Since about 30% of children and adolescents attending primary care and pediatric outpatient departments have psychiatric disorders that cause significant distress and social impairment, the proper functioning of National Health System assumes a determinant role on promoting early detection and intervening in the prevention of mental illnesses which can almost only be done through an efficient matching between primary care and hospital care.

This paper aims to characterize the pediatric population hospitalized sent by their general practitioners to our outpatient clinic, on a level III Pediatric Hospital, evaluating the existence of psychopathology.

Retrospective analyses of 309 cases, at their first appointment on our outpatient clinic from June 2002 to March 2013. Self-reported and parent-reported symptoms of mental health problems and associated impairment were identified by the extended version of the strengths and difficulties questionnaire (SDQ) in children and adolescents.

During 10 years, 185 male (45,95% 4–10 years; 54,05% 11–17 years) and 124 female (50,0% on each age group) were evaluated. Eighty-four percent of cases, scored for’any psychiatric disorder’. Correlation between parent-reported and self-reported data was found, slightly higher for male gender. Pronounced divergences were found regarding child and adolescents’ perception and their parents, concerning everyday life difficulties and hyperactivity scores, that is also valid for age group and gender. Total scores: emotional symptoms (51,8%), conduct problems (58,3%), hyperactivity score (59,2%).

We observed a positive impact of primary care medicine on referral network since the majority of the evaluated children and adolescents had psychopathology.

The Internet provides adolescents the chance to experience autonomy through the collection of information and contact with peers with whom to share experiences, emotions and thoughts. A misuse of the Internet can occur if a teenager avoids real relationships and surfing the web turns into a psychological defense, in contrast with a healthy mental development.

and Aims The research investigates forms and motivations of misuse of the internet among a group of Italian teenagers. Objective of the work is the hypothesis of a correlation between massive use of internet and behaviours of social retreat.

The research used a questionnaire. The areas of investigation were: school performance, hours of internet surfing, activity on the Internet (social networks, games, information research, gambling online), psychological reasons of the Internet use, behaviours of social retreat. 583 adolescents (45% males and 54% females, mean age 17 years) responded to the questionnaire.

The 6% of adolescents sample responded to always think the Internet even when not on the computer or gets irritated and reacts impulsively if someone bothers him while it is connected. The 5% prefer surfing rather then going out with friends. Hours of internet sulfing and responses of social retreat were correlated.

The social retreat can be one of consequences of the Internet misuse, with difficulties in socializing and use of the Internet as a psychological defense.

Animal research suggests that weight gain may be caused by olanzapine-induced melatonin suppression. We conducted a pilot study of psychiatric patients treated with olanzapine to examine if melatonin was suppressed and if so the dose needed to replace this deficit. The relationship between melatonin and metabolic indices was also examined.

Ten patients with schizophrenia (N=3), schizoaffective disorder (N=3), or bipolar disorder (N=4) completed the study. All patients were male, average age 50.6 years. Patients were treated with olanzapine for 5 weeks, then randomized to either 0.3mg (N=4) or 3mg (N=6) of melatonin supplementation in addition to the olanzapine for another 6 weeks. We obtained baseline, week-6, and week-12 measures of the major metabolite of melatonin in the urine, 6-Sulfatoxymelatonin (aMT6s) adjusted for creatinine excretion. We measures weekly weight, glycemia, cholesterol, and triglycerides.

Olanzapine treatment was associated with a trend toward decreases in melatonin from baseline to week-6 (p=.14). Analysis of a subsample of patients diagnosed with schizoaffective or bipolar disorder showed significant decreases from baseline to week-6 (p=.02). Both supplementation with melatonin by 0.3mg and 3mg increased urinary melatonin levels from week-6 to week-12 (p=.12 and p=.02 respectively). Total cholesterol increased initially but demonstrated a trend for decrease when melatonin was supplemented (p=.10).

Olanzapine appears to be related to melatonin suppression. Melatonin supplementation reverses this suppression and may have the potential to reverse metabolic effects associated with olanzapine. Further studies are needed to examine the metabolic effects of olanzapine with melatonin.

Electroconvulsive therapy (ECT) is a highly effective treatment for major depression with response rates of up to 80%. However, a significant minority does not respond, and no evidence-based guidelines are available for the management of ECT-resistance. Ketamine is an anaesthetic agent with N-methyl-D-aspartate-receptor-antagonist properties, that has a rapid but short-lasting antidepressant effect in treatmentresistant depression.

To present a case of ECT-resistant depression that responded when ketamine anaesthesia was used.

To review the available literature on ECT-resistance and augmentation of ECT.

A case is presented and discussed, followed by a systematic literature review.

We present the case of a 75-year-old woman with severe major depression unresponsive to several adequate treatments with antidepressants, augmentation with antipsychotics, and ECT with anaesthesia using propofol or etomidate. When ketamine was used for anaesthesia, she experienced remission of her condition. She remained well with a continuation of this treatment at a decreasing rate. A literature review revealed that most augmentation strategies for ECT concerned the optimisation of seizures by using of substances that lowered the seizure threshold (e.g. xanthines) or anaesthetics that do not increase the seizure threshold (e.g. remifentanil). Ketamine anaesthesia was shown to speed up response to ECT, but did not increase response rates. However, these studies were not done with ECT-resistant patients. This case suggests that switching to ketamine anaesthesia may be beneficial in these patients.

There are little evidence-based augmentation options for ECT-resistance. This case suggests that ketamine anaesthesia may be efficacious as augmentation in ECT-resistance.

To assess the budget impact of the inclusion of quetiapine vs. aripiprazole or olanzapine on the top of standard bipolar disorder treatment scheme with atypical antipsychotics according to Russian healthcare system.

The 1 year budget impact analysis was conducted. Direct expenses associated with bipolar disorder and resulting follow-up costs were calculated using general tariff agreement of Russian obligatory insurance system and official national statistics. For reference, accepted exchange rate was 1 EUR = 40 RUB.

Quetiapine inclusion into the standard bipolar disorder therapy provided cost saving benefits vs. inclusion of aripiprazole or olanzapine in the bipolar disorder standard therapy scheme. Total healthcare costs of bipolar disorder therapy were approximately 396 539 RUB (9 913 EUR) per patient in quetiapine group, 1 023 089 RUB (25 577 EUR) per patient in aripiprazole group and 557 222 RUB (13 931 EUR) per patient in olanzapine group within one year. Treatment of bipolar disorder using standard therapy with quetiapine inclusion compared to one with aripiprazole or olanzapine leads to cost savings of 626 551 RUB (15 664 EUR) or 160 683 RUB (4 017 EUR) per patient-year, respectively.

The results of budget impact analysis illustrate that including quetiapine into the standard therapy of bipolar disorder in comparison with aripiprazole or olanzapine has potential to reduce Russian healthcare system total costs for bipolar disorder treatment.

There is substantial evidence that patients with schizophrenia present with impaired Theory of Mind (ToM). ToM impairment has been also reported in euthymic bipolar disorder (BD). However, data from direct comparisons of patients with schizophrenia and BD on ToM abilities are limited.

It has been suggested that different aspects of mentalizing processing, such as epistemic and emotional mental representations, i.e. cognitive and affective ToM, must be separately examined.

The aim of the study was to compare ToM ability and both its cognitive and affective components between schizophrenic and euthymic BD patients.

Fifty three BD type I euthymic patients, 54 patients with schizophrenia and 53 healthy controls (HC) completed a multi-facet battery of ToM tasks, including False belief task, Hinting task and Faux Pas Recognition Test (FP). Besides the overall ability to recognize Faux Pas, two specific components of ToM – cognitive and affective – were assessed with FP. The three groups were matched for gender, age and education.

BD and schizophrenia patients showed no impairment in the False belief task. Schizophrenia patients performed significantly lower than HC and BD patients in Hinting task, FP recognition and affective ToM. Both patient groups were impaired in cognitive ToM. However, only BD patients with a history of psychosis performed significantly lower than HC in affective ToM.

In contrast to schizophrenia patients, euthymic BD patients show a specific deficit only in cognitive but not in affective ToM. Further research on the impact of these deficits on social and occupational functioning is warranted.

To estimate the efficiency of the atypical antipsychotics (quetiapine, risperidone, aripiprazole or olanzapine) used to reduce relapses in bipolar disorder, taking into account costs and effectiveness (QALY).

The Russian health care system perspective and a five year temporal horizon have been used. An annual discount rate assumed was of 5%. Taking into account the last literature review on bipolar disorder, four fundamental aspects related with bipolar disorder management were analyzed: relapse rates, inpatient treatment, outpatient treatment and hospitalization rates. The health care direct costs corresponding to the drug acquisition costs have been analyzed together with the costs of inpatient diagnostics, costs of inpatient treatment and costs of hospitality relapses updated with data from Russian health care system.

Quetiapine or risperidone treatment presents the lower total costs (€13 562 and €13 097 respectively) versus the other strategies (aripiprazole = €36 328 and olanzapine = €19 957). Quetiapine presents the higher QALY compared with the alternatives (quetiapine = 3.551, risperidone = 3.534, aripiprazole = 3.528 and olanzapine = 3.525). With these results one can emphasize that quetiapine or risperidone treatment is dominant with the cost-effectiveness ratio (CER) of 3 819 and 3 706, respectively, versus aripiprazole or olanzapine groups (CER 10 297 and 5 662 respectively). The incremental CER (quetiapine vs. risperidone) is €27 322 per QALY.

The results illustrate that quetiapine is dominant versus aripiprazole or olanzapine. Also quetiapine therapy is within willingness to pay threshold in case of risperidone substitution in Russian patients with bipolar disorder

The research investigates the possibility of reducing the level of post-stroke dementia.

The research involved 92 patients after massive ischemic stroke aged 32–72. The patients underwent: CDR, MMSE, cerebral CT, MRI, SG, REG, cerebral multi-gated angiography (MUGA).

Initial dementia and cognitive impairment severity was identified among 33 patients (35.87%):

• moderate dementia (CDR-2) - 18 (54.55%) patients (MMSE 11–18);

• severe dementia (CDR-3) - 15 (45.45%) patients (MMSE 7–10).

Transluminal treatment was performed in 68 cases - Test Group.

Conservative treatment was performed in 24 cases - Control Group.

Test Group. Good immediate angiographic outcome manifested in the restoration of vessels lumen and patency, as well as in collateral revascularization, was achieved in 66 (95.59%) cases. The following positive trend was observed in 12–24 months:

1. ■ Absence of dementia signs, cognitive function restoration to MMSE 28–30 - 14 (20.59%) patients;

2. ■ Dementia severity reduction to CDR-1, cognitive function restoration to MMSE 21–27 - 30 (44.12%) patients;

3. ■ Dementia severity reduction to CDR-2, cognitive function restoration to MMSE 17–20 - 24 (35.29%) patients;

Control Group. The following was observed in 12–24 months:

1. ■ Dementia severity reduction to CDR-1, cognitive function restoration to MMSE 21–26 - 2 (8.33%) patients;

2. ■ Dementia severity reduction to CDR-2, cognitive function restoration to MMSE 17–20 - 5 (20.83%) patients;

3. ■ Absence of clear signs of declining dementia - 17 (70.85%) patients.

Transluminal laser revascularization of cerebral blood vessels is more efficient than therapy in the treatment of ischemic stroke; it can significantly reduce dementia level and bring patients back to their normal active life.

The Health Utilities Index-Mark 2 (HUI2), a generic instrument for assessing health status, is an important effectiveness input for pharmacoeconomic modelling. It has not previously been used in patients with attention deficit/hyperactivity disorder (ADHD).

To use HUI2 to assess health utility in patients aged 6–17 years with ADHD receiving the prodrug stimulant lisdexamfetamine dimesylate (LDX).

SPD489-325 was a 7-week, randomized, double-blind, placebo-controlled trial of LDX, with osmotic-release oral system methylphenidate (OROSMPH) as a reference treatment. Patients’ parents or guardians completed HUI2 questionnaires at baseline and weeks 4 and 7. Utilities were estimated for treatment responders and non-responders, with response defined as a Clinical Global Impressions-Improvement (CGI-I) score of 1 or 2, or a ≥25% or ≥30% reduction in ADHD Rating Scale IV (ADHD-RS-IV) total score.

Of 336 patients randomized, 317 were included in the full analysis set (LDX, n=104; OROS-MPH, n=107; placebo, n=106) and 196 completed the study. At endpoint, mean HUI2 utility scores across all treatment groups were higher for responders than non-responders when response was based on CGI-I score (responders: 0.896 [SD, 0.0990]; non-responders: 0.838 [0.1421]), on a ≥25% reduction in ADHD-RS-IV score from baseline (responders, 0.899 [0.0969]; non-responders, 0.809 [0.1474]), or on a ≥30% reduction in ADHD-RS-IV score from baseline (responders, 0.902 [0.0938]; non-responders 0.814 [0.1477]).

The HUI2 instrument is sensitive to treatment response in the child and adolescent ADHD patient population. Health utilities generated using HUI2 are therefore suitable for cost effectiveness evaluations of ADHD medications.

Supported by funding from Shire

The Weiss Functional Impairment Rating Scale–Parent Report (WFIRS-P) is an ADHD-specific instrument comprising 50 items, grouped into six domains. Parents score each item on a Likert scale (0–3 or not applicable).

To evaluate functional impairment using the WFIRS-P in two phase 3 studies (SPD489-325 and SPD489-326) of lisdexamfetamine dimesylate (LDX) in children and adolescents with ADHD.

Patients’ parents or guardians completed WFIRS-P assessments at baseline, and weeks 4 and 7 of SPD489-325, a 7-week, randomized, placebo controlled trial incorporating a reference treatment (osmotic-release oral system methylphenidate; OROS-MPH). Statistical comparison of LDX versus OROS-MPH was not pre-specified. In SPD489-326, WFIRS-P assessments were performed in the ≥26-week open-label period and the subsequent 6-week randomized-withdrawal period.

In SPD489-325, statistically significant placebo-adjusted effects of LDX were observed in WFIRS-P total score (effect size, 0.924; p<0.001) and in Family, Learning and School, Social Activities and Risky Activities; OROS-MPH effects were significant in total score (effect size 0.772; p<0.001) and in all domains. In SPD489-326, scores were improved or stable in the open-label period. In the randomized-withdrawal period, total score and all domain scores were stable in the LDX group, but worsened in the placebo group. LDX was significantly more effective than placebo in Family, Learning and School, Risky Activities and in total score (effect size, 0.908; p<0.001).

Short-term treatment with LDX or OROS-MPH led to improved functional impairment scores. These benefits were maintained during long-term LDX treatment, and scores declined following treatment withdrawal.

Supported by funding from Shire.

Psychosomatic families can usually be characterized by the problem of conflict management, which is associated with the low level of communication among the family members.

One of the characteristic properties of these dysfunctional families is the way they sweep the problems under the carpet and/or triangulation that always involves a pair of the family members and a third person in the conflict situation to divert the attention from the essential problem, which thus remains unresolved.

The aim of my study was to explore the manifestation of the hidden conflicts in the family structure if there is at least one psychosomatic patient in the family, as well as to investigate his/her position in the family structure.

There were 12 asthmatic and 18 healthy young adults in my study and I used Gehring's (2010) Family System Test (FAST) to learn more about the above-mentioned phenomenon. The applied method gave me the possibility to recognize the characteristic arrangement (triangulation), which is about the third person's involvement in the other two people's conflict.

Participants with asthma – primarily in the conflict situation - represented triangulation on the board and located their schematic wooden figure between the parents in a triangular shape more often than it was found in the healthy control group.

Thus in line with the previous studies the special position of the asthmatic patients in their family has been confirmed, and the significance of dyspnoea with its central, fire-fighting role was also found.

Orthodox theories of autism spectrum disorder (ASD) focused on cognitive impairments, but other kinds of problems can also be observed.

While play as a fundamental activity in the child's life supports several aspects of his/her development, certain forms show particularly large differences in ASD compared to the typical developing (TD) children's play.

The aim of my study was to explore the relationship between the child's sensitivity in his/her certain modalities and quality of object use/play.

On the one hand, I used Bogdashina's (2003) Sensory Profile Checklist Revised (SPCR) to know more about ASD-children's sensory-perceptual processes. On the other hand, video analysis was applied by Noldus Observer XT 8.0 program software to explore some characteristics of object play.

Different sensory-perceptual experiences and patterns of object use were explored in TD and ASD. The latter group usually demonstrated a higher level of sensitivity than control persons. Tactility was found to be in stronger correlation with exploration, and this type of object use also showed correlation with adequate object use in TD. Furthermore, conventional object use also correlated with creative object play. ASD-children rather demonstrated stronger association between taste and imitation but did not present a similar relation between the frequency and/or time duration of the diversified forms of play activity with objects.

In this way, ASD-children usually demonstrated unusual behaviour patterns. However, the various types of object use build on each other, thus the lack of any kind of play activity causes further problems in the individuals’ life.

While illegal drug abuse has been recently stabilized in western countries, iatrogenic opiod dependence is increasing. In EEUU, opioids abuse is more prevalent than other legal or illegal drug abuse. Prevention actions and strategies to optimize short and long term treatments need to be outlined.

Learning to prevent, diagnose and treat iatrogenic opioid dependence.

We review 9 cases of iatrogenic opioid dependence hospitalized in the Psychiatric department of a general hospital, considering demographic and personal data, treatment patterns and strategies followed. Pubmed bibliographic search was performed.

Patients came from different clinical resources (44,4% from pain center, 33,3% from emergency department, 22,22% scheduled admission).

N°1:48-year-old man with dependence to oral codeine (1200 mg/day). Maximum methadone dose required (MMR): 30 mg/day.

N°2:43-year-old woman with dependence to oral fentanyl (3000 mcg/day). MMR:25 mg/day.

N°3:50-year-old woman with dependence to fentanyl patches (2,25) and oral tramadol (300 g/day). MMR:20 mg/day.

N°4:55-year-old woman with dependence to oral oxicodone (60 mg/day). MMR:20mg/day.

N°5:39-year-old woman with dependence to subcutaneous meperidine (600 mg/day). MMR:25 mg/day.

N°6:61-year-old woman with dependence to oral codeine (600 mg/day). MMR:15 mg/day.

N°7:45-year-old man with dependence to transmucous fentanyl (600 mcg/day). MMR:90 mg/day.

N°8:49-year-old man with dependence to oral tramadol (450 mg/day). Progressive tramadol withdrawal until suppression.

N°9:38-year-old woman with dependence to transmucous fentanyl (2400 mcg/day). MMR:22,5 mg/day.

Classically, methadone has been the main opioid dependence treatment, as shown in almost all cases exposed. However, new treatments are being developed, e.g. monthly parenteral naltrexone. Opioid dependence treatment must be combined with other substances abuse/dependence or psychiatric comorbidities treatment and psycotherapeutical intervention.

Studies conducted in Pakistan reveal a high prevalence of depression, particularly in women. Evidence based and effective treatments are available, yet there is a significant gap between the numbers of women in need of treatment and those who receive services. This qualitative study identifies the barriers in access to mental health services for women screened for depression from primary care clinics in Karachi.

In-depth interviews were conducted with 30 women screened for depression from three purpose fully selected primary care sites in Karachi.

Interviewees reported that they mostly did not share their depressive symptoms and suicidal attempts with health care providers due to perception of these being their personal problems and health care providers also not asking about it. Interviewees perceived health care providers too busy, overburdened and not interested in their emotional problems. Those who shared their symptoms also did not receive proper diagnoses, treatment or referral from their health care providers.

The study highlights the need to increase mental health literacy about depression through mass media, community engagement, and educational institutions so that women can recognize the depression in themselves and other women around them and be able to share their symptoms with their health care providers. Religious scholars needs to be involved in raising awareness on depression as an illness for which women should seek medical treatment besides taking support from religion. It also indicates the need for a referral system to help women reach to the required mental health services.