BackgroundSuicidal behaviours are major public health concerns worldwide. They are associated with risk factors that vary with age and gender, occur in combination, and may change over time. The aim of our study was to investigate how frequently patients visiting a hospital emergency room (ER) require a psychiatric consultation for attempted suicide, and to outline the characteristics of this population.MethodsDeterminants of emergency room visits for psychiatric reasons were studied prospectively from 2008 to 2011 at the “Maggiore” Hospital in Novara.Results280 out of 1888 patients requiring psychiatric consultation were referred to the ER because of suicide attempt. Suicide attempters were more often female. The rate of suicide attempters among Italian people was 14.2%, compared to 19.5% in foreigners. Subjects living with parents or own family and those having a permanent job had a higher frequency of suicide attempt. Suicide attempts were more frequent among patients with a history of psychiatric disorders; nonetheless, suicide attempts were more common among those who had not previously been hospitalized in a psychiatric ward or were not under the care of a psychiatrist. The multivariate analysis found that female gender was a risk factor for suicide attempt, while being in the colder months of the year and, surprisingly, unemployment were protective factors.ConclusionsA better understanding of patients referring to the ER due to attempted suicide may allow the identification of at-risk subjects and the implementation of targeted treatment approaches.

Alexithymia, difficulties in facial emotion recognition, poor socio-relational skills are typical of Anorexia Nervosa (AN). We assessed patients with AN and healthy controls (HCs) with mixed stimuli: questionnaires (Toronto Alexithymia Scale-TAS, Interpersonal Reactivity Index-IRI), photographs (Facial Emotion Identification Test-FEIT) and dynamic images (The Awareness of Social Inference Test-TASIT). TAS and IRI Personal Distress (PD) were higher in AN than HCs.Few or no differences emerged at the FEIT and TASIT, respectively. Despite higher levels of alexithymia, patients with AN seem to properly acknowledge others' emotions while being inhibited in the expression of their own.

BackgroundFrontotemporal dementia (FTD) may present with psychiatric symptoms, usually together with neurological ones and in cases with a family history of dementia. We describe the case of an FTD behavioural variant with a psychiatric presentation and a normal neurological examination, due to a C9Orf72 gene mutation.Case presentationThe patient was a 57 years-old Caucasian woman with a recent onset of bizarre behaviours and mystic delusions. She had a negative clinical history for previous psychiatric disorders and treatments and this was her first admission to a Psychiatry Ward. A careful assessment was performed including, beyond psychiatric evaluation, the following: blood sampling, neurological examination (including electroencephalogram, electroencephalogram with zygomatic electrodes, Positron Emission Tomography, Cerebrospinal Fluid Analysis), carotid artery Doppler ultrasound, brain Magnetic Resonance Imaging – angio Magnetic Resonance Imaging. Blood sampling for the genetic assessment of mutations associated to primary dementias was performed as well: the genes investigated were FUS, C9Orf72, PSEN-1, PSEN-2.ConclusionsSerological tests were negative, neurological examination was normal, instrumental examinations showed theta waves in the posterior temporal areas bilaterally and frontotemporal cortical atrophy bilaterally. The genetic assessment of mutations associated revealed she carried a GGGGCC hexanucleotide repeat expansion (at least 80 repeats) in C9Orf72 intron 1. Patients carrying the C9Orf72 mutation are likely to receive a psychiatric diagnosis (mainly mood disorder or schizophrenia) prior to correct diagnosis; this may be particularly problematic for those patients with no neurological signs to orientate diagnosis. Understanding the manner in which such FTD variant may present as a psychiatric syndrome, with a negative neurological examination, is essential to provide the best treatment for patients, as soon as possible, especially when the behavioural anomalies interfere with their care.

Rationale:Valproic Acid is a commonly used psychiatric drug primarily used as a mood stabilizer. Mild hyperammonemia is a Valproic Acid common adverse effect. This report presents an example of treated hyperammonemia on Valproic acid therapy managed with L-carnitine administration in BD patients characterized by sudden vulnerability.Patient concerns:We report the case of a 29-year-old man suffering from bipolar disorder (BD) and substance use disorder who exhibited sudden altered mental status upon admittance to the inpatient unit. The patient was started on Valproic acid with no improvement.Diagnoses:The patient had remarkably high ammonia levels (594 μg/dL) without hepatic insufficiency, likely due to his valproate treatment.Interventions:The patient was administered lactulose, intravenous hydration, and i.v. levocarnitine supplementation 4.5 g/day.Outcomes:The administration leads to reduction of ammonia levels to 99 μg/dL within 12 hours upon initiation of carnitine therapy and progressive restore of his mental status within 24 hours.Lessons:Resolution of hyperammonemia caused by Valproic acid therapy may be enhanced with the administration of L-carnitine. An interesting aspect of this case was how rapidly the patient responded to the carnitine therapy.

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The contribute entitled: "Revitalizing monoamine oxidase inhibitors: a call for action" 1 deserves appraisal about the prescribing pattern in Italy and the lack of further effective interventions besides the monoamine oxidase inhibitor (MAOI) drugs. New generation antidepressant drugs released within the past decades promoted the selectivity of action, tolerability, and safety issues. At the same time, a new definition of major depression emerged, with broad and blurred boundaries, relegating the most severe forms of melancholic, atypical and mixed-agitated type to the rank of mere "specifiers." Such a diagnostic shift fostered treatment research in which clinical trials showed an increasingly high rate of placebo response and results that were less and less applicable to clinical practice with the so-called "real-world" patients. Considering that evidence-based medicine (EBM) relies on randomized clinical trials (RCTs), even if limited by selection bias that may reduce their generalizability, international treatment guidelines barely account for older pharmacological agents with no patent-appeal to the brands anymore, and as a consequence, such drugs are less assessed by RCTs. However, in contrast with the initial idea of a similar efficacy to the previous "less tolerated" drugs, the efficacy expectations of new generation antidepressants have been somewhat disappointed in many instances. Almost half of the major depressive disorder (MDD) patients fail to achieve a response, despite sequential combination or augmentation treatment strategies, irrespective to the operational definition adopted for treatment-resistant depression (TRD) 2. Figures of non-response or resistance to new antidepressant drugs in bipolar disorder (BD) can exceed those documented for MDD. Resistance can also occur among people treated for an acute manic episode of BD (Fornaro M. et al. "The concept and management of acute episodes of treatment-resistant bipolar disorder: a systematic review and exploratory meta-analysis of randomized controlled trials," submitted for publication). Consecutive treatment failures can either result in acquired tolerance/resistance phenomena, increased risk of suicidal behavior, inflated rates of polypharmacy and healthcare utilization, at least for a subset of more vulnerable patients. The plea for attention toward the MAOIs made by Gillman et al. 1 seems even more compelling for those prescribing clinicians based in Italy. The last available MAOI for prescription in Italy, namely the nonselective and irreversible inhibitor tranylcypromine, is not available anymore since the year 2018. Its production halted because of poor sales records rather than for safety concerns. According to the most current report disclosed by the "Agenzia Italiana del Farmaco" (AIFA or Italian Medicines Agency-http://www.agenziafarmaco.gov.it/en), even the utilization rate of the tricyclic antidepressants (TCAs) lowered over the time. However, the TCAs still represent a cornerstone treatment for melancholic depression, usually less r...

The immigrant population in Italy is currently increasing, particularly, foreigners in East Piedmont raised by 16,8 % last year. We aim to compare immigrant and Italian patients' Emergency Room (ER) admissions due to psychiatric symptoms. Results: Of the 658 admissions we observed, 13.1 % of ER contacts concerned immigrants mostly coming from Russia, Albania, Morocco and Romania, consistently with migration streams in East Piedmont. Compared to the Italians, immigrant patients were younger (35.70; SD = 10.56 versus 44.78; SD = 16.57) and more frequently admitted for alcohol and substance abuse/withdrawal. Italians had a higher probability of having a psychiatric history including previous hospitalizations and contacts with Mental Health Services (OR = 2.60; CI 95 %: 1.64-4.12). The presence of social/relational problems associated with admission was significantly lower among the Italians (OR = 0.55; CI 95 %: 0.35-0.88). Conclusions: Preliminary data suggest that ER utilisation by immigrants may represent their main way to primary health care. Monitoring ER contacts may provide relevant information for the development of culturally sensitive Mental Health Services. Methods: We considered Italian and immigrant patients with psychiatric symptoms who were admitted to the ER Department of Novara during a period of 13 months. We compared sociodemographic (gender, age, education, occupational history, marital status, living circumstances) clinical-anamnestic (history of psychiatric illness, presentation symptoms, previous contacts with Substance Abuse/Mental Health Services, social/relational problems) and admission (type of admission, intervention and discharge) characteristics of the two groups (Italians versus immigrants).