118 young people identified with mild or more mental health symptoms were blindly randomly allocated at the individual level, to either the intervention group (mobiletype plus usual care) or the comparison group (abbreviated mobiletype plus usual care) according to CONSORT guidelines. Participants and doctors completed baseline and follow-up questionnaires measuring mental health, patient-doctor relationship, and pathways to care (i.e. referrals, medication, and testing). Participants were followed-up at 6 weeks and 6 months.

Results from fixed effects analyses of covariance examining the differences between the experimental and control groups on the main outcome measures, with the baseline values as the covariates will be presented. The extent to which the mobiletype program reduces mental health symptoms, enhances the patient-doctor relationship and assists patients in pathways to care will be explored in detail.

Mobile and new information and connected technologies have much to offer clinical care in terms of increased efficiencies in data collection, increased engagement of participants and overall enhanced care.

35.6 million people are living with dementia worldwide. Up to 40% of people with a dementia go into residential care. There is a need to understand PSI practice and training requirements of practioners.

Interview and observe stake holders (service users, carers, educationalists and practitioners). Participants were asked to explore their understanding of the value of PSIs. Develop grounded theory to inform the development of a structured education programme for PSIs.

Identify current practice and the potential to develop PSI training. Contribute to a structured education programme. Develop a framework for the implementation of PSIs.

Classical Grounded theory.

Delivery of PSIs is dependent upon the influence of: attributes, experience and education. These factors are affected by the need to be flexible and individual ideas of what is effective. All of these factors are shaped by the need to make the most of limited resources and complete basic physical tasks.

A complicated range of influences impact upon the delivery of PSIs. Theory developed indicates that PSI education must address practitioner attitude and emphasise the benefits to staff efficiency and reducing agitation in people with dementia along with improving the quality of life of people with dementia.

The longevity of population is an evidence over the past decades. Elderly physical and mental health are imperative. Despite anxiety is common and has adverse consequences, literature is meagre.

To estimate the prevalence of generalized anxiety disorder (GAD) in elderly and to investigate the association with physical comorbidity, depression, daily habits.

426 subjects from the population-based Faenza Community Aging Study (De Ronchi et al 2005), mean age 85,1 (Standard Deviation = 6,9). The Geriatric Anxiety Inventory short-form (GAI-sf) was utilized to define GAD (score ≥ 3). Logistic-regression were used to estimated odds ratio and 95%Confidence Intervals (CI).

Subjects with anxiety were 84 (21,2%), 63,1% were women. For age < 80 the prevalence of GAD was 38,1% while for age> 95 was 4,8%. When we compared elderly with GAD to elderly not affected we found the following results: no hobbies (83,3% vs 79,6%) p = 0,124, no friendship (21,8% vs 15,8%) p = 0,425, they don’t make physical activity (53,7% vs 45,6%) p = 0,214 than subjects without anxiety. To have comorbidity was associated with anxiety: one disease OR (CI95%) = 2,71 (1,15–6,24), two or three OR (CI95%) = 2,57 (1,07–6,16) and > three OR (CI95%) = 7,5 (1,81–31,05). Hypertension was positively associated with anxiety OR (CI95%) = 1,94 (1,04-3,62). Depression was highly correlated with anxiety OR (CI 95%) = 5,82 (3,39–9,98). Moderate alcohol consumption was negative associated with anxiety OR(CI 95%) = 0,49 (0,25–0,95).

Anxiety in elderly is frequent and should be actively investigated especially in elderly with comorbidity.

Diagnosing Alzheimer Disease (AD) is a long-lasting process, mainly due to the variability of initial symptoms (i.e. memory problems, speech difficulties, behavioral changes). Patients are usually either unaware of their difficulties or attempting to conceal them.

We wanted to establish whether, based on existing knowledge, a better understanding of the leading causes of miscommunication can overcome communication barriers for AD patients.

We tried to summarize the existing recommendations and gold-practices and to contract them into key messages in order to improve quality of communication.

We performed a systematic overview of medical literature (PubMed search, disclos* OR communic* NOT communicate AND Alzheimer), selecting of the 516 resulting titles those papers focused on doctor/patient and doctor/caregiver communication issues.

Specific communication requirements were identified for effective collaboration between

1. (1) physician and patient,

2. (2) physician and patient's caregivers/family and

3. (3) caregivers/family and patient.

A minimal set of communication skills and predictable courses of action was further developed, depending on

1. (a) best practices and

2. (b) recommended practices.

Although communicating with people with Alzheimer is difficult, quite often the communication barriers are mainly due to an inaccurate perception of the disease and of patient limitations and disabilities. Understanding the mechanisms involved and acquiring certain interpersonal habits may significantly improve communication effectiveness, particularly in mild and moderate AD.

Cardiac surgery is being performed more frequently in octogenarians with huge pressure on health care resources. Quality of Life (QoL) improvement should be the primary goal in this high-risk patients.

This study evaluates the feasibility of QoL assessment in octogenarians after cardiac surgery.

QoL was assessed by three self-administered psychometric tests: modified Seattle Angina Questionnaire, SF-36, and Hospital Anxiety and Depression Scale. QoL was evaluated after a mean time of 5.5 years after operation in 86 patients, and before and 6 months after surgery in 21 patients.

Retrospective evaluation of QoL showed absence of physical limitation in 50% of patients, treatment satisfaction in 80%, symptoms-free conditions in 62%, poor or absent disease perception in 94%, satisfactory wellbeing and enjoyment of life in 78%. QoL six-month variance analysis showed significant improvement in 4 of 5 modified SAQ domains (except of Treatment Satisfaction), 6 of 8 SF-36 domains (except of Emotional Role Limitation and Vitality), and in both depression and anxiety HADS subscales. However, test's self-administration failed, always necessitating physician and relatives’ help. Moreover, several questions showed to be unfit for this subset of patients.

Despite the emerged limitations using these tests, cardiac surgery seems to improve QoL in octogenarians with cardiac disease. After 5 years the prevalence of physical disability, cardiac symptoms and functional limitation due to cardiac symptoms, are comparable to the overall octogenarian population. QoL improvement appears more evident 6 months after the operation. New suitable tests are required for old patients.

Previous research has suggested substantial variation in prevalence rates of psychiatric disorders in individuals with intellectual disability and also differential patterns of associations between psychiatric disorders and challenging behaviours in people with intellectual disabilities. The aim of this study was to determine with the prevalence rate of specific psychiatric disorders and challenging behaviours and the relationship between them in a community based sample of individuals with intellectual disability.

A community based sample of 159 adults primarily with mild and moderate intellectual disabilities was surveyed for the presence of psychiatric disorders and challenging behaviour using the Behaviour Problem Inventory (BPI) and the Psychiatric Assessment Schedule (PAS-ADD). Individuals who met threshold on the PAS-ADD were subsequently evaluated using the Mini- PAS-ADD Interview.

Screening for psychiatric disorder using the PAS-ADD indicated a prevalence rate of 10%. There was a large discrepancy between the overall rate of challenging behaviour (45%) and the rate of psychiatric disorders identified by the Mini PAS-ADD Interview (6%). However, the rate of more severe behaviour problems (8%) was closer to the rate of psychiatric disorders (6%). Thirty one percent of people with severe challenging behaviours also were rated as having psychiatric disorders and odd ratio analysis indicates that individuals with severe challenging behaviour are substantially more likely to present with a psychiatric disorder. However, there does not appear to be a relationship between different topographies of challenging behaviour and discrete diagnostic categories of psychiatric disorder.

ADHD occurs in 3–5% of children and adults. Yet little is known about ADHD in elderly.

To review the literature and to present first Dutch epidemiological data on ADHD in elderly (VUmc/LASA and PsyQ).

The study aims to estimate the prevalence of ADHD in eldery and to correlate symptoms of ADHD with comorbidity patterns, cognitive decline and somatic disorders. This knowledge may help predict the future of the current group of adults with ADHD.

The Longitudinal Aging Study Amsterdam (LASA) included a selfreport questionnaire for ADHD in 2009 in around 1500 elderly, aged 63–94 years. From those with low, intermediate and high scores, a random sample was interviewed using the DIVA, a structured Diagnostic Interview for ADHD in adults (N = 234).

First data on prevalence of ADHD in elderly in the general Dutch population will be discussed. The long term consequences of the persistence of the disorder in adults and elderly, and the impact for the organisation of treatment of this lifespan disorder will be reviewed.

The continuity of ADHD symptoms and impairment from childhood into to old age, may pose psychiatric services for important questions like the usefulness of separate treatment facilities for different age groups in case of a lifespan disorder like ADHD.

Aggression and violent behaviour are often noticed as a threat of society. Therefore, the understanding of violent behaviour has high social relevance.

The investigation sample comprised 80 right-handers: 40 prisoners who committed severe violent crimes and 40 controls with no history of violence. All subjects were male and matched for age.

We performed a study with transcranial magnetic stimulation (TMS) in a sample of violent offenders in order to measure cortical inhibition in the motoneural system which is part of the frontal cortex.

To investigate the intracortical inhibition and the intracortical facilitation we conducted paired-pulse stimulation according to the technique of Kujirai et al. (1993). The investigation sample comprised 80 right-handers: 40 prisoners who committed severe violent crimes and 40 controls with no history of violence. All subjects were male and matched for age.

Using the paired-pulse paradigm with interstimulus intervals (ISI) of 1–15 ms, a reduced cortical inhibition (ISI 3 ms) was found in violent offenders compared with control subjects in the left cortex.

These findings corroborate the hypothesis of inhibition deficits in violent offenders when compared with control subjects due to a lack of impulsive control.

Fetal programming refers to the concept that early environmental factors, including prenatal exposure to stress and drugs, can permanently organize or imprint physiological and behavioural systems and increase vulnerability to disorders such as depression and anxiety later in life.

Is prenatal exposure to alcohol a factor which re-programs the brain?

Effects of prenatal alcohol exposure (PAE) on:

1. 1) the hypothalamus-pituitary-adrenal (HPA) axis;

2. 2) the hypothalamus-pituitary-gonadal (HPG) axis;

3. 3) serotonergic (5-HT) system and

4. 4) adult hippocampal neurogenesis are presented.

Offspring from prenatal ethanol (PAE), pair-fed (PF) and ad lib-fed control (C) dams are studied across the development or in adulthood. Immunocytochemistry and in situ hybridization techniques are used.

In term of the HPA axis: PAE alters the balance of mineralocorticoids/glucocorticoids (MRs/GRs) receptor levels in the hippocampus of adult females. In the case of the HPG axis: PAE delays puberty and changes hormonal profiles in males and females. PAE also decreases numbers of 5-HT-immunoreactive neurons in the dorsal raphe nucleus of the brainstem in ovariectomized rats and estradiol and progesterone modulate those effects. Finally, in adult PAE males, but not females stress-induced decrease in neurogenesis is altered.

In our animal model PAE re-programs the brain. Effects of PAE are long-lasting, affect HPA and HPG axes, 5-HT system and adult hippocampal neurogenesis and if seen in humans could contribute to increased vulnerability to depression and anxiety.

The glutamatergic theory of schizophrenia proposes a dysfunction of ionotropic N-Methyl-D-aspartate (NMDA)-receptors (NR). Several therapeutic strategies address NR function and effects of antipsychotic agents on NR expression have been described.

The partial dopaminergic and serotonergic agonist aripiprazole (APZ) was able to counteract behavioural effects of NR antagonists, but effects of APZ on NR expression have not been investigated.

To evaluate effects of APZ on NR mRNA and protein expression

We treated Sprague-Dawley rats for 4 weeks or 4 months with APZ in daily oral doses of 10 and 40 mg per kg body weight. Expression of the NR subunits NR1, NR2A, NR2B, NR2C and NR2D was assessed by semiquantitative radioactive in situ-hybridization, and in parallel receptor binding using 3H-MK-801 receptor autoradiography.

Increased expression levels of NR1 (4 weeks), NR2A (4 weeks), NR2C (4 weeks and 4 months) and NR2D (4 months) were observed in several hippocampal and cortical brain regions. The parallel reduced expression of NR2B mRNAs (4 months) resulted in a relative increase of the NR2A/NR2B ratio. Marked differences between specific brain regions, the doses and time points of assessment became obvious. On the receptor level, increased MK-801-binding was found after 4 weeks in the 40 mg-group and after 4 months in the 10 mg-group.

The effects of APZ converge in enhanced NMDA-receptor expression and a shift of subunit-composition towards adult-type receptors. Our results confirm regulatory connections between dopaminergic, serotonergic and glutamatergic neurotransmission with relevance for cognitive and negative symptoms of schizophrenia.

The prediction, prevention and treatment of violence pose several challenges that are partly due to incompletely described neurobiological underpinnings of human violent behavior.

This work's objectives are establishing greater recognition of the neurochemical substrates of violent behavior and importance of the gene-environment interplay in the development of violence, distinguishing the components of the functional neural networks involved in violent behavior and facilitating the interpretation of relations between brain damage and alterations in social behavior from a perspective that takes into account variables such as developmental phase, brain-environment interactions and neuroplasticity.

We provide an overview of the neurobiological underpinnings of violence and the roles and advantages of using static and functional brain imaging in studying violent behavior.

A comprehensive review of the scientific literature on the neurobiology of violence was performed. A theoretical framework for the possible role of epigenetic factors in mediating the predisposition for violence is advanced.

Research data from various fields (such as genetics, cognitive and affective neurosciences, static and functional neuroimaging) suggest that the predisposition for violent behavior is influenced by both genetic and environmental factors. Epigenetic mechanisms underlying lasting environmentally-induced modifications in gene expression have recently been implicated in the pathogeny of various psychiatric and non-psychiatric diseases and social behavior disturbances.

The genetic, neurochemical and neuroimaging findings from various studies emphasize the complex role of the gene-environment interplay in the pathogenesis of violence and open a path of hope for the development and optimal timing of violence prevention strategies.

Many experience low mood and energy during winter. Brain serotonin is involved in the regulation of many physiologic and pathologic functions that vary with season. Seasonal variations in peripheral serotonergic markers have been described in clinical and nonclinical populations, and a postmortem study shows seasonal differences in hypothalamic serotonin concentration.

We investigated the molecular background of seasonal changes in serotonin function by conducting a series of studies on serotonin transporter (5-HTT) density and function in depression and health.

In a large study in drug-free patients with seasonal affective disorder (SAD) we aimed at detecting state-related alterations in 5-HTT-mediated inward and outward transport in platelets. Another study in healthy subjects aimed at detecting seasonal variations in 5-HTT binding in the living human brain using [11C] DASB positron emission tomography. Regional 5-HTT binding, an index of 5-HTT density, was assessed in a large sample of drug-naïve healthy volunteers, and was related to meteorological and astronomical data.

In patients with SAD we showed that the 5-HTT is in a hyperfunctional state during winter depression, and normalizes after light therapy and in natural summer remission. In healthy subjects, 5-HTT binding was higher in autumn/winter as compared to spring/summer. Regional 5-HTT binding correlated negatively with daily sunshine, such that higher values occurred at times of lesser light.

Since high 5-HTT density is associated with low synaptic serotonin levels, regulation of 5-HTT density and 5-HTT function by light is a mechanism that may explain seasonal changes in normal and pathologic behaviours.

Evaluation of oscillation pattern of GnRH release by the hypothalamus in different mental states

Twenty two patients were evaluated by a computer algorithm to find oscillation of LH/GnRH pulsation measured on four sessions (day 6 and 14) every 10 minutes within two consecutive cycles in addition to the MCMI-III and Hamilton test.

The pattern of oscillation was indirectly correlated with Hamilton scale and the anxiety state and showed statistically significant lowering of frequency during anxiety and depression states. Besides, the slope of GnRH between two consecutive sessions (d0GnRH0/GnRH1dt) showed also a prominent reduction and even flattening. In addition the time to ovulation was also postponed in cycles with prominent anxiety.

1. 1. Psychological stress exerts its effect through a reduction of pulsation frequency in GnRH release.

2. 2. Pattern of GnRH pulsation changes in the range of ¼ to 1/15 of the baseline and external stimuli have strength of changing hormonal milieu in this range.

3. 3. MCMI-III is an excellent tool for evaluating psychological state of the patient.

4. 4. Patients with borderline, schizoid, dependent, depressed and passive aggressive personality suffer most from irregularity of menstruation cycles.

5. 5. Patients with chronic major depression are subject to menstrual irregularity highest during stabilization of disease and in the early phases of recovery after treatment with SSRI.

6. 6. Treatment of depression/anxiety causes a reduction of menstrual cycles length.

7. 7. Measurement of GnRH, FSH, LH and Estradiol on two sessions one week apart is a nice marker for regularity and ovulation.

HIV testing is not yet a routine procedure in most mental health settings although adults with severe mental illness (SMI) are disproportionately affected by HIV/AIDS.

We focused our attention to explore if the appropriate care of patients with SMI may include a routine HIV testing offering and thus contribute to diagnose HIV-infected persons earlier in the course of their infection.

We present three case histories related to primary HIV diagnosis in patients presenting with different psychiatric disorders, admitted to Modena teaching Hospital in the passed two years.

Psychiatric symptoms delayed HIV diagnosis in all of the three reported cases.

The case histories here presented suggest that HIV testing is appropriate in the care of people with SMI, avoiding delay in HIV diagnosis with an obvious clinical benefit for the patient. Further studies are needed to assess the prevalence of HIV in those patients. These will be able to validate psychiatric diseases within a specific HIV indicator diseases list and help identifying a segment of the population in which HIV test must be routinely offered as a public health strategy, to face the burden of undiagnosed HIV infection.

The relationship between TB/HIV co-infection and common mental disorders (CMD) has been scarcely investigated. In this study, we compared the occurrence of CMD in TB/HIV co-infected and non-co-infected HIV patients in Ethiopia.

We conducted a cross sectional study in three hospitals in Ethiopia from February to April, 2009.

The study population consisted of 155 TB/HIV co-infected and 465 non-co-infected HIV patients. CMD was assessed through face to face interviews by trained clinical nurses using the Kessler 10 scale. Several risk factors for CMD were assessed using a structured questionnaire.

TB/HIV co-infected patients had significantly (p = 0.001) greater risk of CMD (63.7%) than the non-co-infected patients (46.7%). When adjusted for the effect of potential confounding variables, the odds of having CMD for TB/HIV co-infected individuals was 1.7 times the odds for non-co-infected patients [OR = 1.7, (95%CI: 1.0, 2.9)]. Individuals who had no source of income [OR = 1.7, (95%CI: 1.1, 2.8)], and day labourers [OR= 2.4, 95%CI: 1.2, 5.1)] were more likely to have CMD as compared to individuals who had a source of income and government employees respectively. Patients who perceived stigma [OR = 2.2, 95%CI: 1.5, 3.2)] and who rate their general health as “poor” [OR = 10.0, 95%CI: 2.8, 35.1)] had significantly greater risk of CMD than individual who did not perceive stigma or who perceived their general health to be “good”.

TB/HIV control programs should develop guidelines to screen and treat CMD among TB/HIV co-infected patients.

The development of operation techniques and care of the patients treated with coronary artery bypass graft (CABG) has an influence on the reduction of mortality, the frequency of post-operation myocardial infarctions and other important side-effects. Still a certain remaining problem are cognitive dysfunctions.

The purpose of this study was to the analysis of selected cognitive functions before the operation and shortly after the operation.

120 men aged below 65 were invited to the study. Finally 50 patients were recruited to the study, who underwent CABG with extra-corporeal circulation. The examined group consisted of 50 men with a mean age of 54.4 ± 5.6. 36% of the examined patients had a myocardial infraction in the past, 76% suffered from hypertension, 60% from diabetes. The cognitive assessment was done with a standardized Vienna Test System (VTS) battery. Following cognitive functions were examined visuo-spatial short-term memory (CORSI test), precise and continuous attention (COGNITRON), psychomotor speed and co-ordination (MLS test).

After the operation the visuo-spatial memory and continuous attention improved. The learning abilities did not change, and the psychomotor performance decreased. Statistically significant positive correlations were found referring to visuo-spatial memory and continuous attention before and after the operation.

Coronary artery bypass graft (CABG) with the use of extra-corporeal circulation in young men with no comorbid diseases aged below 65 has no significant impact on such cognitive functions like visuo-spatial memory, continuous attention and learning abilities. However the decrease of psychomotor performance was observed.

Tuberculosis (TB) is one of world's health problems. Morbidity and mortality caused by the disease are increasing annually. Aspects involved in TB are individual, environmental, and bacterial. It is important to consider not only one's physical factor but also mental factor such as comprehension and perception.

Stigma and social isolation may occur and precipitate any psychopathology and thus co morbidity of mental disorders in tuberculosis patients.

The aim of this research is to identify any contributing factors in the occurrence of any mental disorders in pulmonary tuberculosis patients.

Qualitative method of analysis was used; begin with determining the frequency of mental disorders in pulmonary tuberculosis, followed by interview and observation of the samples that mentally disordered.

The frequency of any mental disorders in pulmonary tuberculosis was 20%. From qualitative analysis, themes such as comprehension, treatment seeking behavior, psychological impacts, stigma, financial, occupational impacts, and other stressors were obtained. Respondents’ comprehension to the disease was not satisfying; treatment seeking behavior includes visiting public health services and hospitals; psychological impacts include Kubler-Ross’ response and depression as the most prevalent; financial impact includes financial difficulties; occupational impacts include occupational problems and unemployment; and other stressors.

Respondents’ comprehension to tuberculosis was not satisfying so thus worsen their perception of illness and of treatment seeking behavior. Their false perception will result in behavioral changes and social consequences like self-withdrawal, and together with stigma and any stressors will precipitate mental disorders.

There exists a high prevalence of psychiatric disorders in dermatological patients. However, investigators have so far evaluated psychiatric aspects of the patients suffering from several specific skin diseases, there are a few studies concerning mental health in pemphigus patients. Our objective was to evaluate mental health status, quality of life and psychological well-being of newly diagnosed pemphigus patients.

Between April 2007 and February 2008, all newly-diagnosed pemphigus patients attending the pemphigus outpatient clinic of a dermatological hospital were given a questionnaire comprising the GHQ-28 and DLQI to fill out.

Out of 283 patients, 212 complete forms were returned and analyzed. The bimodal score of GHQ ranged from 0 to 26 (Mean = 9.4) and the Likert score of GHQ ranged from 6 to 68 (Mean = 31.9). The DLQI score ranged between 0 and 30 (Mean of 13.8). A total of 157 patients (73.7%) were yielded to be possible cases of mental disorder considering GHQ-28 bimodal scores. Significant correlation between the DLQI score and bimodal and Likert scoring of GHQ-28 was detected.

Our study has depicted the prevalence of psychiatric morbidity in pemphigus patients. It underlines the fact that physicians, who are in charge of care for these patients, are in an exceptional position to distinguish the psychiatric morbidity and to take appropriate measures.

Depression and anxiety disorders are prevalent mental disorders in China. But some those patients do not seek help from psychiatrists firstly but see internists first.

This study aimed to investigate the prevalence of depressive - anxiety disorders in gastroenterology outpatients and assess the detection rate provided by physicians in China.

A multicenter, hospital-based cross-sectional study was carried on in the 15 large general hospitals of five cities cross China. A total of 1995 gastroenterological outpatients were screened by Hospital Anxiety and Depression Scale (HADS). Subjects whose HADS scores ≥ 8 were interviewed by psychiatrists, using Mini International Neuropsychiatric Interview (M.I.N.I) to make further diagnoses. Physicians’ diagnoses and treatment were recorded.

The adjusted prevalence of depressive disorder and anxiety disorders was 14.39% and 9.42% respectively.

The prevalence of depressive-anxiety disorder is high in gastroenterology outpatients in China, which suggests the related training of detecting these mental disorders is needed to gastroenterologists.

Psychiatric Advance Directives (PADs) are documents that allow severe and chronic mentally ill users notifying preferences of treatment and appointing a surrogate decision-maker for crisis relapses. Despite many expected benefits at the intrapersonal, interpersonal and organisational levels of the mental health system, PADs take-up rate remains low and many barriers to their use were identified. Moreover, a recent Cochrane systematic review provided little evidence on these benefits.

A realist review was carried out to clarify the theoretical frameworks underlying PADs, examine data evidencing these frameworks and determine the conditions in which PADs may have an effect, on what issues, and how.

After a selection process, 38 references were retrieved from health and social sciences databases containing empirical data on PADs. Papers were thematically coded along identified theoretical frameworks and levels of effects, and populated with empirical data. Results were reported within a multistage process including the PAD definition, completion, registration, access, and honouring.

Three theoretical frameworks were identified: users' autonomy, therapeutic alliance and health providers' networking. Although PADs were set up in a user's autonomy approach, they produce better results within a therapeutic alliance framework. Networking is determining on access and honouring stages. However, the literature mainly focused on definition and completion stages. Very little is known about their actual honouring.

PAD is a complex intervention with effects and barriers at each step of the process and levels of action. Their take-up rate and evaluation could be improved assessing these levels and stages separately.