Reasons for non-attendance in youth mental health clinics: Insights from mobile messaging communications.

AIM: Non-attendance at appointments in youth mental health services is a common problem which contributes to reduced service effectiveness and unmet needs. Reasons cited by young people for non-attendance are poorly understood. Information derived from short-message-service (SMS) conversations about appointments between patients and clinicians can uncover new insights about the circumstances leading to 'did not attend' events. METHODS: Text messages between young people and clinicians were examined in a retrospective audit of medical records in two youth mental health services in Perth, Australia. Frequently non-attending young people aged 16-24 (n = 40) engaged in 302 SMS message chains about appointments. Mixed methods included quantitative data and qualitative thematic analysis of textual data. RESULTS: Medical reasons (32/190, 16.8%) and forgetfulness (20/190, 10.5%) were the most frequent reasons for non-attendance. Major issues included non-avoidable events while others were potentially preventable and could be addressed by the service. CONCLUSIONS: The analysis of mobile communications in clinical practice can be used for service evaluation and to reveal barriers that impede attendance to ongoing care.

Aripiprazole in young people with early psychosis: a systematic review and meta-analysis of weight gain.

OBJECTIVE: Aripiprazole is often prescribed to young people, although there remain unanswered questions about its effects on weight gain. This study undertook a meta-analysis of weight gain occurring in young people with early psychosis who were prescribed aripiprazole. METHOD: A systematic search was conducted for studies reporting on aripiprazole and weight change in young people with a psychotic disorder. A meta-analysis integrated the data into an estimate of effect size. RESULTS: Eleven studies met the inclusion criteria amounting to 886 participants (mean age 18 years). The results showed significant weight gain averaging 2.7 kg. These increases were associated with a longer duration of exposure to aripiprazole but not a higher dosage. CONCLUSIONS: The results highlight the importance of regular patient monitoring and the early implementation of interventions to manage antipsychotic-related weight gain.

Mobilization after joint arthroplasty surgery: who benefits from standing within 12 hours?

BACKGROUND: Early mobilization following joint arthroplasty surgery has been shown to be beneficial for patients, but it is unclear whether it is associated with a shorter length of stay (LOS) for both hip and knee arthroplasty (KA) patients. METHODS: We undertook a retrospective observational study, reviewing the case notes of 386 patients admitted to an enhanced recovery programme for total hip (THA) or total/unicompartmental KA. We evaluated the influence of early mobilization on LOS, adjusting for possible confounders, stratifying by surgery type. RESULTS: THA patients first mobilized within 12 h of returning to the acute orthopaedic ward following surgery had a significantly shorter mean LOS (mean = 3.6, standard deviation = 1.1) than THA patients who first mobilized 12 or more hours (mean = 4.1, standard deviation = 1.2), P = 0.004. There was no statistical significant difference in the mean LOS between the KA patients mobilized earlier or later. CONCLUSION: Early mobilization as part of an enhanced recovery programme was associated with decreased LOS for patients having THA; however, this was not the case for KA patients.

Mental health recovery and physical health outcomes in psychotic illness: Longitudinal data from the Western Australian survey of high impact psychosis catchments.

OBJECTIVE: There is a dearth of longitudinal data on outcomes in prevalent cases of psychotic illness across a range of ages and levels of chronicity. Our aim was to describe changes over time in mental and physical health outcomes, as well as patterns of service utilisation that may have influenced outcomes, in a representative prevalence sample of 641 Western Australians with a psychotic illness who, at Wave 1, were part of the National Survey of High Impact Psychosis. METHODS: In Wave 1 (2010, 2012), a two-phase design was employed to ensure representativeness: Phase 1 psychosis screening took place in public mental health and non-government organisation services, while, in Phase 2, a randomised sample was interviewed. In Wave 2, 380/641 (59%) of participants were re-interviewed, with interviews staggered between 2013 and 2016 (follow-up time: 2.3-5.6 years). Data collection covered mental and physical health, functioning, cognition, social circumstances and service utilisation. Mental health outcomes were categorised as symptomatic, functional and personal recovery. Physical health outcomes covered metabolic syndrome and its component criteria. RESULTS: In mental health, there were encouraging improvements in symptom profiles, variable change in functional recovery and some positive findings for personal recovery, but not quality of life. Participants ranked physical health second among challenges. Metabolic syndrome had increased significantly. While treatment for underlying cardiovascular risk conditions had improved, rates of intervention were still very low. More people were accessing general practices and more frequently, but there were sharp and significant declines in access to community rehabilitation, psychosocial interventions and case management. CONCLUSION: Although we observed some positive outcomes over time, the sharp decline in access to evidence-based interventions such as community rehabilitation, psychosocial interventions and case management is of great concern and augurs poorly for recovery-oriented practice. Changes in service utilisation appear to have influenced the patterns found.

The time course of psychotic symptom side effects of ketamine in the treatment of depressive disorders: a systematic review and meta-analysis.

OBJECTIVE: Ketamine is a potential rapid-acting treatment for depression. Studies have suggested that the side effects are minimal and temporary, but the psychotic symptom side effects have yet to be fully examined. This study investigated whether ketamine infusion in the treatment of mood disorders is associated with increases in positive symptoms and whether these symptom effects endure over time. METHODS: A systematic review and meta-analysis of studies of ketamine in the treatment of depression. Embase and Medline databases were searched for studies including (a) participants with major affective disorders, (b) 0.4 or 0.5 mg intravenously administered ketamine, (c) measurement of positive symptoms using BPRS+, and (d) a within-subject repeated-measures design with participants serving as their own baseline. RESULTS: Seventeen studies met the inclusion criteria, comprising 458 participants. The meta-analyses examined symptom change occurring within the first 4 h, after 1 day, and after 3 days. Results showed significant BPRS+ increases within the first 30-60 min in 72% of studies, followed by a return to baseline levels. CONCLUSION: Peak symptom change occurred within the first hour post infusion. There are limited data to determine if ketamine is safe in the longer term, but there were no indications that psychotic symptoms re-occurred after the first hour and in the days following administration.

Emergency department mental health presentations before and during the COVID-19 outbreak in Western Australia.

OBJECTIVE: Coronavirus (COVID-19) has led to high levels of psychological distress in the community. This study aimed to examine whether emergency departments (EDs) also recorded a rise in mental health presentations. METHOD: Changes in the number, and type, of mental health presentations to Western Australia EDs were examined between January and May 2020, and compared to 2019. RESULTS: Data showed an unexpected decrease in the number of mental health presentations, compared to 2019, which was temporally coincident with the rise in local COVID-19 cases. Presentations for anxiety and panic symptoms, and social and behavioural issues, increased by 11.1% and 6.5%, respectively, but suicidal and self-harm behaviours decreased by 26%. CONCLUSION: A rise in local COVID-19 cases was associated with a decrease in mental health presentations to EDs. This has important implications for the planning and provision of healthcare services in the current pandemic.

Different patterns of treatment response to Cognitive-Behavioural Therapy for Insomnia (CBT-I) in psychosis.

People with psychosis benefit enormously from Cognitive Behavioural Therapy for Insomnia (CBTI), although some variability exists in treatment outcomes. While recent efforts have focused on profiling sleep at treatment initiation, an alternative methodological approach involves using treatment response as a starting point to better understand what constitutes an effective treatment. This study used Grade of Membership analysis (GoM) to estimate the occurrence of unique treatment outcomes and associated patient characteristics. Outcome measures included changes in sleep (self-reported latency, efficiency, duration, quality), functional outcomes (daytime dysfunction, negative mood, need for sleep medication) and treatment goal, collected in 50 individuals with a psychotic disorder and insomnia who underwent CBT-I treatment. Three distinct profiles were identified: (1) Strong responders, who met their treatment goals and showed broad improvements in both sleep and functional domains; (2) Partial responders, who showed sleep improvements (particularly in total sleep time), without noticeable gains in function, and who were predominantly female; and (3) Non-responders who showed little treatment response and failed to meet their treatment goals. This group was also more likely to have greater psychopathology (high levels of negative mood and psychotic symptoms, and antipsychotic medication dosage). These findings suggest that (i) CBT-I can serve to improve sleep and daytime function (although sleep can improve independently from function), (ii) client-elicited treatment goals are a key predictor of CBT-I response, (iii) other important variables associated with treatment response include sleep profile, clinical acuity, and sex.

Sleep profiles and CBT-I response in schizophrenia and related psychoses.

This study investigated sleep subtypes in schizophrenia, and their response to Cognitive Behavioural Therapy for Insomnia (CBT-I) treatment. Sleep profiling was conducted using latent class analysis on baseline Pittsburgh Sleep Quality Index data (N = 74 outpatients with schizophrenia who were poor sleepers, 52% male, mean age = 41.4 years). Of these, 40 took part in CBT-I treatment. Analyses revealed three sleep subtypes based on total sleep time (TST), sleep efficiency (SE), and sleep onset latency (SOL) parameters: Cluster 1 ('classic severe insomnia', 44.6%), Cluster 2 ('insomnia with normal sleep duration', 37.8%), and Cluster 3 ('insomnia with hypersomnia', 17.6%). Gains analysis of pre- and post-treatment data from CBT-I participants revealed improvements in sleep and psychopathology in all three clusters, although there were some group differences in the areas and magnitude of improvement. Cluster 1 showed the greatest benefits with longer TST and improved SE. Cluster 2 showed a comparatively blunted treatment response although TST moved closer to recommended sleep guidelines. Cluster 3 showed significant reductions in TST. Altogether, this is the first demonstration of different sleep profiles in schizophrenia and their influence on treatment response to CBT-I. It also supports the notion that therapies should be tailored to the person and their insomnia presentation.

The utility of the Diabetes Anxiety Depression Scale in Type 2 diabetes mellitus: The Fremantle Diabetes Study Phase II.

BACKGROUND: Previous research using latent class analysis (LCA) identified classes of people with type 2 diabetes and specific profiles of depression and anxiety. Since LCA-derived anxious depression strongly predicts cardiovascular outcomes and mortality but cannot be applied to individuals, we developed a validated combined depression-anxiety metric, the Diabetes Anxiety Depression Scale (DADS), for potential clinical application in people with type 2 diabetes. METHODS: 1,337 participants with type 2 diabetes from the observational community-based Fremantle Diabetes Study Phase II completed the Patient Health Questionnaire 9-item version (PHQ-9) to assess symptoms of depression, and the Generalised Anxiety Disorder Scale (GADS) to assess symptoms of anxiety. A single score was calculated by adding all the PHQ-9 items and the four GADS items used for the LCA. Cut-off scores were calculated with Receiver Operating Characteristic (ROC) area under the curve (AUC). RESULTS: The optimum cut-off scores in terms of sensitivity, specificity, positive and negative predictive value were 18 points for major anxious depression and 8 points for minor anxious depression. A score of 8-17 was associated with a significantly increased incidence of coronary heart disease, whereas a score 18-39 was associated with an increase in both coronary heart disease and cardiovascular mortality. CONCLUSIONS: The DADS has strong psychometric validity in the identification of mixed depression-anxiety in type 2 diabetes, and may contribute to cardiovascular risk prediction.

Hallucinations as a presenting complaint in emergency departments: Prevalence, diagnosis, and costs.

Hallucinations occur in the context of many disorders. When experienced as distressing, they are a likely cause of presentation to emergency departments. Knowledge about the rates, diagnoses, and associated costs of hallucinations in emergency departments however is currently lacking. In this study, we analysed patients' presenting complaints in Western Australia's Emergency Department Data Collection dataset during a two year period (n = 1,798,754). Visits to emergency departments because of distressing hallucinations were more common than previously assumed. Hallucinations (auditory, visual, undifferentiated modality) accounted for 1.8% of all mental health-related presentations and 0.09% of all general health presentations (84.7 per 100,000 persons). Psychotic disorders accounted for a third of all presentations, and hallucinations without a clear medical or psychiatric cause represented 17% of the sample. Hallucination presentations had significantly prolonged lengths of stay compared to other mental health presentations (15 vs 7.5h, p < 0.001) and were linked to frequent re-admissions (average of 7.4 visits per year). Cost estimates revealed that hallucinations were in the top-10 most costly mental health complaint, and twice as costly to treat as delusions. Altogether, the service utilisation and care needs of people with distressing hallucinations outside of mental health services appear much larger than usually estimated.

Successful implementation of a cognitive remediation program in everyday clinical practice for individuals living with schizophrenia.

OBJECTIVE: This article evaluates the feasibility and benefits of implementing cognitive remediation interventions in everyday clinical practice among individuals living with schizophrenia. METHOD: We retrospectively assessed short-term cognitive and occupational outcomes of 89 consecutively admitted people with schizophrenia at a public mental health service. A computerized cognitive remediation program was offered at the facility as an integral component of psychosocial treatments. Data of service recipients who had completed the Brief Assessment of Cognition in Schizophrenia (BACS; Keefe et al., 2004) on admission and discharge were included for evaluating outcomes. RESULTS: Thirty-seven service recipients did not participate (nontrainee), 18 completed less than 20 hr (incomplete trainee), and 34 completed more than 20 hr of cognitive remediation (completed trainee). Whist a variety of factors affected involvement, lack of interest was the predominant reason voiced for nonparticipation. Repeated measures analysis of variance did not reveal significant Group × Time interaction. Exploratory contrasts showed statistically significant improvement within the completed trainee group from baseline to discharge on the BACS composite score, list learning, and token motor task. Logistic regression analysis indicated that although improved cognition predicted enhanced employment outcome, there was no significant difference among the 3 groups. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Cognitive remediation interventions were accepted by a sizable proportion of people with schizophrenia admitted to an inpatient clinical treatment and rehabilitation facility. Promising improvement in cognitive function among those who completed the training suggests the need for methodologically rigorous research exploring the feasibility and benefits of cognitive remediation programs at everyday clinical settings. (PsycINFO Database Record

Sexual health and sexual trauma in women with severe mental illness: An exploratory survey of Western Australian community mental health services.

Australian women attending community mental health services were surveyed to determine the relationship between sexual trauma, sexual activity, and sexual health seeking behaviors. Self-reported history of "forced sex" was 58.4% (n = 122 out of 220). Latent class analysis revealed a three-class model: "sexually active and health seeking," "low sexual activity and health seeking" and "low sexual activity and not health seeking." An association with general practitioner engagement and sexual health seeking behaviors was found. Rates of self-reported sexual trauma reinforce the need for screening and trauma informed care. Groupings may reflect different aspects of recovery associated with sexual health behaviors.

Exome array analysis suggests an increased variant burden in families with schizophrenia.

The exome array assays rare-but-recurrent, likely deleterious, exonic variants and represents an intermediary between single nucleotide polymorphism (SNP) arrays and sequencing for genetic association studies. Multiplex families with multiple affected individuals may be enriched for disease-associated variants of this class compared to unrelated populations. We present an exome array study of schizophrenia in 99 multiplex families (n=341, including 118 cases) from the Western Australian Family Study of Schizophrenia (WAFSS). Compared to 55,726 individuals from the DIAGRAM sample not selected for schizophrenia, overall allele frequency of exome variants was higher in the WAFSS (P<2.2E-16). This was pronounced in variants nominally associated (P<0.05) with schizophrenia. Genes harbouring variants present only in WAFSS cases were enriched (FDR-corrected P=0.05) for membership of the 'extracellular matrix (ECM) - receptor interaction' biological pathway, adding to evidence that processes affecting the composition or turnover of ECM may contribute to neuropsychiatric disease. We did not find individual variants significantly associated with schizophrenia, although like previous studies, power to detect associations of small effect size was low. Cases did not exhibit a higher burden of variants compared to their unaffected relatives and the finding of previous exome chip studies of unrelated samples that 'schizophrenia gene-sets' were enriched for case-only variants was not replicated in the WAFSS. The higher frequency of moderately rare, exonic variants in these multiplex families compared to a population-based sample may account for some of their genetic liability to schizophrenia, and adds to evidence for a role of exome array variants from previous studies of unrelated samples.

Do the generalised cognitive deficits observed in schizophrenia indicate a rapidly-ageing brain?

Background and Objectives: The nature and pattern of cognitive deficits (CD) in schizophrenia and whether the deficits are generalised or domain specific continues to be debated vigorously. We ascertained the pattern of CD in schizophrenia using a novel statistical approach by comparing the similarity of cognitive profiles of patients and healthy individuals. Methods: In a consecutive sample of 78 patients with schizophrenia, performance on six cognitive domains (verbal memory, working memory, motor speed, processing speed, verbal fluency and executive functions) was measured using the Brief Assessment of Cognition in Schizophrenia (BACS). The similarity of cognitive profile between patients and two groups of healthy controls (age-matched and older adults who were in the age group of 70-79) was evaluated using a special purpose-built macro. Results: Cognitive performance profiles in various domains of patients with schizophrenia and age-matched controls were markedly similar in shape, but differed in the overall performance, with patients performing significantly below the healthy controls. However, when the cognitive profiles of patients with schizophrenia were compared to those of older adult controls, the profiles remained similar whilst the overall difference in performance vanished. Conclusions: Cognitive deficit in schizophrenia appears to be generalised. Resemblance of cognitive profiles between patients with schizophrenia and older adult controls provides some support for the accelerated ageing hypothesis of schizophrenia (AU)

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Comorbid Anxiety and Depression and Their Impact on Cardiovascular Disease in Type 2 Diabetes: The Fremantle Diabetes Study Phase II.

BACKGROUND: The aims were to determine whether anxious depression, defined by latent class analysis (LCA), predicts cardiovascular outcomes in type 2 diabetes and to compare the predictive power of anxious depression with Diagnostic & Statistical Manual Versions IV and 5 (DSM-IV/5) categories of depression and generalized anxiety disorder (GAD). METHODS: Prospective observational study of 1,337 type 2 participants. Baseline assessment with the 9-item Patient Health Questionnaire and the GAD Scale; LCA-defined groups with minor or major anxious depression based on anxiety and depression symptoms. Cox modeling used to compare the independent impact of: (1) LCA anxious depression, (2) DSM-IV/5 depression, (3) GAD on incident cardiovascular events and deaths after 4 years. RESULTS: LCA minor and major anxious depression was present in 21.9 and 7.8% of participants, respectively, DSM-IV/5 minor and major depression in 6.2 and 6.1%, respectively, and GAD in 4.8%. There were 110 deaths, 31 cardiovascular deaths, and 199 participants had incident cardiovascular events. In adjusted models, minor anxious depression (Hazard ratio (95% confidence intervals): 1.70 (1.15-2.50)) and major anxious depression (1.90 (1.11-3.25)) predicted incident cardiovascular events and major anxious depression also predicted cardiovascular mortality (4.32 (1.35-13.86)). By comparison, incident cardiovascular events were predicted by DSM-IV/5 major depression (2.10 (1.22-3.62)) only and cardiovascular mortality was predicted by both DSM-IV/5 major depression (3.56 (1.03-12.35)) and GAD (5.92 (1.84-19.08)). CONCLUSIONS: LCA-defined anxious depression is more common than DSM-IV/5 categories and is a strong predictor of cardiovascular outcomes in type 2 diabetes. These data suggest that this diagnostic scheme has predictive validity and clinical relevance.

Screening for the metabolic syndrome in Australia: a national survey of psychiatrists' attitudes and reported practice in patients prescribed antipsychotic drugs.

OBJECTIVE: To investigate current reported psychiatric practice in relation to screening for the metabolic syndrome in patients prescribed antipsychotic drugs within Australia. METHOD: A postal survey of all Fellows of the Royal Australian and New Zealand College of Psychiatrists. A 28-item questionnaire inquired into different aspects of screening and monitoring for metabolic syndrome in patients on antipsychotic medication. RESULTS: Of 3123 questionnaires sent, 955 were returned. Of respondents, 55% had no established metabolic monitoring protocol or guidelines in their work place, with 13% saying they did not know what to monitor to detect metabolic syndrome. Altogether, 76% reported there was no reliable system in place to remind them when to monitor. Fewer than 50% of respondents routinely check weight, fasting glucose or lipids in their patients on antipsychotics and under than 30% checked blood pressure. Waist circumference was routinely checked in fewer than 7% of patients. Basic monitoring equipment was reported unavailable in more than 50% of clinical settings. However, more than 80% of respondents considered monitoring for metabolic syndrome to be their responsibility and 83% felt they had a medicolegal obligation in this respect. CONCLUSIONS: Routine screening for metabolic syndrome in patients on antipsychotic agents, by Australian psychiatrists, is inadequate. Interventions to improve screening rates need to be developed, implemented and evaluated.

A clinical communication tool for the assessment of psychotropic medication side effects.

The primary aim was to assess usability of the My Medicines and Me Questionnaire (M3Q) as a self-reported questionnaire for mental health patients to subjectively express side effects experienced with their psychotropic medications. The secondary aim was to evaluate patients' attitudes towards treatment and psychotropic medications following dialogue with their clinicians about side effects. Questionnaires were administered at six adult mental health facilities. A total of 205 participants were divided into intervention (facilitated dialogue) and non-intervention groups (no facilitated dialogue). The mean completion time for the M3Q was 15min (SD=6.5) with only 11 (5%) patients requiring assistance. The most commonly reported side effect was sedation (77%) and weight gain was ranked as the most bothersome (23%). The previously validated M3Q provided patients with the opportunity to express the impact these effects had on their lives. Side effects were the most common reason given for non-adherence. There were no significant changes in patient attitudes towards treatment and medications in the intervention group, mainly due to the logistical challenges in the clinicians' ability to view the questionnaire for the subsequent meeting with the patient. The M3Q demonstrated its usability in allowing patients to easily express their subjective experiences with side effects.

No additive effect of cannabis on cognition in schizophrenia.

BACKGROUND: We aimed to examine the association between lifetime cannabis use and estimates of both premorbid and current cognitive function in psychotic disorders in an Australian cohort. METHODS: In an Australian multicenter cohort, 1237 participants with an established ICD-10 diagnosis of psychotic disorder were categorised according to history of lifetime cannabis use (non-users, n=354; cannabis users, n=221; cannabis dependency, n=662). Groups were analyzed according to available indices of cognitive ability: the National Adult Reading Test - Revised (NART-R) for ability prior to illness onset; and the Digit Symbol Coding Test (DSCT) for current ability. Two-way analysis of variance was conducted without any covariate, followed by a two-way analysis of covariance (using age, age at onset of psychiatric illness, premorbid IQ and the Socio-Economic Index for Areas (SEIFA) rankings). RESULTS: Whilst there appeared to be a significant association between cannabis use and mean DSCT (higher DSCT scores in cannabis using groups) F(2,1080)=9.478, p<0.001, η2=0.017), once covariates were used in the analysis there were no significant differences between groups in mean DSCT scores (F(2,1011)=0.929, p=0.395, η2=0.002). Similarly there were no differences between groups in mean NART scores once, age, age at illness onset and SEIFA rankings were used as covariates (F(2,1032)=1.617, p=0.199, η2=0.003). CONCLUSIONS: Confounding variables underpin the association between cannabis use and cognitive function in psychotic disorders. Taken together, it would appear that cannabis use or dependence has no additive effect on cognitive dysfunction in these disorders.

Construction and validation of the My Medicines and Me Questionnaire for assessment of the self-reported side effects of psychotropic medication.

We aimed to construct and assess the psychometric properties of the My Medicines and Me Questionnaire (M3Q), a self-report side-effect questionnaire for mental health patients. Thirty individuals taking a psychotropic medication completed the M3Q side-effect checklist along with the Liverpool University Neuroleptic Side Effect Rating Scale. Thirty healthy comparison individuals also completed the M3Q checklist. Data were analyzed using factorial analysis. Psychometric evaluations including validity and reliability testing were carried out on the questionnaire's checklist. The original 54-item checklist of the M3Q was shortened to include only those items found to be significant in the factorial analysis. The revised 32-item checklist of the M3Q was found to be valid and reliable. The M3Q is a simple, valid and reliable questionnaire that can be used routinely in clinical practice for detecting bothersome side effects of a range of psychotropic medications. This will provide a platform for improved communication between the clinician and the patient.

The impact of emotional distress on motor blocks and festination in Parkinson's disease.

Recent studies suggest that depression and anxiety in patients with Parkinson's disease may predispose them to freezing. Although festination is also frequent, the association with emotional disorders has not been examined. The aim of the authors was to clarify the association between freezing and festination with anxiety, depressive disorders, and emotional distress. The authors examined a consecutive series of 95 patients with Parkinson's disease using comprehensive psychiatric assessments and a new instrument specifically designed to assess the severity of freezing, festination, and emotional distress (Motor Blocks and Festination Scale). All patients were assessed with the Motor Blocks and Festination Scale, the Mini International Neuropsychiatric Interview, and scales to measure the severity of mood and anxiety disorders. A linear regression analysis showed that both motor blocks and festination were significantly associated with emotional distress and deficits on activities of daily living. Conversely, there was no significant association between motor blocks or festination and generalized anxiety disorder, panic disorder, agoraphobia, social phobia, or depression. Motor blocks and festination are significantly associated with emotional distress, but no significant associations were found with anxiety or affective disorders.