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Unlike well-known global patterns of plant species richness along altitudinal gradients, in the mountainous areas of the Brazilian Caatinga, species richness and diversity reach their maxima near mountain tops. The causes of this unusual pattern are not well understood, and in particular the role of edaphic factors on plant community assembly along these gradients has not been investigated. Our goal was to assess the role of edaphic factors (fertility and soil texture) on plant community composition and structure on two mountains of the Brazilian semi-arid region. In 71 plots (Bodocongó site, twenty-one 200-m2 plots, 401–680 m asl; Arara site, fifty 100-m2 plots, 487–660 m asl) we recorded 3114 individuals representing 61 plant species; in addition, at each plot we collected composite soil samples from 0–20 cm depth. Significant altitude-related changes were observed both for community structure and composition, and edaphic variables. A canonical correspondence analysis allowed the distinction of two groups of plots according to species abundances, indicating a preferential habitat distribution of species depending both on altitude and soil variables. Although soil fertility was lowest at the highest altitudes, these areas had high richness and diversity. Conversely, the more fertile foothills were characterized by the dominance of generalist pioneer species. Despite the relatively short altitudinal range that characterizes the studied mountains, this study elucidates the role of edaphic factors on the floristic composition and species richness patterns on the mountains of the Brazilian semi-arid region.
Functional impairment is a defining feature of psychotic disorders. A range of factors has been shown to influence functioning, including negative symptoms, cognitive performance and cognitive reserve (CR). However, it is not clear how these variables may affect functioning in first-episode psychosis (FEP) patients. This 2-year follow-up study aimed to explore the possible mediating effects of CR on the relationship between cognitive performance or specific clinical symptoms and functional outcome.
A prospective study of non-affective FEP patients was performed (211 at baseline and 139 at follow-up). CR was entered in a path analysis model as potential mediators between cognitive domains or clinical symptoms and functioning.
At baseline, the relationship between clinical variables or cognitive performance and functioning was not mediated by CR. At follow-up, the effect of attention (p = 0.003) and negative symptoms (p = 0.012) assessed at baseline on functioning was partially mediated by CR (p = 0.032 and 0.016), whereas the relationship between verbal memory (p = 0.057) and functioning was mediated by CR (p = 0.014). Verbal memory and positive and total subscales of PANSS assessed at follow-up were partially mediated by CR and the effect of working memory on functioning was totally mediated by CR.
Our results showed the influence of CR in mediating the relationship between cognitive domains or clinical symptoms and functioning in FEP. In particular, CR partially mediated the relationship between some cognitive domains or clinical symptoms and functioning at follow-up. Therefore, CR could improve our understanding of the long-term functioning of patients with a non-affective FEP.
Efficient algorithm integration is a key issue in aerial robotics. However, only a few integration solutions rely on a cognitive approach. Cognitive approaches break down complex problems into independent units that may deal with progressively lower-level data interfaces, all the way down to sensors and actuators. A cognitive architecture defines information flow among units to produce emergent intelligent behavior. Despite the improvements in autonomous decision-making, several key issues remain open. One of these issues is the selection, coordination, and decision-making related to the several specialized tasks required for fulfilling mission objectives. This work addresses decision-making for the cognitive unmanned-aerial-vehicle architecture coined as ARCog. The proposed architecture lays the groundwork for the development of a software platform aligned with the requirements of the state-of-the-art technology in the field. The system is designed to provide high-level decision-making. Experiments prove that ARCog works correctly in its target scenario.
Introduction: Despite recent advances in resuscitation, some patients remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Vector change defibrillation (VC) and double sequential external defibrillation (DSED) have been proposed as alternate therapeutic strategies for OHCA patients with refractory VF. The primary objective was to determine the feasibility, safety and sample size required for a future cluster randomized controlled trial (RCT) with crossover comparing VC or DSED to standard defibrillation for patients experiencing refractory VF. Secondary objectives were to evaluate the intervention effect on VF termination and return of spontaneous circulation (ROSC). Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services and included all treated adult OHCA patients who presented in VF and received a minimum of three defibrillation attempts. In addition to standard cardiac arrest care, each EMS service was randomly assigned to provide continued standard defibrillation (control), VC or DSED. Services crossed over to an alternate defibrillation strategy after six months. Prior to the launch of the trial, 2,500 paramedics received in-person training for VC and DSED defibrillation using a combination of didactic, video and simulated scenarios. Results: Between March 2018 and September 2019, 152 patients were enrolled. Monthly enrollment varied from 1.4 to 6.1 cases per service. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, patients, families, or ED staff about the trial. In the standard defibrillation group, 66.6% of cases resulted in VF termination, compared to 82.0% in VC and 76.3% of cases in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusion: Findings from our pilot RCT suggest the DOSE VF protocol is feasible and safe. VF termination and ROSC were higher with VC and DSED compared to standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact patient-centered, clinical outcomes
Mixed Bipolar patients are those who have co-existing depressive symptoms during mania. These patients are supposed to have a worse evolution.
The objective of this study was to compare the long-term outcomes of patients who had at least one mixed episode with those who experienced only pure manic episodes.
169 outpatients diagnosed of Bipolar I disorder and treated at least during two years were included. 120 patients (71%) complited the follow-up over 10 years. Baseline demographic and clinical variables were included.
The patients with mixed episodes (37%) had a significantly younger mean age at onset comparing with those with manic episodes (25.3 years vs. 30.8 years; p=0.025) they also had more previous mood- incongruent psychotic symptoms χ2= 6.77, p=0.034), more number of hospitalizations (OR= 1.36, 95% CI = 1.14; -1.63; p< 0.001), and more number of episodes (OR= 1.21, 95% CI = 1.10-1.31; p< 0.001). There were no significant differences relating to depressive episodes, alcohol use, drug abuse, suicidal behaviour and suicide attempts.
Age at onset differed significantly between the mixed episode and pure mania groups, with mixed episode patients having a younger age of onset. This is interesting as one of the major results of the study we have found that age at onset mediates some of the factors classically related to outcome in mixed episodes like alcohol abuse and suicide attempts. However, independently of age at onset, these patients represent a especially severe type of bipolar disorder.
Oxidative stress suposses an imbalance between oxidants and antioxidants molecules. Negative and positive family environment have been related with worse and better outcomes respectively in schizophrenic patients.
Our objetive is to determine antioxidant defense in healthy controls and unaffected relatives of early onset psychosis patients and to asses its relationship with familiar environment.
We included 82 healthy controls (HC) and 14 healthy controls with second degree family history of psychosis (HCWFHP), aged between 9 to 17.
Total antioxidant status and lipid peroxidation test were determined in plasma and antioxidant enzime activities and glutathione levels were determined in erytrocytes.
We used the Global Assesment Functioning scale (GAF) and the Family Environment Scale (FES). The FES is made up of ten subscales: cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural, social, moral, organization and control.
The analyses showed a significant decrease in total antioxidant level in HCWFHP compared with the HC (U Mann Withney = 281.00, p=0.009, effect size= -0.78).
HC and HCWFHP did not differ in the GAF scale, nevertheless the scores of HCWFHP were significantly higher in cohesion and intellectual-cultural dimensions of the FES (p=0.007, p=0.025).
Adjusting by this two FES dimensions, antioxidant status remained significantly different between groups: OR= 10.86, p=0.009.
Although we cannot induce causative relations, we can state that family environment is not playing a role in inducing oxidative stress in these subjects. It could be hypothesized that families with affected relatives protect themselves with positive envionmental factors such as cohesion and intellectual-cultural activities.
Vascular Dementia (VD) is the second most frequent cause of dementia (20–30% of cases) with a similar percentage associated with Alzheimer’s disease (AD). Due to increased prevalence, its early diagnosis is of particular importance for prevention and correction of risk factors.
An 82-year-old Caucasian woman has been taken to the emergency department by her husband, presenting changes in behaviour defined by aggressiveness, delusional and paranoid ideation with 1M of progression. She had also suffered cognitive impairment (memory deficits, prosoprognosia, disorientation) and some functional decline. She also experienced isolation and reduced communication, anxiety, almost total insomnia, emotional lability, slurred speech, slowed gait and urinary incontinence.
This elderly patient with multiple medical comorbidities (HTA, DM, chronic AF hypocoagulated, MI, Craneoencephalic trauma with a stroke episode) was admitted to the Department of Psychiatry and investigated with auxiliary diagnostic tests and neuroimaging. We found ischemic injury and haemorrhagic sequelae in the latter and in the neuropsychological assessment cognitive deficits were found (executive function, attentional, semantic memory and visuoespacial). Due to this findings and the rapid evolution of symptoms, the diagnosis was Cortical and Subcortical VD.
The patient was treated with a minor anxiolytic, a hypnotic inducer and an antidemencial, with improvement, after one week, of her emotional lability, behavioural symptoms and remission of delusional ideation. At discharge, she maintained slow gait, urinary incontinence, as well as attentional, mnesic and executive deficits, and she was partially oriented, in spite of anosognosia.
She was transferred to geriatrics and to a day center.
Both oxidative stress and the inflammatory chemokine MCP-1 have been linked to the pathophysiology of certain mental illnesses such as psychosis. There are previous studies in rats and dogs suggesting that oxidative stress can cause cognitive impairment.
To correlate oxidative stress and the chemokine MCP-1 levels with cognitive impairment in first episode psychosis.
28 patients with first episode psychosis and 28 healthy controls matched by sex and age were included in the study, who were given a battery of neurocognitive tests and we determined their blood levels of lipid peroxidation (TBARS), nitric oxide, total antioxidant status (TAS), glutathione, activity of enzymes catalase (CAT), glutathione peroxidase (cGPx) and superoxide dismutase (SOD) and the inflammatory chemokine MCP-1.
Healthy controls had better TAS than patients and increased activity of enzymes cGPx and CAT.
We found a statistically significant negative relationship between levels of MCP-1 and working memory, attention and verbal memory. At higher levels of chemokines, worse cognitive functioning in these areas.
Verbal memory was also negatively related, in a meaningful way, with nitric oxide levels in blood.
Likewise, we found that higher levels of glutathione correlated with better scores on the 3 tests performed of verbal fluency.
In patients with a PEP, levels of certain markers of oxidative stress and inflammation are associated with poorer cognitive functioning.
To describe possible differences in the initial cognitive profile between schizophrenia and non-schizophrenia first episode psychosis patients.
We assessed attention, working memory, and executive functioning in 57 first episode psychosis patients at baseline and at a one-year follow-up.
No significant differences were detected in the cognitive profile among schizophrenia (n=20) and non-schizophrenia (n=37) patients at baseline or at the one-year follow-up. For the overall group, significant reductions in the percentage of omission and commission errors for the sustained attention task (p< 0.001 and p=0.001 respectively), in the total time to complete the Stroop-I task (p< 0.001), in the percentage of omission errors for the working memory task (p=0.001), and in the percentage of perseverative errors for the WCST (p< 0.001) were detected, as well as a significant increase in the number of categories completed in the WCST (p< 0.001). The other cognitive variables analyzed remained stable (4 of the 10 variables tested). The pattern of change was similar for schizophrenia and non-schizophrenia patients in the areas of attention and working memory. For executive functioning, the non-schizophrenia group showed a more beneficial pattern of change.
Our results indicate a lack of specificity of cognitive alterations related to the degree of affectation, at least during the first year after instauration of treatment. The course of cognitive deficits in first episode psychosis showed significant improvements over this period, being the patter of change in executive functioning slightly more beneficial for patients with a non-schizophrenia psychosis.
Psychotic symptoms may develop after traumatic experiences. This is documented in Wartime situations. Childhood Abuse is linked with psychosis in later life. PTSD, and ‘Borderline’ symptoms are often linked with a past history of childhood trauma.
We hypothesise that the development of psychotic symptoms related to trauma may occur in a different pattern than the development of psychosis of neuro-developmental origin [schizophrenia].
We present a series of Vigniettes, all of whom have developed psychosis. Three have experienced major trauma, in Early Adulthood, Two have experienced a major trauma related to a war situation., and two, have developed psychotic illness of a neuro-developmental type [schizophrenia].
As expected, the cases of neuro-developmental psychosis developed psychosis over a long prodromal period, in which symptoms developed from non-specific depression and anxiety to a gradual increase of positive psychotic symptoms over time, until full psychosis developed.
The five cases where psycho-trauma occurred in adulthood [including the two wartime cases and the three other cases] showed sudden development of symptoms at the time of the trauma including PTSD and borderline symptoms. The psychotic symptoms developed, also suddenly, some time later, after a subsequent episode of psycho-trauma.
These different patterns of development of psychotic symptoms suggest different mechanisms of causation. Nonetheless, in all these cases, a full blown psychotic illness may result. In cases of psycho-trauma, the illness may continue to be accompanied by ongoing symptoms of PTSD and Borderline features, making these patients difficult to treat.
Cognitive deficits have been consistently described in psychosis and have been proposed as endophenotype markers. Nicotine administration can improve attentional and working memory deficits in schizophrenia. Compared to the general population, smoking is specially prevalent in schizophrenia.
To describe possible differences in cognitive performance in smoking versus non-smoking patients with first-episode psychosis and to determine the presence of smoking-related cognitive enhancement.
Sixty-two patients with first-episode psychosis were assessed with a neuropsychological battery that included computerized measurements of attention, working memory, and executive functioning. Patients were grouped into two categories: non-smokers (0 cigarettes/day; n=31) and smokers (20 or more cigarettes/day; n=31).
Groups were paired for sociodemographic and clinical data. In the sustained attention task, smokers exhibited shorter reaction times than non-smokers (p=0.026) and presented a significantly lower % of omissions (p=0.046). No differences were found in the % of commissions. Similarly, in the working memory task, smokers exhibited shorter reaction times than non-smokers (p=0.020) and presented a significantly lower % of omissions (p=0.002), with no differences in the % of commissions. Compared to non-smokers, smokers needed significantly less time to complete the Stroop interference task (p=0.013) with no significant differences in the % of correct responses. No differences were detected between groups in the Wisconsin Card Sorting Test.
Cigarette smoking is associated with less marked attentional and working memory deficits in first-episode psychosis and may constitute a self-medication behavior for remediation of neuropsychological dysfunction. This may be relevant for developing new pharmacotherapies for cognitive deficits in psychosis.
Addiction, depression, anxiety and antisocial personality disorder may share common biological mechanisms and changes in impulsivity may contribute to the characterization of different clinical phenotypes.
Our aim was to identify diagnostic profiles in a sample of inmates in a Portuguese prison.
We examined a sample recruited at Paços de Ferreira Penitentiary Centre (n=89). Diagnosis was performed using the International Neuropsychiatric Interview (MINI). Six Version of Addiction Severity Index – European version (EuropASI) and the Psychopathy Checklist –Revised (PCL-R) were used to assess the severity of drug addiction and the presence of psychopathy.
Drug misuse was found in 61.8% of the studied subjects according to MINI. A high prevalence of psychiatric comorbidity was detected, with antisocial personality disorder (70.9%), depression (30.9%), and anxiety (32.7%) being the most common disorders. The total PCL-R score was 24. 1 (SD 8.8), 36 prisoners presented a diagnosis of psychopathy (PCL-R>30). The presence of depression in addicted individuals is associated with a lower severity of dependence (p <0.05) and lower PCL-R scores (p <0.05). The presence of addiction and depression reduces the risk of violent crime, whereas the presence of psychopathy (PCL-R> 30) increases (OR = 3.87, p <0.05).
Psychiatric disorders and addiction were successfully evaluated. Depression is associated with a lower addiction severity. The different types of psychiatric diagnoses produce a modulation in the frequency of violent crimes. The prevalence of psychiatric comorbidity underscores the advantages of a structured psychiatric assessment in prison inmates in order to provide the best treatment.
Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.
The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.
There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.
These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.
Morbid obesity is a serious public health problem due to its increasing prevalence, increased morbidity and mortality and medical and psychological consequence. Obesity has a multifactorial etiology that includes genetic, environmental, dietary, cultural and psychosocial factors.
The surgical treatment of obesity has been consistently shown to be effective in long-term marked weight loss and in bringing significant improvement to medical comorbidities. Surgery is indicated in patients with BMI greater than 35 kg/m2 with severe obesity-related comorbidity and for those with BMI greater than 40 kg/m2 with or without comorbidity. Surgery candidates should be selected and evaluated in order to achieve optimal outcomes.
Psychological factors are thought to play an important role for maintaining the surgical weight loss. The findings suggest that pre-surgical cognitive function, personality, state of mental health, psychological variables and binge eating may predict post-surgical weight loss to the extent that these factors influence post-operative eating behaviour.
The high prevalence of psychiatric disorders in surgery candidates is gaining more attention than before. Studies show that around 40% of all bariatric surgery patients have at least one psychiatric diagnosis. Depressive, anxiety, and binge eating disorders are the most common diagnoses and should be treated before surgery. The most common psychiatric conditions contraindicated to surgery are active psychosis, current substance abuse, heavy drinking, and multiple suicide attempts or a suicide attempt within the previous year.
We made a review of literature on psychological predictors of surgical weight loss in order to clarify the role of pre-surgical psychiatric evaluation.
Psychiatric training in the European Union is undergoing a process of harmonization of national curricula in order to establish a common postgraduate training framework. The Research Group of the European Federation of Psychiatric Trainees (EFPT) is conducting a multi-national study on psychiatry education of trainees among the European countries in regard to the Union Européenne Des Médecins Spécialistes (UEMS) 2009 competencies framework.
The aims are to raise awareness on these competencies, compile data on trainees‘ experience of their training and assessment methods, opinions on level of confidence, and on relevance of these competencies.
This study surveyed trainees from 15 EFPT countries using a questionnaire developed specifically for this research.
Psychiatric training in Europe differs significantly regarding length, with a training duration ranging from 4 to 8 years. Only 26,7% of the trainees were well acquainted with the UEMS competencies and trainees from only 8 countries declared to have a competency based national training curriculum. These results reveal that trainees have different experiences and opinions on competencies and assessment methods depending on their country of residence.
A limitation of the results may be that our respondents are the EFPT representatives’ and probably have better knowledge on the educational issues.
The combined quantitative and qualitative outlook on national training programmes from the trainees point of view enhances our understanding and perspective of the dynamic processes of psychiatric education in Europe. Data obtained from this research study contributes to the efforts to unify psychiatric training curricula.
Even at therapeutic doses, mood stabilizers do not completely address symptoms in bipolar depression. Some guidelines recommend add-on antidepressant therapy or quetiapine.
Early effectiveness of quetiapine extended release (quetiapine XR) vs. sertraline in adults with bipolar depression; treated with lithium or valproate at clinically therapeutic blood levels (change from baseline in the MADRS global score at week 2 (LOCF) endpoint). Others (secondary objectives) were measured at week 8.
Prospective, open label, randomized study of 8 weeks follow-up (D1443L00058).
27 patients were randomized to quetiapine XR (14) or sertraline (13). Mean age was 46.07 years. 17 patients (62.96%) were male. 20 (74.07%) were diagnosed with bipolar disorder type I. Mean number of previous events were 9.74. Mean baseline MADRS score was 28.23 (SD 5.86) and 29.50 (SD 5.00) for sertraline and quetiapine XR groups, respectively (p = 0.59).
Mean change in MADRS score (2 weeks from baseline) was: -6.62 (sertraline group) and -13.14 (quetiapine XR group) (p = 0.08). Final change from baseline was: -10.62 (sertraline) and -17.14 (quetiapine XR) (p = 0.1). Patients with at least one AE and one AE leading to study withdrawal were 12 and 3, respectively (quetiapine XR group); and 9 and 2, respectively (sertraline group). the most frequent AEs were somnolence, dry mouth (35.7%, 21.4%, respectively) (quetiapine XR group), and insomnia, diarrhea, dyspepsia (14.3% for each one) (sertraline group).
Numeric differences (though not significant) in favour of quetiapine XR exist for the early effectiveness of quetiapine XR in bipolar depression. Sponsorship by AstraZeneca.
This is the first European psychiatric exchange programme and it aims to promote an intercultural professional exchange and cooperation among psychiatric trainees across Europe, with a focus on individual experience.
To provide trainees with the opportunities to:
promote awareness of intercultural aspects of psychiatry
engage in clinical, and/or research, and/or teaching activities
become acquainted with different mental health systems
gain experience of different illness manifestations and treatment options
experience a different training programme
socialise with peer group, promote networking and discuss coping strategies regarding work life balance
The programme was developed by the exchange working group of the EFPT in 2011 and it offers 2-6 weeks in observational placements across Europe in diverse areas.
Feedback from pilot phase (January-July 2012) has shown excellent overall satisfaction of participants in the project. In the 2nd phase (August-December 2012) the programme has expanded offering more observational placements in 8 countries such as: Croatia, Denmark, France, Italy, Portugal, Slovenia, Spain and UK. In the 3rd phase (January-July 2013) it expanded further to include Ireland, Netherlands and Romania in a total of 11 hosting countries. Placements are offered in many subspecialties such as: psychotherapy, emergency psychiatry, child and adolescent psychiatry, eating disorders, family therapy, liaison psychiatry and psychosomatics, drug addictions, learning disabilities, forensic psychiatry and old age psychiatry.
We hope that the diversity of placements offered by this innovative programme will constitute a new approach to the improvement of psychiatric training and practice across Europe.
A functional polymorphism of the brain-derived neurotrophic factor gene (BDNF) Val66Met has been associated with cognitive function and symptom severity in patients with schizophrenia. It has been suggested that the Val66Met polymorphism has a role as a modulator in a range of clinical features of the illness, including symptoms severity, therapeutic responsiveness, age of onset, brain morphology and cognitive function. However, little work has been done in first-episode schizophrenia (FES) spectrum disorders. The objective of this study is to investigate the association of the BDNF Val66Met polymorphism on cognitive function and clinical symptomatology in FES patients.
Using a cross-sectional design in a cohort of 204 patients with FES or a schizophrenia spectrum disorder and 204 healthy matched controls, we performed BDNF Val66Met genotyping and tested its relationship with cognitive testing (attention, working memory, learning/verbal memory and reasoning/problem-solving) and assessment of clinical symptom severity.
There was no significant influence of the BDNF allele frequency on cognitive factor scores in either patients or controls. An augmented severity of negative symptoms was found in FES patients that carried the Met allele.
The results of this study suggest that in patients with a first-episode of schizophrenia or a schizophrenia spectrum disorder, the BDNF Val66Met polymorphism does not exert an influence on cognitive functioning, but is associated with negative symptoms severity. BDNF may serve as suitable marker of negative symptomatology severity in FES patients within the schizophrenia spectrum.
Global trends in the nature of working conditions pose significant threats to the training of medical professionals, as a result of cuts in educational grants and the salaries of professionals in training. Psychiatric trainees are not exempt from these changes.
To determine the current working conditions of psychiatric trainees and how they impact on their experience of training.
A semi-structured survey was distributed to all members of the European forum of psychiatric trainees. Responses were collected online from 34 participating countries. The respondents were representatives of national trainee associations. Data collection was completed between May and July 2016.
Respondents reported that the most important issues affecting postgraduate training were firstly working conditions, then salary, psychotherapy training and supervision, respectively. The average official mandatory working hours for a trainee, including on call duty was reported to be on average 40.16 (± 10.14 hours per week). In reality, the time that trainees report working is more than 20% higher than official working hours (on average 49.08 ± 15 per week). There is an officially recognized minimum vacation period of 20 days in almost all countries, ranging up to a maximum of 40 days (mean: 26.93 ± 4.97, per year). Salaries demonstrate an even greater variation, ranging from 100 Euros (as in the case of Moldova), up to over 5000 Euros (as in the case of Germany or Switzerland) per month.
Psychiatric trainees often work longer than the officially recognized hours and their income varies considerably between countries, which have been identified as the two biggest challenges trainees face.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Grief is as normal reactive to a significant personal loss. It is characterized by affective, cognitive, behavioural and physiological symptoms. The grieving process is usually divided in five different stages, but in most cases presents a benign course, with decreased suffering and better adaptation to the new context. However, when high levels of emotional suffering or disability persist over a long time period, it becomes a case of complicated grief (CG), which should be adequately addressed.
To review the characteristics of CG, the evidence that supports it as an individual pathological entity, and its place in current classification systems.
We performed a bibliographic search in Pubmed and PsychInfo, of articles written in English, Portuguese and Spanish, containing the key words: grief, bereavement, psychiatry, classification.
The main issue regarding grief is the degree to which it is reasonable to interfere with a usually benign process. Since DSM-III bereavement has been referred to as an adaptive reaction to an important loss, which should not be diagnosed as major depressive disorder or adjustment disorder. However, DSM-5 has stated persistent complex bereavement disorder as an independent entity. In fact, CG fulfils the general criteria of every psychiatric syndrome, namely regarding specific diagnosis criteria, differential diagnosis from depressive disorders and post-traumatic stress disorder, and improvement with adequate treatment.
It is important to correctly approach CG, since it presents with characteristic diagnosis features and much improvement may be achieved once adequate treatment is provided.
Disclosure of interest
The authors have not supplied their declaration of competing interest.