Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation.

Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months.

10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation.

Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

A small subset of patients with above average admissions to psychiatric inpatient units is recognized in clinical practice. These frequent users tend to be younger and to have a diagnosis of schizophrenia or affective disorder. Social conditions and the severity of the illness seem to be associated with this increased number of admissions.

To study demographic and clinical characteristics of frequent and non-frequent users of a psychiatric inpatient unit.

Retrospective data of all the patients admitted to a psychiatric inpatient unit from January 2004 to December 2008 were reviewed. Frequent-users were defined as patients with 3 or more admissions over that period of time, and non-frequent users as those with less than 3 admissions. The two groups were compared in terms of age, gender, ethnicity, psychiatric diagnosis and compulsory admissions

In a total of 2018 admissions and 1348 patients, the frequent-user group represented 10.2% (n = 137) of the patients and 28.9%(n = 584) of the admissions. Frequent-users were significantly younger (39.5 vs. 44.5 years, p = .001), more frequently black (22.6 vs. 19.4%, p < .001) and compulsorily admitted (27.7 vs. 14%, p < .001) than non-frequent users. Patients with bipolar disorder (p = .001), schizophrenia (p = .003) belonged significantly more to frequent-users group, while unipolar depressive patients (p = .016) and other diagnosis (p = .011) was more significantly represented in the non-frequent users group. Frequency of admission did not differ with gender.

The results concerning age and psychiatric diagnosis are consistent with previous studies. Compulsory admissions and black ethnicity were significantly higher among frequent- users.

Psychoeducation is currently considered an essential intervention in the management of bipolar disorders. A psychoeducation group programme for patients with bipolar disorders named “Porta Aberta” (Open Door) has been implemented since 2007 at the Day-hospital of our psychiatric department.

To assess the efficacy of group psychoeducation in reducing the average number and duration of readmissions and to determine the individual characteristics (gender, marital status and disorder subtype) that might influence these outcomes.

Review of the clinical records of a consecutive sample of patients with bipolar disorders discharged from the inpatient unit, attending at least 4 out 8 programme sessions, and with a one-year follow-up since 2007. Variables assessed were: gender, age, marital status, subtype of bipolar disorder (I or II), and number and duration of psychiatric admissions in the year before and in the year following the programme attendance.

The 69 patients included were 37.3 ± 10.7 years old, mainly women (68.1%), and single (47.8%). A statistically significant reduction in the average duration of readmissions (24.7 versus 17.3 days, p = .028), and in the average number of readmissions (1.3 versus 0.3, p = .032) was found. Only 15 patients were readmitted. Patient's gender and marital status, as well as disorder subtype had no influence in the results.

Group psychoeducation is an effective intervention in reducing the number and duration of readmissions in bipolar patients despite gender, marital status and subtype of bipolar disorder.

Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patient's health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness.

The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. all four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted.

To raise awareness to the importance of this rare but highly disabling disease.

Review of clinical records and complementary exams.

All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis.

Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.

There is robust evidence recommending electroconvulsive therapy (ECT) in treating severe acute affective disorders. The clinical use of bitemporal electrode placement is still favoured to unilateral placement with just a relative disadvantage in cognitive side effects. Recently, bifrontal placement has gained popularity but there is still limited evidence on its relative benefits.

Compare bitemporal and bifrontal ECT efficacy in patients with pharmacologically resistant affective disorders, based on the number of acute phase treatments required to reach symptomatic remission.

Review of all patients' charts submitted to acute phase ECT, between June 2006 and June 2011. A total of 70 ECT treatment courses performed in a group of 67 patients met inclusion criteria. Thirty-eight of the total 70 courses received bitemporal ECT, and 32 received bifrontal ECT. A statistical analysis was performed. An attempt to use t-test was foiled due to breach of population variance homogeneity (p = 0,021). The non-parametric Mann-Whitney test was the alternative choice (M-W = 534;p = 0,377).

Bitemporal and bifrontal groups matched for age and sex. Bitemporal patients received on average five ECT treatments, while the average of bifrontal treatments to remission was six, but this difference was not statistically significant (p > 0.05).

Our results showed that bitemporal and bifrontal placements are equally effective. According to the largest randomised controlled trial conducted on ECT in depressive illness (Kellner et al,2010), bitemporal placement led to a faster rate of improvement. Additional studies and larger samples are required to understand if bifrontal placement's efficacy and cognitive advantages justify its popularity.

The co-occurrence of mania and delirium, named “delirious mania”, is an under-recognized entity not listed in major diagnostic classifications. Literature about this syndrome is still scarce and lacking evidence. Usually, reports of affective syndromes with delirium tend to be subdued in the manic descriptor

We report the case of a 44 year old female patient with a simultaneous affective episode and delirium.

To demonstrate the co-occurrence of depressive/mixed symptoms and delirium

Review of clinical records and complementary exams.

The patient was admitted after a three week long depressive syndrome with psychomotor agitation, followed by a week-long fluctuating pattern of delirious and mixed affective features. Shortly after admission the patient exhibited a stuporous state, with nocturnal agitation. A fluctuating pattern of symptoms ensued, with disorientation, disorganized behavior, cognitive impairment, anxiety and depressive features. the patient was put on mood stabilizers, antipsychotics and benzodiazepines. She was discharged symptom-free two months later and re-admitted 4 weeks later due to recurrence of symptoms. Electroconvulsive treatment was applied,with quick remission of affective symptoms. Yet, it took another two months until discharge, due to persistent cognitive symptoms. Medical conditions were excluded.

This case shows the simultaneous occurrence of an affective syndrome alongside delirium. the strongest treatment response occurred with ECT. the presence of depressed mood highlights the fact that this syndrome can begin without clear-cut manic symptoms. We suggest that its name should be changed to Delirious Affective Disorder, which might help to avoid misdiagnosis. Persistent cognitive deficits raise some questions in this case.

Bipolar mixed states were systematically described for the first time by Emil Kraepelin. Since then, their high prevalence has been repeatedly recognized, but they still remain poorly understood. These patients appear to be extremely difficult to treat, many being refractory to pharmacological approaches. Clinical experience supports the use of electroconvulsive therapy (ECT) in mixed states, but there is little information on its effectiveness in scientific literature.

Report our experience in using acute phase ECT (aECT) in mixed states.

The authors reviewed the clinical records of all patients submitted to aECT between June 2006 and June 2011. The inclusion criteria were: a) presence of a mixed state according to Akiskal's criteria (Akiskal et al,2005); b) completed treatment course with aECT. The following variables were collected: demographic characteristics, previous response to pharmacotherapy, presence of psychotic symptoms, number of aECT sessions, referral to continuation or maintenance ECT (c/mECT), number of readmissions. Relation between the diagnostics and the number of ECT sessions was validated with Eta-coefficient. Comparison between these two groups was carried out with One-Way-ANOVA.

Eighteen patients met inclusion criteria and were resistant to pharmacotherapy. Eight patients had psychotic features. All patients but one showed a positive clinical response, as documented on CGI. The average number of ECT sessions was five, while the mean of ECT treatments in manic and depressive patients was seven and six respectively. Thirteen patients were scheduled for c/mECT.

Our results confirm the effectiveness of ECT in medication nonresponsive patients experiencing a mixed state.

Common mental disorders are highly prevalent and disabling, leading to substantial individual and societal costs. This study aims to characterize the association between disability and common mental disorders in Portugal, using epidemiological data from the World Mental Health Survey Initiative.

Twelve-month common mental disorders were assessed with the CIDI 3.0. Disability was evaluated with the modified WMHS WHODAS-II. Logistic regression models were used to assess the association between disability and each disorder or diagnostic category (mood or anxiety disorders).

Among people with a common mental disorder, 14.6% reported disability. The specific diagnoses significantly associated with disability were post-traumatic stress disorder (OR: 6.69; 95% CI: 3.20, 14.01), major depressive disorder (OR: 3.49; 95% CI: 2.13, 5.72), bipolar disorder (OR: 3.41; 95% CI: 1.04, 11.12) and generalized anxiety disorder (OR: 3.14; 95% CI: 1.43, 6.90). Both categories of anxiety and mood disorders were significantly associated with disability (OR: 1.88; 95% CI: 1.23, 2.86 and OR: 3.94; 95% CI: 2.45, 6.34 respectively).

The results of this study add to the current knowledge in this area by assessing the disability associated with common mental disorders using a multi-dimensional instrument, which may contribute to mental health policy efforts in the development of interventions to reduce the burden of disability associated with common mental disorders.

One important aspect of the societal burden of mental disorders is the extent to which these problems cause disability.

To assess days out of role associated with commonly occurring mental disorders in comparison with physical disorders in Portugal.

National cross-sectional survey, with home interviews carried out with 3849 adult (aged 18+) respondents (57.3% response rate).

Twelve-month prevalence for any mental disorder was 21.8%, any physical disorder 55.1% and any disorder 63.1%, with an average of 2.3 disorders per respondent with a disorder. Close to one out of every 10 respondents (9.2%) reported at least one day totally out of role in the past month (median of 6.4 days/any). The 18 conditions accounted for 78.2% of all days out of role, with 20.2% because of mental disorders and 59.2% because of physical disorders.

Mental disorders account for a substantial proportion of all role disability in the Portuguese population. Early detection and intervention would have a positive societal effect. Owing to highly frequent comorbidity, simultaneous management of mental and physical disorder comorbidities is advised for greater effect.

Traumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.

To investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.

We assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.

Respondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR=3.1, 95% CI 2.7–3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.

Exposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.