Browsing by Author "Marić, Nadja P. (57226219191)"

Introduction: In literature, algorithms (guidelines) are often synonymous with problem-solving procedures. The importance of using algorithms in psychiatry can be seen in many areas. For physicians, algorithms ease clinical decision making, provide an adequate clinical basis for therapy, stimulate research, and stimulate sources of financing. For users of psychiatric services, algorithms tailor treatment to the individual, enhance the standard of care by using efficient therapeutic techniques, improve outcome, cut costs, and provide continuity of care after hospital treatment. Aim: Our goal with this paper is to present the advantages of using algorithms, but also to advise caution in their application. It is important to be aware and critical of limitations present in algorithm use. Methods: A MEDLINE and KOBSON search was conducted combining the following key words and phrases: "treatment guidelines"; "algorithms"; "psychiatry"; "bipolar"; "depression"; "schizophrenia". Results: We investigated the advantages and disadvantages of algorithms presented in the publications we found in our search. Conclusion: We consider algorithms to be a necessary component in the treatment of psychiatric patients, but recommend that one should maintain a critical attitude and remember that guideline proposed therapy should always be tailored to the individual. © Medicinska naklada - Zagreb, Croatia.

Objective: To prospectively evaluate depressive symptoms and risk factors for depression in patients with chronic hepatitis C (CHC) treated with pegylated interferon alpha therapy combined with oral ribavirin (PEG-IFN-α+RBV) and to analyze self-rating scale for depression in comparison to observer-based scale in the given population. Subjects and methods: The Hamilton Depression Rating Scale and Zung Self Rating Depression Scale were used to screen for depressive symptoms in 74 subjects with CHC before PEG- IFN-α (mean dose 152.6±25.6 mcg), and in the follow-up visits (4, 12 and 24 week). Results: Incidence of depressive symptoms in patients (mean age 39.9±13.4 years; equal sex distribution p=0.225) treated by PEG- IFN-α was the highest on 12th week of the treatment, when more than a 20% of our sample had moderate/severe symptoms of depression, and about 30% had minor depressive symptoms. For the screening of depression during PEG- IFN-α self-assessment scale was equally reliable as observer-based assesment of depressive symptoms. Common clinical parameters- subject related risk factors (age (p=0.955 ), sex (p=0.008), lifetime psychiatric disorder (p=0.656)), illness related risk factors (duration of CHC (p=0.267), i.v drug aplication as way of transmission (p=0.292)) and therapy-related risk factors (recommended duration of PEG-IFN-α (p=0.993) and dose of PEG-IFN-α (p=0.841)) were not significantly associated with depressive symptoms on PEG-IFN-α. Conclusions: Liason-consultation services should collaborate with hepatologists in creating screening programmes, supplemented by objective criteria and guidelines, for early recognition and treatment of interferon-induced depression. © Medicinska naklada.

Background: Tianeptine, a new generation antidepressant, possesses a unique mechanism of antidepressive action and has a specific pharmacokinetic profile. The aim of this study was to determine the efficacy, tolerability and safety of tianeptine in a "fragile" population of depressive patients: (1) a group of elderly patients and (2) a group with comorbid alcohol addiction. Subjects and methods: This was an open multicentric eight-week study of tianeptine efficacy, tolerability and safety including patients with mild to moderate depression (DSM-IV), age ≥55 years (group 1; n=45) or with comorbid alcohol addiction (group 2; n=32). Assessments was made with the following rating scales; MADRS, HAM-A and CGI for efficacy and DESS for tolerability. Results: After eight-week tianeptine therapy, remission (MADRS ≤12) was established in 51.1% and 84.4%patients, respectively. On day 7, the therapy led to a significant decrease of MADRS. On endpoint, there were significant differences on HAM-A, CGI-I and CGI-S scores (p<0.01). No adverse effects with frequency ≥ 10%, were registered. A lower tolerability of tianeptine was registered in a group of elderly (nausea 4.5%, leg fatigue 4.4%, irritability 2.2%, bursts of crying and sadness 2.2%), while only 3.1% depressive patients with comorbid alcohol addiction had dizziness. Conclusion: This is the first clinical study to evaluate tolerability, efficacy and safety of tianeptine in a special population of depressive patients in the region. The study showed that tianeptine had good efficacy in treatment of mild to moderate forms of depression in special populations of depressive patients (elderly population and patients with comorbid alcohol addiction). The drug was well tolerated. © Medicinska naklada.

This is the first survey of the practice of electroconvulsive therapy (ECT) in the Republic of Serbia. A retrospective chart review was undertaken including all patients having received ECT in Serbia in 2012. Only one center in Serbia offered ECT in 2012 to a total of 54 patients (54% women). Thirty-six (36) patients received acute ECT treatment and eighteen (18) patients maintenance ECT, yielding a ECT utilization rate of 0.05/100.000 population. ECT was delivered with a modern square-wave (brief pulse) machine with EEG and ECG monitoring. In all cases the electrode placement was bifrontal and treatment modified (with anesthesia). The most frequent indication was recurrent depressive disorder (66.7%) for both acute and maintenance treatment. The limited availability of ECT in Serbia raises serious concerns. Provision of updated and effective treatment modalities for severe psychiatric disorders is crucial and the need for additional ECT services in Serbia is urgent. © Medicinska naklada.

Background/Aim. Antidepressants are a widely used class of drugs. The aim of this study was to investigate different aspects of antidepressant prescribing practice at University Psychiatric Clinic in Belgrade. Methods. This cross-sectional study was carried out by retrospective analysis of the patient's medical charts. The study included all patients with antidepressant prescribed at discharge during 2009 (n = 296). The evaluation was focused on patient- related factors (socio-demographic and illness related), psychiatrist-related factors (sex and duration of working experience) and drug related factors (type of antidepressant, dose, polypharmacy and reimbursement by national health insurance). Results. Antidepressants were prescribed for unipolar depression (F32-34, ICD X) either without comorbidity (46.2%) or with comorbidity (24.7%), mostly as a monotherapy (91% had one antidepressant), to the patients who were 65% female, aged 50.1 ± 8.9, most of them with 12 years of education (52.6%), married (69.3%) and employed (55.9%). The majority of patients had a history of two hospitalizations (Med 2; 25th-75th perc. 1-4) during nine years (Med 9; 25th-75th perc. 2-15) after the first episode of depression. Among them, 19% were found to be suicidal in a lifetime. The single most prescribed antidepressant was sertraline (20.4%), followed by fluoxetine (13.3%) and maprotiline (11.7%). Utilization of antidepressants was positively correlated with the rate of reimbursement (p < 0.01). The most prescribed antidepressant group was selective serotonin reuptake inhibitors (SSRI) (47.8%), followed by tricyclic antidepresants (TCA) (25.3%) and new antidepressants - venlafaxine, tianeptine, mirtazapine, bupropion, trazodone (15.1%). Most of the drugs were prescribed in doses which are at the lower end of the recommended dose-range. Regarding severity of the actual depressive episode, TCA were prescribed for severe depression with psychotic features, while SSRI were choice for episodes with moderate symptom severity (p = 0.01). Psychiatrists with longer working age (20-30 years) hesitated to prescribe new antidepressants in comparison to younger colleagues (p = 0.01). Conclusion. Economic issues in Serbia as developing country influence the choice of antidepressants, as well as a psychiatrist's working age and severity of depression. However, SSRI are the drugs of the first choice, as it was shown in most of the developed countries nowadays.

Depressed patients demonstrate alterations in motor and cognitive functioning that can affect their adjustments to the variations in everyday life environment. The objective was to explore gait parameters and variability of patients with major depressive disorder in dual task walking situations. Eight patients and 20 healthy controls performed motor, mental and combined motor+mental tasks while walking. Calculated parameters were cycle time, stride length, swing time, double support time and their coefficients of variation (CV). Patients demonstrated greater gait variability (swing time CV) than controls during baseline walk (t(26)=2.64, p<0.05) and motor dual task (t(26)=3.68, p<0.05). Moreover, the transition from mental to combined task decreased stride length (M=126.48±15.35 and M=121.19±13.55, p<0.001) and increased double support time (M=0.266±0.072 and M=0.287±0.076, p<0.01) only in controls. Also, gait variability increased in controls during the combined task, while remaining the same or decreasing in patients. Tasks that required greater cognitive involvement affected gait variability in patients more than controls, but only up to a certain level, after which patients[U+05F3] stability appeared unaffected by the increase of cognitive demand. This could be explained by a tendency of patients to neglect complex cognitive tasks while walking in order to preserve stability and prevent possible falls. © 2014 Elsevier Ireland Ltd.

Depressed patients demonstrate alterations in motor and cognitive functioning that can affect their adjustments to the variations in everyday life environment. The objective was to explore gait parameters and variability of patients with major depressive disorder in dual task walking situations. Eight patients and 20 healthy controls performed motor, mental and combined motor+mental tasks while walking. Calculated parameters were cycle time, stride length, swing time, double support time and their coefficients of variation (CV). Patients demonstrated greater gait variability (swing time CV) than controls during baseline walk (t(26)=2.64, p<0.05) and motor dual task (t(26)=3.68, p<0.05). Moreover, the transition from mental to combined task decreased stride length (M=126.48±15.35 and M=121.19±13.55, p<0.001) and increased double support time (M=0.266±0.072 and M=0.287±0.076, p<0.01) only in controls. Also, gait variability increased in controls during the combined task, while remaining the same or decreasing in patients. Tasks that required greater cognitive involvement affected gait variability in patients more than controls, but only up to a certain level, after which patients[U+05F3] stability appeared unaffected by the increase of cognitive demand. This could be explained by a tendency of patients to neglect complex cognitive tasks while walking in order to preserve stability and prevent possible falls. © 2014 Elsevier Ireland Ltd.

Background: Taking the Initiative to evaluate students' affinity toward psychiatry seems to be a global issue and is an essential part of programs to improve the status of the profession. The aim of this study is to explore medical students' attitudes toward psychiatry in comparison to other residencies (internal medicine, surgery, pediatrics, gynecology and general medicine) in the pre-clinical year and to observe which factors influence the creation of these attitudes. Subjects and methods: The survey included 114 students of the second year, School of Medicine in Belgrade (academic year 2007/08). The data was collected trough a 23-item questionnaire. Results: Fifteen percent of students stated that psychiatry was their career of choice, while 25% expressed a strong aversion. Psychiatry was ranked less attractive than internal medicine, surgery and pediatrics, but more attractive than general medicine or gynecology. Those who like psychiatry attributed more importance to an interesting and challenging job than to prestige and financial reward. Also, they found this field to be intellectually challenging and to rapidly expand the frontier of medicine. Students with negative attitude were convinced that psychiatry was lacking in scientific foundation and was clinically inefficient, they disliked intensive emotional involvement, exposure to stress and frequent unpleasant situations and had prejudices toward the patients or simply a lack of the interest. Conclusion: The present study is the first of its kind in Serbia which used a precise and internationally comparable methodological instrument and It shows that pre-clinical medical students at the University of Belgrade, have a stronger affinity towards psychiatry when compared to their peers from most countries worldwide. Also, the study points out the fact that prejudices toward patients with mental dysfunctions and lack of confidence in the efficacy of psychiatric treatment should be specially targeted by the curriculum in the later part of undergraduate education. How this will affect the attitude of clinical students and graduates is to be examined. © Medicinska naklada.

A hundred years after psychoanalysis was introduced, neuroscience has taken a giant step forward. It seems nowadays that effects of psychotherapy could be monitored and measured by state-of-the art brain imaging techniques. Today, the psychotherapy is considered as a strategic and purposeful environmental influence intended to enhance learning. Since gene expression is regulated by environmental influences throughout life and these processes create brain architecture and influence the strength of synaptic connections, psychotherapy (as a kind of learning) should be explored in the context of aforementioned paradigm. In other words, when placing a client on the couch, therapist actually placed client's neuronal network; while listening and talking, expressing and analyzing, experiencing transference and counter transference, therapist tends to stabilize synaptic connections and influence dendritic growth by regulating gene-transcriptional activity. Therefore, we strongly believe that, in the near future, an increasing knowledge on cellular and molecular interactions and mechanisms of action of different psycho- and pharmaco-therapeutic procedures will enable us to tailor a sophisticated therapeutic approach toward a person, by combining major therapeutic strategies in psychiatry on the basis of rational goals and evidence-based therapeutic expectations. © Medicinska naklada.

Introduction Repetitive transcranial magnetic stimulation (rTMS) is a method of brain stimulation which is increasingly used in both clinical practice and research. Up-to-date studies have pointed out a potential antidepressive effect of rTMS, but definitive superiority over placebo has not yet been confirmed. Objective The aim of the study was to examine the effect of rTMS as an adjuvant treatment with antidepressants during 18 weeks of evaluation starting from the initial application of the protocol. Methods Four patients with the diagnosis of moderate/severe major depression were included in the study. The protocol involved 2000 stimuli per day (rTMS frequency of 10 Hz, intensity of 120% motor threshold) administered over the left dorsolateral prefrontal cortex (DLPFC) for 15 days. Subjective and objective depressive symptoms were measured before the initiation of rTMS and repeatedly evaluated at week 3, 6, 12 and 18 from the beginning of the stimulation. Results After completion of rTMS protocol two patients demonstrated a reduction of depressive symptoms that was sustained throughout the 15-week follow-up period. One patient showed a tendency of remission during the first 12 weeks of the study, but relapsed in week 18. One patient showed no significant symptom reduction at any point of follow-up. Conclusion Preliminary findings suggest that rTMS has a good tolerability and can be efficient in accelerating the effect of antidepressants, particularly in individuals with shorter duration of depressive episodes and moderate symptom severity. Keywords: transcranial magnetic stimulation; depression; an-tidepressants; HAMD. © 2014, Serbia Medical Society. All rights reserved.

Background The Patient Health Questionnaire (PHQ-9) score ≥ 10 balances best sensitivity and specificity when detecting probable depression in patients. In the general population, different cut-offs are suggested. European studies on general populations validating the PHQ-9 against a diagnostic interview to detect depression are rare. Methods This was a cross-sectional observational epidemiological survey using multistage household probabilistic sampling to recruit a representative adult sample (N = 1203; age = 43.7 ± 13.6; 48.7% male). Mental disorders including current major depressive episode (MDE) were observer-rated (Mini International Neuropsychiatric Interview). The PHQ-9, quality of life (QoL), and loneliness were self-assessed. We performed validity and reliability tests of the PHQ-9 and receiver operating curve (ROC) analysis. Results The Serbian PHQ-9 was internally consistent and correlated in the expected directions with QoL and loneliness. At the cut-off score ≥ 8, sensitivity was .85 and specificity was .91. ROC analysis showed that the area under the curve was .95, indicating that the Serbian PHQ-9 can discriminate very well between persons with/without MDE. Conclusions When the PHQ-9 is assessed against the structured diagnostic interview in the general population to detect depression, the cut-off of ≥8 balances best sensitivity and specificity. © The Author(s) 2023. Published by Oxford University Press on behalf of Faculty of Public Health.

Backround: Stigmatization of psychiatric patients is present both in the general population and among healthcare professionals. Aim: To determine the attitudes and behaviour of medical students towards a person who goes to a psychiatrist, before and after psychiatric rotation, and to compare those attitudes between medical and non-medical students. Methods: The study included 525 medical students (second and sixth year of studies) and 154 students of law. The study instrument was a three-part self-reported questionnaire (socio-demographic data, Rosenberg Self-Esteem Scale and a vignette depicting a young, mentally healthy person). The experimental intervention consisted of ascribing a psychiatric label to only one set of vignettes. All the vignettes (with or without the psychiatric label) were followed by 14 statements addressing the acceptance of a person described by vignette, as judged by social distance (four-point Likert scale). Results: Higher tendency to stigmatize was found in medical students in the final year, after psychiatric rotation (Z U = ?3.12, P = .002), particularly in a closer relationship (Z U = ?2.67, P = .007) between a student and a hypothetical person who goes to a psychiatrist. The non-medical students had a similar tendency to stigmatize as medical students before psychiatric rotation (Z U = ?0.03, P = .975). Neither gender, nor the size of students place of origin or average academic mark was associated with the tendency to stigmatize in our sample. However, students elf-esteem was lower in those with a tendency to stigmatize more in a distant relationship (P = ?0.157, P = .005). Conclusions: Psychiatric education can either reinforce stigmatization or reduce it. Therefore, detailed analyses of educational domains that reinforce stigma will be the starting point for anti-stigma action. © The Author(s) 2011.

The introduction of antipsychotic medication in the 1950s forever changed the outlook on the treatment of schizophrenia, although there is still a large proportion of patients who do not reach functional recovery. At least 30% of patients do not respond to clozapine, the tricyclic dibenzodiazepine with complex pharmacological actions, which was proven to be more effective than any other antipsychotic in the treatment of schizophrenia. According to most of the therapeutic guidelines for schizophrenia, clozapine is the third line therapy for patients who did not respond to other antipsychotics. Large inter-individual variability exists for clozapine bioavailability and plasma steadystate concentrations and clearance. Clozapine is metabolized by the cytochrome P450 oxidase enzyme family (CYP450). Cytochrome P450 1A2 (CYP1A2), which is polymorphically expressed in humans, is the main enzyme of clozapine metabolism. This case report addresses the influence of CYP1A2∗1F genetic polymorphism on cloza - pine metabolism, explains the primary non-response of a young patient with schizophrenia due to increased gene expression in homozygous genotype ∗1F/∗1F (increased metabolism of clozapine) and underlies the importance of personalizing schizophrenia treatment by means of genetic and other molecular tools, at least in the cases of "treatment resistance". © by Nadja P. Marić 2015.

The introduction of antipsychotic medication in the 1950s forever changed the outlook on the treatment of schizophrenia, although there is still a large proportion of patients who do not reach functional recovery. At least 30% of patients do not respond to clozapine, the tricyclic dibenzodiazepine with complex pharmacological actions, which was proven to be more effective than any other antipsychotic in the treatment of schizophrenia. According to most of the therapeutic guidelines for schizophrenia, clozapine is the third line therapy for patients who did not respond to other antipsychotics. Large inter-individual variability exists for clozapine bioavailability and plasma steadystate concentrations and clearance. Clozapine is metabolized by the cytochrome P450 oxidase enzyme family (CYP450). Cytochrome P450 1A2 (CYP1A2), which is polymorphically expressed in humans, is the main enzyme of clozapine metabolism. This case report addresses the influence of CYP1A2∗1F genetic polymorphism on cloza - pine metabolism, explains the primary non-response of a young patient with schizophrenia due to increased gene expression in homozygous genotype ∗1F/∗1F (increased metabolism of clozapine) and underlies the importance of personalizing schizophrenia treatment by means of genetic and other molecular tools, at least in the cases of "treatment resistance". © by Nadja P. Marić 2015.

A rapid expansion of new treatment options in recent decades and the increasing volume of scientific evidence published on a daily basis have been followed by the necessity of introduction of clinical guidelines and therapeutic algorithms. The development of these guidelines and algorithms has also been driven by increased cost-awareness and the increasing pressure to improve cost-efficiency. The Serbian Physicians Society published "Therapeutic Guidelines for the Treatment of Schizophrenia" in 2003 and "Therapeutic Guidelines for the Treatment of Bipolar Affective Disorder" in 2004. The School of Medicine, University of Belgrade published "Therapeutic Guidelines for the Treatment of Depression" in 2004. All of these national guidelines, at the moment of development, were based upon up-to-date scientific evidence. According to the recently conducted survey at the Institute of Psychiatry, Clinical Centre of Serbia, about 65% of psychiatrists stated that they adhere to the national or relevant international therapeutic guidelines. When asked to cite which international or foreign guidelines in particular they used, approximately 50% failed to do so, while the other half cited mostly the APA Guidelines or NICE Guidelines. Among the national guidelines, physicians are, according to the survey, familiar with the Therapeutic Guidelines for the treatment of Schizophrenia (46,3%), Therapeutic Guidelines of Depression (41,5%) and Therapeutic Guidelines for the Treatment of Bipolar Affective Disorder (34,1%). The majority of Serbian psychiatrists rely on the efficacy and safety of the drugs as the major determining factors in the choice of therapy, bearing in mind the patients' best interests. However, it is unclear why such a discrepancy between practice and guidelines still persists, since guidelines also recommend therapy based on their safety and efficacy data. It is possible that a substantial percentage of psychiatrists obtain indicators on drugs' efficacy and safety from their personal professional experience. It is doubtful whether this knowledge is valid, or just represents unproven prescribers' habits. Furthermore, the influence on other factors, such as treatment costs or drug availability should be further investigated. © Medicinska naklada.