The relationship between metacognitive beliefs and symptoms in eating disorders.

The present study aimed to explore the role of dysfunctional metacognitive beliefs in Eating Disorders (EDs) and their potential associations with core and comorbid symptoms. The Metacognition Questionnaire-30 (MCQ-30), the Eating Disorder Examination Questionnaire 6.0 (EDE-Q), the Hospital Anxiety and Depression Scale (HADS) and the Maudsley Obsessive- Compulsive Inventory (MOCI) were used to evaluate 44 Anorexia Nervosa (AN), 50 Bulimia Nervosa (BN) patients and 37 controls. Patients featured more dysfunctional metacognitive beliefs which positively correlated with ED and comorbid symptoms. Both AN and BN patients had higher scores than healthy controls on MCQ-30 total score, Positive Beliefs about Worry, Negative Beliefs about Thoughts Uncontrollability and Danger and Need to Control Thoughts. AN patients also featured higher scores than healthy controls on Cognitive Self-Consciousness. No statistically significant difference was found between the two clinical groups in MCQ-30 total and subscale scores. Among metacognitive beliefs, Negative Beliefs about thoughts Uncontrollability and Danger showed the stronger correlations with core EDs symptoms, (coefficients ranging from 0.24 to 0.40), followed by Need to Control Thoughts (coefficients ranging from 0.22 to 0.38). Dysfunctional metacognitive beliefs were also significantly positively correlated with HADS-Anxiety, HADS-Depression and MOCI Total, in a similar manner. Dysfunctional metacognitive beliefs also predicted 19%, 35%, 20%, and 21% of the variance in Global EDE-Q, HADS-Anxiety, HADS-Depression and MOCI Total scores respectively, in regression analyses. Nevertheless, mediation analysis indicated that the relationship between Negative Beliefs about thoughts Uncontrollability and Danger and core EDs symptomatology as measured by EDE-Q, was not mediated by comorbid anxiety, depression and obsessionality. As a result, dysfunctions in metacognitive beliefs may reflect a common, trans-diagnostic path in AN and BN patients, towards a wide range of symptoms, both core and comorbid.

Health professionals' attitudes towards breastfeeding among women with schizophrenia: Greek version of a specific rating scale.

Breastfeeding is the optimal feeding mode for the mother and her child. The pregnancy rates of mothers with schizophrenia do not differ significantly from those of the general population. However, research on breastfeeding among women with schizophrenia is extremely limited. The current study aims to explore the health professionals' attitudes towards breastfeeding among women with schizophrenia in Greece and to examine the validity and reliability of the Greek version of a specific rating scale for further research on attitudes towards breastfeeding among women with schizophrenia. This study had a cross-sectional descriptive design and the participants were health professionals working closely with women/mothers at different health care settings in Athens (health visitors, midwives, nurses working in mental health care). Data were collected using a self-report questionnaire on knowledge and attitudes regarding breastfeeding, knowledge, feelings and attitudes regarding schizophrenia, professional guidance for women with schizophrenia about breastfeeding; and personal and professional attitudes towards breastfeeding among women with schizophrenia. The results of the study showed that health care professionals of different disciplines seemed to have similar positive attitudes towards breastfeeding among women with schizophrenia. Professionals that had attended breastfeeding seminars had significantly greater scores on both knowledge of breastfeeding and attitudes towards breastfeeding. Greater scores on attitudes towards women with schizophrenia and attitudes towards breastfeeding among women with schizophrenia were found in those that had previous contact with a person with schizophrenia. Furthermore, greater scores on attitudes towards women with schizophrenia imporwere found in those that have provided consultation to a woman with schizophrenia on breastfeeding issues. The results suggest that this tool is a reliable and valid measure. The results of the exploratory factor analysis showed that there was a discriminative capacity among items. The five derived factors were knowledge of breastfeeding, attitudes towards breastfeeding, knowledge of schizophrenia, attitudes towards women with schizophrenia, attitudes towards breastfeeding among women with schizophrenia. Further research is needed among medical doctors and other mental health professionals who are involved in the care of women with schizophrenia. In addition, the experiences and the needs of mothers with schizophrenia should be explored in order to gain useful information for practice. The results of the current and future studies are expected to inform strategic planning.

[The impact of the recent financial crisis on the users' profile of a community mental health unit].

During previous financial crises as well as the recent global financial crisis, a strong impact of the crisis on the population mental health in many countries has been observed. Similarly, in Greece, a series of epidemiological studies pointed out the consequences of the economic crisis on the population mental health. However, there is limited data available, both in Greece and worldwide, regarding the impact of the economic crisis from the perspective of mental health services. The goal of the present study was to examine possible changes on the community mental health during the first years of the Greek financial crisis, as they are reflected on the operation of a community mental health unit with a specific catchment area within Athens (Byron and Kessariani). The demographic, social and clinical characteristics of adult users who were admitted for the first time at ByronKessariani Mental Health Community Center during the years 2008-2013 were analysed. The impact of the financial crisis on the workload of the center was also assessed during the same period. The sample of the study consisted of 1865 adult users and the data was collected with the use of an ad hoc structured questionnaire as well as from the users' case files. No significant differentiation on the number of clients admitted to the center per year after the beginning of the financial crisis was found. However, it is possible that an upper limit has been reached on the center's capacity to admit new clients, i.e. a ceiling effect, as it is shown from the increased number of provided sessions per year as well as from the increase in the mean waiting time for the intake of new patients during the same period. A constant increase in the number of women among the new clients of ByronKessariani Mental Health Community Center was found, but no significant differentiations were detected during the study period. Moreover, the study showed an upward trend in aggressive behavior as a reason for admission, a significant and continuous increase in the rate of unemployed individuals among the new clients, as well as a statistically significant increase in the number of referrals for psychotherapy during the study period. There was also an increase in the number of patients who had psychiatric history, even though they were admitted to Byron-Kessariani Mental Health Community Center for the first time. No significant differentiations were found in the remaining users' demographic and clinical characteristics assessed. Our study showed that during the crisis community mental health services are under pressure due to the increased needs of patients, especially the needs for psychotherapeutic intervention and psychological support. The increased unemployment rates affect the influx of new patients as well as the therapeutic management of many users. Reinforcement of the community mental health service network is an important strategy against the consequences of the crisis on the population mental health.

Insight across mental disorders: A multifaceted metacognitive phenomenon.

There is now general agreement that lack of insight is not merely a fundamental aspect of delusions and hallucinations, or just a symptom of psychotic disorders but rather a multi-dimensional construct. Several different components of insight have been proposed and empirically examined during the last three decades, such as the ability to recognize that one has a mental illness, the capacity to relabel unusual mental events as pathological, the specific attribution of one's symptoms to having a mental illness, awareness of illness' consequences, and compliance with treatment.1 Insight impairment is an important prognostic factor in schizophrenia, impacting negatively on medication adherence, treatment outcome, and social functioning.2 Although largely investigated in schizophrenia and other psychoses, insight impairments are observed in many, if not all, mental disorders. Varying levels of awareness of mental illness and/or of specific symptoms are expected in patients with bipolar disorders, Alzheimer disease and other neurocognitive disorders, obsessive-compulsive (OCD) and related disorders.1,3 While in DSM-5 an "insight" specifier was incorporated for OCD, body dysmorphic and hoarding disorder, patients' insight has been found ranging from good to absent in other disorders, such as depressive disorders,4 eating disorders,5 and even specific6 and social7 phobias. Moreover, impaired insight is a common reason that many people with clinical depression or anxiety disorders never seek appropriate treatment and most of the people with addictions and personality disorders fail to recognize and address their problems even when the consequences are devastating: personal suffering, broken relationships, and physical health problems. Depending on the disorder and reflecting different conceptual approaches, many different terms are used to describe lack of insight, such as poor self-awareness, denial, anosognosia (mainly in neurological deficits, e.g. hemiplegia), ego-syntonic symptoms, or even self-deception. At any rate, as an aspect of self-knowledge, insight has psychological (defense mechanisms, coping strategies), social and cultural facets. On the other hand, the attitudes and behaviours towards one's illness are products of inference processes and therefore can be influenced by cognitive dysfunctions. Previous research in schizophrenia showed correlations between neurocognitive functions and insight measures but the strength of this association is rather weak.8 Social cognition may be a crucial cognitive determinant of impaired insight in schizophrenia. The correct attitude toward morbid change in oneself relies on the capacity to reflect upon self from the perspective of the other (i.e., "to see ourselves as others see us"). This capacity is clearly linked to the ability to understand mental states (e.g., beliefs, knowledge, and intentions) of others, that is, theory of mind or mentalizing. Recent research has shown that mentalizing deficits may substantially contribute to insight impairment in schizophrenia.9 This effect could be further examined in the broader context of patient's failures in metacognition, i.e. the general ability to think about thinking, and their relationships with insight impairment in schizophrenia. Mentalizing and introspection are closely related developmentally and it is yet unclear which one is the primary ability: we are able to understand others and then apply this understanding to ourselves or we are able to reflect on ourselves and then apply this reflection to others. A recent line of research in schizophrenia is based on the distinction introduced by Beck et al10 between clinical insight (i.e., awareness of illness) and cognitive insight, which describes a metacognitive ability, specifically patients' flexibility towards their beliefs, judgements and experiences. The self-report Beck Cognitive Insight Scale (BCIS) examines two subcomponents: self-certainty, assessing overconfidence about being right (e.g. "I know better than anyone else what mycomponents: self-certainty, assessing overconfidence about being right (e.g. "I know better than anyone else what my problems are"), and self-reflectiveness, assessing willingness to accept external feedback and recognition of dysfunctionalreasoning style (e.g. "Some of the ideas I was certain were true turned out to be false"). Cognitive insight in thisform describes two related but distinct aspects of metacognition in patients with psychosis, differentially associated withclinical insight, symptoms, treatment outcomes, and functioning.11 Another method for assessment of similar metacognitiveskills also used in schizophrenia is a scale (Metacognition Assessment Scale - Abbreviated, MAS-A) that is administeredthrough a specific interview and examines the capacities of self-reflectivity, understanding of the other individuals'mental states, and using metacognitive knowledge to respond to psychosocial challenges. Lysaker and colleaguesfound recently that metacognitive deficits assessed with MAS-A predict impaired insight in schizophrenia independentof symptoms.12 It is questionable whether BCIS and other methods used so far to assess self-reflection in psychoses arevalid and useful for patients with non-psychotic disorders.11 However, the metacognitive conceptualization of insightmight contribute to a new research framework for insight impairments across mental disorders. According to this approach, poor insight is in part a failure of self-reflection, i.e. the process by which we synthesizeand comprehend ideas about ourselves. This may be due to general deficits in metacognitive abilities (self-reflectivity,mentalizing) or may represent limited, domain-specific, or transient dysfunctions in metacognitive processes. Insight hasto be thought of as a relational concept, that is insight into something: insight into illness, current syndrome, specificsymptoms, pathological personality traits, social difficulties etc.1,3 In an integrated model of insight across mental disorders,aspects of metacognition interacting with multiple other (clinical, neurocognitive, emotional, and social) factorsdetermine patient's ability to correctly process information into self-awareness. The identification of these factors andtheir interactions may be a fruitful field in the research of insight.

The impact of unemployment on mental health examined in a community mental health unit during the recent financial crisis in Greece.

Financial crisis has significant impact on the mental health of the population, resulting in increasing incidence of mental disorders and suicides. Specific social and financial factors mediate the effects of financial crisis on mental health, such as poverty, financial difficulties and unemployment. During the recent international financial crisis, studies in many countries have shown that the worsening of various mental health indicators was related to financial difficulties and unemployment. In Greece, which is one of the countries that experienced intense and prolonged economic and social burden due to the recent crisis, the epidemiological findings were similar and the increase of the prevalence of major depression and suicide was excessive. However, the information about the mental health of the population deriving from health services is limited. The aim of this study was to investigate the impact of the crisis on community mental health -more specifically the rates of mental disorders and suicide, as well as the role of unemployment- among the new cases of a community mental health unit. The sample consisted of 1,865 adult users, men and women, who came seeking for help to the Byron-Kessariani Community Mental Health Centre (CMHC) during the years 2008-2013, i.e. the early years of the current crisis. Regarding the rates of the diagnostic categories in the new cases of CMHC per year, no significant differentiation was observed. There was an increase in the proportion of the unemployed individuals in the total sample of new cases during the study, from 9.65% in 2008 to 26.17% in 2013 and a significant association between unemployment and the occurrence of anxiety and depressive disorders, as indicated by the increase in the proportion of unemployed individuals among new cases with disorders of these categories. There was an upward trend in the rate of new patients referred to CMHC after a suicide attempt, which was doubled during the first years of the crisis. There was also an increase in the rate of unemployed individuals among these cases, from 10% in 2008 to 41.7% in 2009, reaching the highest level in 2011 (53.3%). The findings of this study suggest that during economic crisis unemployment plays an important role in the development of anxiety and depressive disorders and is closely related to suicide attempts. Our results were derived from a specific catchment area and therefore they have high ecological validity.

Criminality in Greece during the years of financial crisis: 2008-2014.

The link between poverty, unemployment and economic downturns and increases in crime rates has long been the subject of social science study. However, the relationships between these phenomena has not been studied sufficiently and through time in most European countries that suffered, or, like Greece, are still suffering the recent financial crisis. We examined if the recent financial crisis in Greece has coincided with an increase in crime, analyzing crime rates since the start of the financial crisis and over an extensive time period (7 years). Crime statistics were taken from the Greek Police. Repeated measures analyses of variance were performed to reveal potential differences in criminality for the years 2008, 2010, 2012 and 2014. There was a significant increase in global criminality rate per 100,000 residents (Wilks' Lambda=0.32, F (3,11)=7.93, p=0.004). There was a significant increase in illegal gun possession (Wilks' Lambda=0.16, F (3,11)=18.68, p=0.001), fraud (Wilks' Lambda=0.10, F (3,11)=32.35, p=0.001), extortion (Wilks' Lambda=0.38, F (3,11)=4.45, p=0.040), and beggary (Wilks' Lambda=0.33, F (3,11)=6.22, p=0.014). A reversed U shape was found for homicides, thefts and robberies, with rates peaking in 2010 and 2012 before dropping off in 2014. Narcotics and sexual exploitation crime rates remained unchanged. Surprisingly, the incidence of rape decreased (Wilks' Lambda=0.42, F (3,11)=5.14, p=0.018). Our results are in agreement with the results of previous broader studies as well as with criminological theories according to which in times of economic stress an increase in both property crimes and violent crimes is expected. As predicted, an increase in financial crime was observed (e.g. fraud and extortions) as well as petty crime related to financial hardship like beggary. Concerns regarding the escalation of white-collar crimes in times of economic downturns that have been raised in the literature warrant further investigation.

[Patients coming back after interruption of care in a community mental health center: Associations with care provision and psychopathological features].

A large number of people with mental health problems do not receive any treatment and in a large number of patients under care the treatment is interrupted. Non-compliance to treatment, observed in many different settings, is a major challenge in providing mental health care. The aim of the present study was to assess the demographic, social and psychological characteristics of the patients coming back for help to community psychiatric services and to shed some light to the reasons of interrupting and coming back. Special emphasis was placed on the possible correlation with specific mental disorders and whether or not the treatment was completed. The survey was carried out at the Byron- Kessariani University Mental Health Center, in a middle-classes catchment area and offering free of charge services. During the years from 2012 to 2016: 346 patients interrupting treatment (PIT) came back, while 1643 new patients were registered. The PIT were assessed with a specific questionnaire consisting of 34 open and closed-ended questions on changes in socio-demographic data, diagnosis, reported causes of discontinuation of care, services provided, important life events, follow-up by other mental health services after interruption of care, medication, and hospitalizations. The data were collected by trainee psychologists through a structured interview lasting 15-30 minutes and also from patients' medical records. Out of the 525 PIT during the study period, we excluded 148 who asked only for a certificate and 31 with many missing values. The final sample consisted of 346 patients and the analysis has focused on 299 PIT falling into one of the following four basic diagnostic categories: (a) schizophrenia and other psychotic disorders (12.7%), (b) mood disorders (41.3%), (c) neurotic and stress-related disorders (22.0%), (d) family and couple problems (10.4%). 64.1% of the PIT considered that they had not completed their previous treatment in the center, 19% attributed the interruption of care to reasons related to the center operation, and 88.4% considered that their demand had been satisfied. The highest rate of patients coming back was observed in the first year (31.7%) and then in four or more years (43.4%) after interruption of care. 32.7% discontinued the medication, 21,4% continued the medication following previous prescription. 47.3% had no follow-up, while 52.7% had been followed-up (36.6% of them by a private psychiatrist and 30.7% by a psychiatrist in a public institution). 45.5% of people with schizophrenia and other psychotic disorders were hospitalized in the meantime. The relationships between diagnosis and follow-up status with unemployment were tested but these associations were not statistically significant. There was greater satisfaction by those who completed treatment, as expected. Reasons for interruption related to the center operation, such as the work shift, the frequent changes in stuff members and the quality of care, are of particular importance.

Rates of childhood trauma in a sample of university students in Greece: The Greek version of the Early Trauma Inventory-Self Report.

The self-report Early Trauma Inventory (ETI-SR-SF) was developed by Bremner et al in 2007 and has been proven a valid tool for the assessment of childhood trauma. The inventory covers four types of traumatic experiences: general trauma, physical abuse, emotional abuse and sexual abuse. The primary aim of the present study was to assess the internal consistency, test-retest reliability, convergent validity and factor structure of the Greek version of the ETI-SR-SF. The study sample consisted of 605 individuals (402 women), undergraduate and postgraduate students of Athens universities with a mean age of 24.3 years. All participants completed a questionnaire on demographic characteristics, the Greek version of the ETI-SR-SF and the Greek version of the Trauma Symptoms Checklist (TSC-40). Both ETI-SR-SF and TSC-40 were re-administered to 56 participants after three to four weeks. ETI-SR-SF was found to display high levels of internal consistency (Cronbach's α=0.91) and test-retest reliability (ICC=0.93). In addition, the internal structure of every subscale was examined by the means of factor analysis, which revealed that the items in every subscale contribute to a single factor explaining a great proportion of the variance. The correlation between total scores of ETI-SR-SF and TSC-40 was significantly strong (r=0.42, p<0.001), indicating satisfactory convergent validity. The most frequently reported type of childhood trauma was corporal punishment, at a rate of 89.9%, followed by emotional abuse (67.2%) and sexual abuse (27%). These rates are higher than those found in the international literature indicating that the various types of early traumatic experience are very common phenomena in the Greek student population. This finding should alert the experts and requires replication and further investigation by studies with larger samples. The findings of the present study suggest that the Greek version of the self-report Early Trauma Inventory (ETI-SR-SF) is a valid and reliable tool useful for future studies on childhood traumatic experiences in Greek populations. Moreover, according to our preliminary findings further investigation of the childhood trauma in Greece appears to be very much warranted.

Clinical and cognitive factors affecting psychosocial functioning in remitted patients with bipolar disorder.

Impaired interpersonal, social, and occupational functioning is very often observed in patients with bipolar disorder, not only at the acute stages of the illness but in remission as well. This finding raises the question of multiple factors that might affect psychosocial functioning in bipolar patients, such as residual subsyndromal symptoms and neuropsychological deficits. Social cognition impairment, especially impaired Theory of Mind (ToM), might also play an important role in bipolar patients' every-day functioning, similarly to what was found in patients with schizophrenia. The present study aimed to investigate the potential effect of clinical and cognitive factors on the psychosocial functioning of patients with bipolar disorder during remission, assessing ToM along with a broad range of basic cognitive functions. Forty-nine patients with bipolar disorder type I in remission and 53 healthy participants were assessed in general intelligence, working memory, attention, speed processing, verbal learning and memory, and executive functions using a comprehensive battery of neuropsychological tests. The Faux Pas Recognition Test was used to assess ToM. The two groups were matched for gender, age and education level. The Hamilton Rating Scale for Depression (HDRS), the Young Mania Rating Scale (YMRS), and the Brief Psychiatric Rating Scale (BPRS) were also administered to the patients. Every-day functioning was assessed with the Global Assessment of Functioning (GAF). In order to examine the contribution of many factors in psychosocial functioning, we used hierarchical multiple regression analysis. Bipolar patients presented significant impairment compared to healthy participants in all the basic cognitive functions tested with the exception of verbal memory. Moreover, patients had significant poorer performance than healthy controls in overall psyand cognitive ToM but not in affective ToM as measured by Faux Pas. Psychosocial functioning in patient group was significantly correlated to symptom severity-especially depressive (p<0.001) and psychotic symptoms (p=0.001), history of psychotic episodes (p=0.031) and ToM, overall (p=0.001) as well as its cognitive (p=0.023) and affective (p=0.004) components. Only the contribution of ToM in psychosocial functioning remained significant in the final multiple regression model. The findings of the current study indicate that residual symptoms and cognitive dysfunctions, especially deficits in social cognition, negatively affect psychosocial functioning of remitted patients with bipolar disorder. Moreover, our results suggest that ToM may play a central role in these patients' functioning. ToM is a mediator of the relationship between other clinical or cognitive variables and functioning, while it has also significant effect on social skills independently of other factors. Therefore, specific therapeutic interventions targeting social cognitive dysfunction might improve functional outcome in bipolar disorder. Putative contribution of other clinical characteristics (comorbid personality disorders, substance abuse, anxiety) and psychosocial factors (stigma, self-stigma, lack of social network) in bipolar patients' functioning should be examined in future studies.

Financial crisis and criminality in Greece: 2008 vs 2011.

Α number of previous articles have dealt with the negative impact of the Greek Economic crisis on public health, including significant increases in major depression prevalence and suicide and homicide rates. The mentally ill seem to represent a vulnerable social group, with particular difficulties in this context. The number of compulsory assessments and involuntary admissions was recorded by reviewing patient records in the Department of Psychiatry of the University Hospital of Patras, through years 2006-2013. Compulsory assessments increased from 176 in 2006 to 262 in 2009 and 354 in 2013, representing a 48.86% and 101.13% increase in the first and the fifth year of economic crisis, respectively. The assessments resulted in 160 involuntary admissions in 2006, which escalated to 262 admissions (63.75% rise) in 2013. Even though a rise in involuntary placements could be attributed to other factors as well, it may also partly represent a not so evident side of the Greek economic crisis.

Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis.

BACKGROUND: Against a backdrop of increasing research, clinical and taxonomic attention in non-suicidal self-injury (NSSI), evidence suggests a link between NSSI and eating disorders (ED). The frequency estimates of NSSI in ED vary widely. Little is known about the sources of this variation, and no meta-analysis has quantified the association between ED and NSSI. METHOD: Using random-effects meta-analyses, meta-regression analyses, and 1816-6466 unique participants with various ED, we estimated the weighted average percentage of individuals with ED, those with anorexia nervosa (AN) and those with bulimia nervosa (BN) who are reported to have a lifetime history of NSSI across studies. We further examined predictors of NSSI in ED. RESULTS: The weighted average percentage of patients with a lifetime history of NSSI was 27.3% [95% confidence interval (CI) 23.8-31.0%] for ED, 21.8% (95% CI 18.5-25.6%) for AN, and 32.7% (95% CI 26.9-39.1%) for BN. The difference between BN and AN was statistically significant [odds ratio (OR) 1.77, 95% CI 1.14-2.77, p = 0.013]. The odds of NSSI increased by 24% for every 10% increase in the percentage of participants with histories of suicide attempts (OR 1.24, 95% CI 1.04-1.48, p = 0.020) and decreased by 26% for every 10% increase in the percentage of participants with histories of substance abuse (OR 0.74, 95% CI 0.58-0.95, p = 0.023). CONCLUSIONS: In the specific context of ED, NSSI is highly prevalent and correlates positively with attempted suicide, urging for NSSI-focused treatments. A novel finding is that NSSI is potentially antagonized by substance abuse.

[Relationship of insight with depression and suicidal ideation in psychotic disorders].

The associations of insight into psychosis (i.e., awareness of illness) with clinical variables have been examined by a great number of studies. Most of these studies revealed that the level of insight is negatively correlated with psychotic symptoms but positively correlated with depression and suicidal ideation. The aim of this study was to test these findings in a Greek sample of patients. Forty-three outpatients (30 men and 13 women) with schizophrenia or delusional disorder being followed up at the Mental Health Centre of Kavala took part in the study. Patients with bipolar or schizoaffective disorder were excluded. Patients' mean age was 40.7 years and the mean duration of illness was 18.67 years. All participants were under treatment and clinically stable at the time of the study. We used the Positive and Negative Syndrome Scale (PANSS) for the assessment of positive and negative symptoms, the Schedule for the Assessment of Insight-Expanded (SAI-E) to assess the insight into psychosis, and the Montgomery-Asberg Depression Rating Scale (MADRS) for the evaluation of depression recording separately the score for item 10 as an estimate of suicidal ideation. All the scales used have been adapted to Greek population. We used Spearman rho coefficient to assess the strength of correlations between the scales because the distributions of some scores were not normal. In order to assess the predictive value of insight for depression and suicidal ideation, we used hierarchical linear regression analysis. Correlation coefficients between SAI-E and the clinical scales of psychopathology, depression and suicide ideation was statistically significant at the p<0.01 level. The correlations between the clinical scales and the three subscales of SAI-E were also significant at the aforementioned p level. The regression analysis showed that our model of positive and negative psychopathology and insight explained 47.4% of the variance of depression and 32.2% of the variance of suicidal ideation. The predictive value of insight was critically important, because only after the introduction of the SAI-E score in the analysis our regression models reached statistical significance. Taking into account its limitations regarding the sample size and the chronicity of the illness, our study confirms the positive correlation of insight with depression and suicidal ideation, offering support to the psychological model of insight.

Pharmacological agents under research for the maintenance treatment in bipolar disorder.

The treatment of bipolar disorder is a current challenge for clinicians and despite progress in psychopharmacology, options remain limited and results are often unsatisfactory. Current research focuses on finding new pharmaceutical agents for all phases of bipolar disorder, i.e. mania, bipolar depression and maintenance. Particularly, relapse prevention and longterm stabilization is a major therapeutic target. Combination treatment and polypharmacy are the most common choices concerning relapse prevention. Furthermore, during maintenance phase patients often experience residual mood symptoms, cognitive deficits and functional decline, which altogether illustrate the inadequate effectiveness of existing treatments and the need for new, targeted, effective and safe treatments for bipolar disorder. This review focuses on active agents for maintenance treatment in bipolar disorder investigated during the last 5 years. The compounds under investigation have been tried or tested either as monotherapy or as an add-on treatment in clinical trials that have progressed up to phase 3 or in preclinical models of bipolar disorder. While awaiting the completion of many ongoing studies, the results so far indicate that paliperidone and pregabalin may have a position in the maintenance treatment of bipolar disorder. Additionally, dextromethorphan, which acts primarily as a NMDA antagonist, may be an interesting compound for further study. However, results on memantine, another NMDA antagonist, were not encouraging. The effects of omega-3 fatty acids and cytidine were not superior to placebo, although they both have neurotrophic and neuroprotective properties. Eslicarbazepine, which has antiepileptic action, provided some evidence of efficacy as monotherapy. Regarding preclinical studies in experimental models, the pharmacological agents under investigation seem to follow the neurobiological pathways related to mechanism of action of lithium, which is still the "golden standard" for preventing recurrence in bipolar disorder. Major therapeutic targets are synthetic glucose kinase 3 (GSK-3) and the path of phosphoinositol (IMP), both probably involved in the action of lithium. Furthermore, the role of circadian rhythms maintenance is being studied in preclinical and clinical trials investigating the efficacy and safety of compounds CK-01 and ramelteon, respectively. Research also focuses on pharmacological agents based on epigenetic changes and gene expression modulation, as the inhibitor of histone deacetylase (HDAC). Of note, the development of valid and reliable experimental models for bipolar disorder, which currently remains quite controversial, will contribute to the understanding of the pathogenic mechanisms and the development of new effective treatments. Improving methodology aspects of clinical trials, such as diagnosis, clinical heterogeneity, monitoring time, gender differences and comorbidities, may promote research. Current studies seem promising for the development of novel pharmacological agents in the near future, although there are methodological limitations in the search for the maintenance treatment in bipolar disorder. New therapeutic targets include not only the already known mechanisms of action, but also novel pathophysiological pathways, probably implicated in bipolar disorder.

The relationship of Theory of Mind with symptoms and cognitive impairment in bipolar disorder: a prospective study.

Previous studies in bipolar disorder suggest patients' deficient performance in Theory of Mind tasks, both during manic or depressive episodes and in remission. However, most of the extant studies were cross-sectional and did not control for potential confounders such as residual symptoms or co-existent deficits in other cognitive functions. The present study is the first prospective study that assessed the effect of remission on Theory of Mind (ToM) in patients with Bipolar Disorder (BD) controlling for other cognitive deficits. ToM was assessed in 29 patients with BD type I during an episode of the illness and in remission as well as in 29 healthy controls. The two groups were pair-matched for gender, age and education level. Three tests with different levels of complexity were used to assess ToM: First Order False Belief Task, Hinting Task and Faux Pas Recognition Test. Concomitantly, a comprehensive battery of neuropsychological tests was administered to all participants assessing general intelligence, working memory, attention, speed processing, verbal learning, and memory and executive functions. The Hamilton Rating Scale for Depression, Young Mania Rating Scale, Brief Psychiatric Rating Scale, and GAF were also administered to the patients. Differences between patients--in acute phase and in remission--and the control group on neuropsychological tests were tested using one-way ANOVA with post hoc Bonferroni corrections. The effect of other cognitive deficits on patients' ToM dysfunction was controlled for using general linear models. The patients showed significantly lower performance in all ToM tests during the acute phases as compared to the control group (p values from 0.001 to 0.014). However, these impairments did not persist beyond acute mood episode, except patients' poor performance on Faux Pas (p=0.001). Additionally, patients had poorer performance compared to control group in verbal learning and memory (p<0.001) as well as visuospatial working memory (p<0.001) during both the acute and the euthymic phases of the illness. Patients also had poorer performance than healthy controls in immediate memory (p=0.026) and executive functions (p=0.001), however only during episodes of illness. Differences in Faux Pas did not remain statistically significant when the effect of verbal memory and visuospatial working memory was controlled for. Differences in other ToM tests during episodes did not remain statistically significant, when other cognitive functions that were found impaired in patients during episodes, were controlled for. The findings of this study support the hypothesis that ToM dysfunction in BD is associated with mood symptoms and it might reflect underlying cognitive deficits rather than representing a specific trait marker of the disorder.

Assessment of the Greek worry-related metacognitions: the Greek version of the Metacognitions Questionnaire (MCQ-30).

The Metacognitions Questionnaire-30 (MCQ-30), developed by Wells and Cartwright-Hatton (2004), represents a multidimensional measure of metacognitive factors considered to be important in the metacognitive model of psychological disorders. The primary aim of the present study was to examine internal consistency, test-retest reliability, convergent validity and the factor structure of the Greek version of the MCQ-30. Moreover, we investigated the associations of the extracted factors with trait anxiety in a Greek sample. The study sample consisted of 547 non-clinical participants (213 males and 334 females). All participants completed the Greek version of the MCQ-30. A subsample of 157 participants also completed the Trait Anxiety subscale of the State -Trait Anxiety Inventory and the Meta-worry subscale of the Anxious Thought Inventory. Thirty participants were retested with the MCQ-30 over a retest interval ranging from three to five weeks. The results confirmed the dimensionality of the MCQ-30 and five factors were extracted consistent with the original English version: (1) positive beliefs about worry, (2) negative beliefs about worry concerning uncontrollability and danger, (3) cognitive confidence, (4) beliefs about the need to control thoughts and the negative consequences of not controlling them, and (5) cognitive selfconsciousness. The MCQ-30 showed high levels of internal consistency and test-retest reliability. The correlation between MCQ-30 total score and AnTI-MW was strong, indicating high level of convergent validity. Moreover, all correlations between MCQ-30 total and subscale scores and STAI-T were significant apart from the correlation between 'cognitive confidence' and trait anxiety. The Greek sample scored higher in the MCQ-30 and its subscales than the English sample in the original study. Women scored significantly higher than men in the overall MCQ-30 and the "uncontrollability and danger" and "need to control thoughts" subscales, whereas no significant differences between genders had been found in the original study. The assumption that the differences in score levels and the gender effect might reflect cultural differences warrants further investigation. The findings of the present study indicate that the Greek version of the MCQ-30 is a comprehensible and psychometrically adequate instrument, as well as a reliable tool in assessing a range of dimensions of worry-related metacognitions in the Greek population. The Greek version of this scale facilitates crosscultural research in metacognition and wider testing of the metacognitive approach to emotional vulnerability, psychological disturbances and mental disorders.

[Ultra-short questionnaires for the detection of depression and anxiety].

Depression and anxiety disorders are the two most common mental health problems seen in the primary care and the general hospital settings. They are both associated with poorer patient functioning, worse quality of life, more frequent utilization of health services, and higher health care costs. However, detection rates of depression and anxiety by non-mental health specialists remain very low, while most of the proposed screening tools are rather not practical and therefore they have not been widely used in practice. Over the last two decades, ultra-short tools including one to three questions have been developed and suggested as case-finding methods and their sensitivity and specificity have been investigated. We reviewed all the ultra-short screening tools for depression and anxiety and the existing evidence on their accuracy in detecting major depression and anxiety disorders. Two simple screening questions for depression, about depressed mood and loss of interest or pleasure in doing things, have been repeatedly applied in primary care settings and found to have satisfactory sensitivity but low specificity. The addition of a third question inquiring if help is needed to the two screening questions for depression improves the specificity, however on the cost of reducing the sensitivity of the method. Screening for depression using only one of these questions alone was found to be less accurate strategy than the two or three question tests. The Patient Health Questionnaire-2 (PHQ-2) includes the same two depression-questions with rating scale answer choices and it was found to be more accurate than the two question test with dichotomous (yes or no) answers. Ultra-short screening strategies for depression in older people were found to have acceptable levels of accuracy, while in patients with cancer the two question tests had higher sensitivity and specificity than in other patient groups. According to the existing data, the Generalized Anxiety Disorder-2 (GAD-2) questionnaire, which includes two questions on "feeling nervous, anxious or on edge" and "not being able to stop or control worrying" appears to have acceptable accuracy in identifying clinically significant anxiety. We concluded that there is sufficient evidence on the suitability of the ultra-short screening instruments for depression and anxiety -especially the PHQ-2, the GAD-2 and their combination, the PHQ-4- for use in epidemiological studies. In primary and secondary care settings, the ultra-short tools can be used only as an initial screening method but diagnosis made by specially-trained clinicians or mental health specialists is warranted for patients who initially screen positive.

[Neurocognitive function in clinically stable patients with schizophrenia or bipolar disorder and normal controls].

There is a substantial body of evidence suggesting that cognitive deficits in schizophrenia (SΖ) and bipolar disorder (BD) persist after the subsidence of active symptoms. However, it is unclear whether the cognitive deficits observed in patients with BD are quantitatively or qualitatively similar to those in SΖ patients. The aim of the study was to assess and compare the cognitive functioning of patients with clinically stable SZ and BD. To the best of our knowledge, this is the first study including a comparison of the Theory of Mind between patients with SZ and BD. General intelligence, attention, speed of processing, working memory, verbal memory and learning, visuospatial ability, executive functions and ToM were assessed in 21 patients with SZ in remission, 23 euthymic BD type I patients, and 27 healthy controls (HC), using WAIS-Vocabulary, Block design, and Digit span, Babcock Story Recall Test, Rey Auditory Verbal Learning Test, Stroop Word-Colour Test, Wisconsin Card Sorting Test, Trail Making Test, and Faux Pas Recognition Test. The three groups were matched for gender, age and education. The SZ and BD groups were also matched in terms of illness duration and the age of the onset of the illness. To be enrolled in the study patients should have been clinically stable for 3 months, operationalized as no change in total Brief Psychiatric Rating Scale, Hamilton Depression Rating Scale (<8), and Young Mania Rating Scale (<6). One-way ANOVA with post hoc Bonferroni corrections was used for the between groups comparisons. Both BD and SC patients were significantly impaired in general intellectual ability, verbal memory and learning, and executive functions compared to HC. Patients with SZ performed significantly worse than patients with BD on verbal memory tasks, whereas BD group did not have significant lower score than SZ in any task. SZ patients performed worse than HC group on attention, processing speed and immediate memory tests, while BD patients on visuospatial ability and working memory. Both SZ and BD groups did not differ from HC regarding Theory of Mind. Our results indicate that stable SZ and euthymic BD exhibit similar profiles of cognitive impairment, consistently with previous studies suggesting that the differences are related to the extent and degree of impairments, rather than being qualitative. Finally, our findings offer support to the hypothesis that the Theory of Mind does not represent a trait marker of schizophrenia or bipolar disorder.

Insight in eating disorders: clinical and cognitive correlates.

BACKGROUND: The aim of this study was to explore the extent of lack of insight and its components in eating disorders (EDs) and to investigate the relationship between insight and clinical and cognitive characteristics in this group. METHOD: Seventy-five participants were enrolled in the study: 25 with anorexia nervosa (AN), 15 with bulimia nervosa (BN) and 35 healthy controls (HC). Insight was assessed with a modified version of the Schedule for the Assessment of Insight for EDs (SAI-ED) and multi-dimensional scaling (MDS) analysis was used to clarify the internal structure of the scale. Neuropsychological tests included the Trail Making Test (TMT), the Brixton Test and a Verbal Fluency Task. RESULTS: Only a subgroup of AN patients (24%) had severe impairment of insight. Patients with the restricting type of AN (AN-R) had poorer overall insight than patients with the binge-purge type of the disorder (AN-B/P). More of the ED patients displayed a deliberate denial of illness rather than a lack of awareness of the illness. A regression model revealed that only performance in part B of the TMT (TMT-B) was a moderate predictor of insight level. No association was found between insight and other cognitive or clinical variables. CONCLUSIONS: Impaired insight is a significant feature of some ED patients. Insight in EDs seems to be partially dependent on intact mental flexibility.

Mental pain and suicide risk: application of the Greek version of the Mental Pain and the Tolerance of Mental Pain scale.

According to Shneidman's theory, mental pain or "psychache", which refers to an endopsychic painful experience consisted of excessively felt negative feelings, is a key component to the understanding of suicidal behaviour, as to its psychological features. Shneidman himself supported that 'suicide is caused by psychache', more precisely suicide occurs when a person can no longer tolerate this pain. Findings of previous studies have shown that mental pain is an independent predictive factor for suicidal behaviour. In the present study we evaluated the psychometric properties of the Greek version of the Mental Pain Scale (MPS) and the Tolerance for Mental Pain Scale (TMPS) ina non clinical sample consisted of 112 participants (73 female and 39 male). Moreover, we explore the relationships between mental pain, depression, and suicide risk and for the first time the effect of the tolerance for mental pain on depression and suicide risk. We hypothesized that both the level of mental pain and the degree of tolerance for mental pain would predict suicide risk, independently of the level of depression. Both MPS and TMPS appear to have satisfactory to high levels of internal consistency, test-retest reliability, and concurrent validity. Suicide risk was correlated to mental pain, tolerance for mental pain, and depression. Multiple regression analysis showed that mental pain and tolerance for mental pain have a significant contribution to suicide risk, independently of depression, confirming our hypothesis.Using an additional multivariate regression with the factors extracted from MPS and TMPS as independent variables, we found that especially 'loss of control' of mental pain and the ability to 'contain the pain' contribute uniquely to suicide risk. Our findings offer support to the hypothesis that mental pain is a clinical entity distinct from depression with a specific and important contribution to the suicide risk.Depression alone is not enough to cause suicide. The mental pain construct, although related to depression,could shed light on the comprehension of the human experience that leads to suicide. Relieving mental pain may constitute a distinct and important treatment goal, along with the remission of depression and despair, so that the person can maintain control and contain all the distressing events that comprise the painful experience. Both MPS and TMPS appear to be valid and reliable tools for the assessment of mental pain and its tolerance, respectively. They could also be employed in further investigation on the role of specific aspects of the mental pain experience in suicidal behaviours.

Clinical symptoms and social functioning among immigrant and greek patients with schizophrenia: A comparative study.

Migration is considered an important risk factor for schizophrenia. However, studies on the differences in psychotic symptomatology between immigrants and native patients revealed mixed results. This study compared clinical symptoms and social functioning between immigrant and native patients with schizophrenia in Greece in order to examine the influence of social factors on the disorder's manifestation and severity. A structured questionnaire including demographic and clinical information was administered to two groups of patients with schizophrenia; the first one was comprised of 65 immigrant patients (38 men and 27 women) and the second included 58 greek patients (35 men and 23 women). Patients' psychopathology was evaluated by the Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Global Assessment of Functioning Scale (GAF). The x2 test and the ANOVA were used for the comparisons of categorical and continuous variables respectively between the two groups of patients. Analysis of eigenvalues and multivariate analysis (MANOVA) were also used. Age and duration of illness were significant greater in the greek group of patients. Lack of insight was the only reason of hospitalization of immigrant patients. The immigrant group of patients had significantly lower scores in the negative syndrome subscale, the general psychopathology subscale and the total PANSS scale while they had significantly higher scores in the GAF scale. No between patients' groups difference was found on CDSS scores. Analysis of eigenvalues and MANOVA revealed that the national group (immigrants vs native) and the reason of admission were the only general variables with significant influence on patients' psychopathological features and functioning. Consistently with previous studies that have shown better prognosis in immigrant compared to the native patients with schizophrenia, immigrant patients in our study had milder negative and total psychotic symptomatology and were less impaired in terms of global functioning than the greek group. Being an immigrant appears to be an important factor related to these differences between our study groups. A possible explanation of our findings could be that immigrant patients with schizophrenia attending to greek mental health services have been 'filtered'because of a 'salmon bias' type phenomenon; the severe ill usually return to their country of birth due to the lack of financial and social support for immigrant patients in Greece. An alternative hypothesis is that the families and the local communities of immigrant patients with schizophrenia, being tied enough, provide support to their ill members that results in better outcome, especially with respect to negative syndrome and social functioning.