly improved to the point of no longer requiring intensive levels of observation or restrictive procedures. Clozapine appears to be efficacious in the management of suicide attempts and self-injurious behavior. Moreover, it appears to be promising as a therapeutic measure for ameliorating the global functioning of patients with severe BPD. Larger, randomized, blinded, and controlled prospective studies are needed to confirm these findings and to determine optimal dosage.

[Minor neurological and physical anomalies in patients with first-episode psychosis]

INTRODUCTION

Over the last several decades, there has been an increasing number of neuroanatomical, neuroimaging, neurophysiological, and neuropsychological studies in search of structural, functional, and cognitive correlates of brain insult(s) that could ultimately lead to unravelling the pathophysiology of schizophrenia. A direct, easily administered, and inexpensive way of investigating brain dysfunction in schizophrenia is the study of neurological soft signs and minor physical anomalies, two putative indices of developmental abnormality. The study of these neurodevelopmental markers in the first-episode psychosis allows the detection of the neurodevelopmental abnormalities at the onset of psychosis.

AIMS OF THE STUDY

The objectives of our study were to determinate the prevalence, the scores, and the nature of neurological soft signs (NSS) and minor physical anomalies (MPA) in patients with first-episode psychosis and to explore the correlations between these neurodevelopmental markers and the demographic, clinical and therapeutic features.

METHOD

A cross-sectional study was carried-out on 61 patients (mean age: 28.9±9.4years; 86.9% were males), hospitalized for first-episode psychosis (DSM-IV-TR diagnosis of schizophrenia, schizophreniform disorder, brief psychotic disorder, delusional disorder, and psychotic disorder not otherwise specified). The evaluation procedure consisted of a retrospective assessment of the premorbid functioning by the Premorbid Functioning Scale (PAS) and the following clinical scales: Positive and Negative Symptoms Scale (PANSS), Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF), the NSS scale of Krebs et al. (23 items exploring motor coordination, motor integrative function, sensory integration, involuntary movements or posture, quality of lateralization) and the MPA scale of Gourion et al. (41 items, exploring anomalies of face, eyes, ears, mouth, hands and feet).

RESULTS

The prevalence of NSS was 83.6% (cut-off point=9.5), with a mean total score of 15.3±6.7. The highest score was for the motor coordination. The prevalence of MPA was 62.7% (cut-off point=5), with a mean total score of 5.8±3.2. The most common MPA were the fine hair (50.8%), adherent earlobes (49.2%) and clinodactyly (31.1%). Correlations were found between the NSS total score and the Poor Premorbid Functioning (r=0.32, P=0.04), the PANSS total score (r=0.36, P=0.005), and the negative (r=0.45, P<0.001) and disorganization sub-scores (r=0.41, P=0.001), the CGI-severity of (r=0.30, P=0.02), the impairment functioning in the GAF (r=-0.26, P=0.04) and with extrapyramidal symptoms (r=0.52, P<0.001). However, no correlation was found between the NSS total scores, age, gender, the PANSS positive sub-score, the daily dosage of antipsychotics, the CGI-improvement score and the MPA total score. There was no correlation between MPA total score and demographic, clinical and therapeutic features of patients. Moreover, there was no correlation between the NSS or MPA scores and the short-term evolution (6months to 1year) towards schizophrenia.

CONCLUSION

These results confirm the data in the literature relating high NSS and MPA scores in patients with a first-episode psychosis. The NSS appear to characterize severe psychotic disorders with more negative and disorganization symptoms and poor social functioning and may be a prognostic indicator.

Decreased glutathione levels and impaired antioxidant enzyme activities in drug-naive first-episode schizophrenic patients

BACKGROUND

The aim of this study was to determine glutathione levels and antioxidant enzyme activities in the drug-naive first-episode patients with schizophrenia in comparison with healthy control subjects.

METHODS

It was a case-controlled study carried on twenty-three patients (20 men and 3 women, mean age = 29.3 ± 7.5 years) recruited in their first-episode of schizophrenia and 40 healthy control subjects (36 men and 9 women, mean age = 29.6 ± 6.2 years). In patients, the blood samples were obtained prior to the initiation of neuroleptic treatments. Glutathione levels: total glutathione (GSHt), reduced glutathione (GSHr) and oxidized glutathione (GSSG) and antioxidant enzyme activities: superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase (CAT) were determined by spectrophotometry.

RESULTS

GSHt and reduced GSHr were significantly lower in patients than in controls, whereas GSSG was significantly higher in patients. GPx activity was significantly higher in patients compared to control subjects. CAT activity was significantly lower in patients, whereas the SOD activity was comparable to that of controls.

CONCLUSION

This is a report of decreased plasma levels of GSHt and GSHr, and impaired antioxidant enzyme activities in drug-naive first-episode patients with schizophrenia. The GSH deficit seems to be implicated in psychosis, and may be an important indirect biomarker of oxidative stress in schizophrenia early in the course of illness. Finally, our results provide support for further studies of the possible role of antioxidants as neuroprotective therapeutic strategies for schizophrenia from early stages.