In Denmark, about 14% of patients with depression develops treatment resistant depression (TRD) in the following year after the first hospital contact. Possible explanations for TRD include lack of adequate clinical effect of pharmacological treatment and reluctance to treatment due to unacceptable side effects. Cold water swimming (CWS), also known as winter swimming, describes swimming outdoors - mainly during the winter season in cold to ice-cold water on a regular basis. Many winter swimmers believe that exposure to cold water is beneficial for their health. However, evidence of health effects have been anecdotal or based on results from small sample-size studies. The availably studies report that winter swimming abolishes general tiredness, boosts self-esteem and improves mood and/or general well-being.

To test if it is possible for patients with depression to participate in two weekly sessions of CWS and to measure the effects of CWS on general well-being and depression among the participating patients.

All psychiatric in- and outpatients from the department of psychiatry at Little Belt Hospital, Vejle with a diagnose of depression are eligible for inclusion. CWS-sessions will include a dip in an inlet - and if desired a short swim for a few minutes – depending on individual preferences. The CWS sessions will take place at the local inlet at a recreational area with sauna and changing facilities available.

The study starts in October 2021 and we expect to have results by April 2022.

Conclusion: Awaiting.

No significant relationships.

Discovered in December 2019, COVID has affected the entire planet, through direct exposure to its virus; SARS-COV-2, or indirectly through the media, Indeed, on January 20, 2020, the World Health Organization declared COVID-19 to be “a public health emergency of international concern.” Along with other public health crises and other collective trauma (terrorism, H1N1 epidemic or SARS-COV), exposure to publicized information on this virus generates psychiatric disorders, in particular anxiety and absence of well-being.

To link exposure to information about this pandemic through social media and anxiety and lack of well-being.

Use of a questionnaire consisting of three sections, individual status and conditions, the French versions of the GAD-7 scale for anxiety (Generalized anxiety scale of 7items) and the WHO-5 (five well-being index). This questionnaire is dedicated to the general population who have not been in direct contact with the virus, but through the media.

We were able to collect 209 participants, they were essentially females with a mean age of 28yo, 17,7% had psychiatric history of anxiety and depression, the median use of social medias was 5.7 hours per day. And they were essentially getting their information about the pandemic from Instagram, Facebook, the Moroccan ministry of health’s website and electronic newspapers. 31,1% of our participants had anxiety which was above a Chinese study, and had a poor well-being.

the use of social media to get information about the pandemic had an impact on well-being and anxiety..

No significant relationships.

No significant relationships.

People presenting first-episode psychosis (FEP) benefit from early intervention programmes, although they are scarce in low- and middle-income countries (LMICs). In Brazil, there are just a few of them unequally distributed across the country.

We aimed to describe the workings of the Ribeirão Preto Early Intervention for Psychosis Programme (Ribeirão Preto-EIP) – an outpatient service for first-episode psychosis patients residents in the Ribeirão Preto catchment area in Southeastern Brazil.

A retrospective cohort of all patients attended throughout four years (2015-2018) was analysed. We excluded patients who attended only the first consultation and those with an initial diagnosis other than a psychotic disorder. Data was obtained through retrospective analysis of medical records.

Our service had 358 new referrals during the four-year period, and 237 patients were followed on average (median) by 14 months. Most of the patients were male (64.1%), single (84.8%), with a median age of 23.5 years (age ranged from 9 to 86 years). Schizophrenia was the main diagnosis (43.4%), followed by substance-induced (25.7%) and affective psychosis (18.6%). Taking follow-up diagnoses as gold-standard, initial diagnoses of bipolar disorder and schizophrenia spectrum disorders had the highest positive predictive values, 83% and 81% respectively. Most referrals to our programme were made by tertiary care (63.7%), followed by secondary (28.5%) and primary care (7.8%).

Here we presented a large sample of FEP patients in a representation as trustworthy to the reality of our programme as possible. Our analysis suggest that Early Intervention Programmes can be successfully implemented in LMICs.

No significant relationships.

COVID-19 pandemic has many psychological and physical effects. University students are among vulnerable population.

We aimed in this study to assess sleep effects of COVID-19 pandemic on university students in Saudi Arabia.

We conducted cross-sectional study to collect responses of 5,140 participations from Saudi universities, responders completed the demographic questions, psychological scales including insomnia severity scale (ISI) between 24th and 30th of April 2020.

About 41% of the sample suffered from moderate to severe insomnia. Mean ISI score was 12.9 (SD 6.62). Insomnia was associated with female gender, younger age, students from new universities, junior students, if a relative got COVID-19, having a chronic medical illness, and having a psychiatric disorder.

Covid-19 pandemic has clear effect on sleep among Saudi university students. Universities need to plan and implement protective and intervention strategies to deal with this important issue.

No significant relationships.

Little is known regarding how the risk of suicide in refugees relates to their host country. Specifically, to what extent, inter-country differences in structural factors between the host countries may explain the association between refugee status and subsequent suicide is lacking in previous literature.

We aimed to investigate the risk of suicide among refugees in Sweden and Norway according to their sex, age, region/country of birth and duration of residence.

Each suicide case between the age of 18-64 years during 1998 and 2018 (17,572 and 9,443 cases in Sweden and Norway, respectively) was matched with up to 20 population-based controls, by sex and age. Multivariate-adjusted conditional logistic regression models yielding adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were used to test the association between refugee status and suicide.

The aORs for suicide in refugees in Sweden and Norway were 0.5 (95% CI: 0.5-0.6) and 0.3 (95% CI: 0.3-0.4), compared with the Swedish-born and Norwegian-born individuals, respectively. Stratification by region/country of birth showed similar statistically significant lower odds for most refugee groups in both host countries except for refugees from Eritrea (aOR 1.0, 95% CI: 0.7-1.6) in Sweden. The risk of suicide did not vary much across refugee groups by their duration of residence, sex and age.

The findings of almost similar suicide mortality advantages among refugees in two host countries may suggest that resiliency and culture/religion-bound attitudes could be more influential for suicide risk among refugees than other post-migration environmental and structural factors in the host country.

No significant relationships.

We have been using LAB (Buvidal) in Cardiff after its pandemic use was funded by Welsh Government.

We wished to review the benefits of introducing LAB (Buvidal) into treatment during the pandemic.

This service development review of the first 73 patients treated with LAB (24mg/96mg rapid titration Welsh protocol) was analysed using Kaplan-Meier survival curves.

43 (58%) male, 30 (41%) female. <25years=1, 38 (52%) aged 25-40, 34 (47%) 40-55. Prior to LAB 14% (10 people) using Espranor, 8% (6) Buprenorphine, 28% (20) Methadone. 50% (36) illicit opiates (mainly Heroin). We had continuous data for patients for up to 9 months of LAB. Two stopped for non-discontinuation reasons: One wanted to detox, one died of natural causes (LAB-unrelated). Both were excluded from discontinuation rate analysis. 55 people have data for over a month. Of these, 11 discontinued treatment. 80% remained on LAB for 1 month or more [95%CI 67-90%]. Kaplan-Meier plots showed similar discontinuation rates when comparing different OST programmes or none prior to LAB, and comparing by age, sex and initial illness severity (CGI severity). These rates all far exceeded data for traditional OST. CGI scores dramatically improved, even at one week. By month 2 all scores “much improved” or “very much improved”.

Buvidal (LAB) has 80% retention rates, regardless of underlying prescribed/illicit opioid /demographics. The commonly held belief that those on heroin are further from Recovery than those more stable on OAD may be incorrect. LAB may be a more acceptable and useful first line therapy that other OSTs

Dr Melichar has provided consultancy work, presentations, training and chaired panel discussions for all the companies in this area in the UK and some outside the UK. Recent work includes Althea (UK), Britannia (UK), Camurus (UK and Global), Martindale (U

Conspiracy theories are popular during the COVID-19 pandemic. Conspiratorial thinking is characterised by the strong conviction that a certain situation that one sees as unjust is the result of a deliberate conspiracy of a group of people with bad intentions. Conspiratorial thinking appears to have many similarities with paranoid delusions.

To explore the nature, consequences, and social-psychological dimensions of conspiratorial thinking, and describe similarities and differences with paranoid delusions.

Critically assessing relevant literature about conspiratorial thinking and paranoid delusions.

Conspiratorial thinking meets epistemic, existential, and social needs. It provides clarity in uncertain times and connection with an in-group of like-minded people. Both conspiratorial thinking and paranoid delusions involve an unjust, persistent, and sometimes bizarre conviction. Unlike conspiracy theorists, people with a paranoid delusion are almost always the only target of the presumed conspiracy, and they usually stand alone in their conviction. Furthermore, conspiracy theories are not based as much on unusual experiences of their inner self, reality, or interpersonal contacts.

Conspirational thinking is common in uncertain circumstances. It gives grip, certainty, moral superiority and social support. Extreme conspirational thinking seems to fit current psychiatric definitions of paranoid delusions, but there are also important differences. To make a distinction with regard to conspiratorial thinking, deepening of conventional definitions of delusions is required. Instead of the strong focus on the erroneous content of delusions, more attention should be given to the underlying idiosyncratic, changed way of experiencing reality.

No significant relationships.

Depression and anxiety are very frequent and associated with high societal costs, much suffering and functional impairment. Employment is essential and pivotal recovery after sick-leave. In many countries, health care interventions are delivered separately from vocational rehabilitation services. This fragmented placement of interventions often implies lack of coordination, creating despair among sick-listed persons.

The aim of this trial was to investigate an integrated mental health care and vocational rehabilitation intervention to improve and hasten the return-to-work process among people sick-listed with anxiety or depression.

In this RCT, participants were randomly allocated to A) integrated interventions (INT), B) improved mental health care (MHC) or B) service as usual (SAU). Primary outcome was time to return-to-work during 12-month. Secondary outcomes were time to return-to-work at 6-month follow-up; levels of anxiety, depression, stress symptoms and social and occupational functioning at 6-month follow-up; and return-to-work measured as proportion in work at 12-month follow-up.

631 individuals randomized. INT showed higher proportion in work compared with both SAU and MHC at the 12-month follow-up. We found no differences regarding return-to-work time at either the 6- or 12-month follow-up. No differences in symptoms between SAU, MCH or INT were detected, but MHC and INT showed lower scores on Cohen’s perceived stress scale compared with SAU at 12-month follow-up.

Although INT did not hasten return-to-work, it yielded higher proportion in work compared with MHC and SAU.

No significant relationships.

Schizophrenia is a chronic disease that requires lifelong medical care and supervision. There is a high rate of relapse, mostly caused by poor adherence to oral antipsychotics. Long-acting injectable (LAI) antipsychotics have proved effective in schizophrenia and other severe psychotic disorders due to the stable blood levels, leading to a reduction of the risk of relapse. LAIs are associated with better functioning, quality of life, and patient satisfaction. In Treatment-resistant schizophrenia the combination of antipsychotics is a common practice. Nevertheless, the combination of two different long-acting injectable antipsychotics is not frequent.

A case of a 34-year-old man is presented, previously diagnosed of Schizophrenia, with highly disabling chronic positive symptoms. With no in-sight and no will in receiving treatment. Has been stable for a year while being in treatment with paliperidone 525mg LAI/ 10 weeks, and aripiprazole 400mg LAI/28 days.

The patient was closely observed and given oral paliperidone, after 5 days long-acting paliperidone was introduced. He was discharged with mild improvement of his psychiatric symptoms. While being in treatment with Paliperidone 525mg, he kept vivid delusions and hallucinations. The patient still refused to take any oral medications. Long-acting aripiprazole 300mg was added to the treatment.

He showed clinical improvement after a month. He has been stabilized for one year.

Treating resistant schizophrenia is among the most challenging clinical endeavors. A very helpful approach to improve adherence in schizophrenia is the use of long-acting injectable (LAI) antipsychotics. A major effort on scientific research of combination of LAI is needed.

No significant relationships.

Language and conversation are deeply interrelated: language is acquired, structured, practiced in social interactions and linguistic resources (specifically syntactic, prosodic and pragmatic aspects) contribute to finely tuning turn-taking. Nevertheless, most studies focused on verbal aspects of speech in schizophrenia, with scant attention to their relation to conversation, where language is experienced at most.

The present study was aimed at investigating a possible association between language impairment and conversational characteristics in a sample of clinically stable patients diagnosed with schizophrenia (N = 35, ages 18-65).

A spontaneous speech sample was recorded. For the assessment of language skills, the Scale for the Assessment of Thought, Language and Communication (TLC) and the Clinical Language Disorder Rating Scale (CLANG) were used, while conversational variables were extracted with an innovative method of semi-automatic analysis. The possible associations were investigated through the Pearson Correlation.

Figure 1 represents graphically the correlational matrix between conversational variables and linguistic scale scores. In the heatmap, blue means negative and red positive correlations, the stronger the colour, the larger the correlation magnitude. Moreover, the significant associations are indicated with stars.

The results suggest that in schizophrenia spectrum disorders the disturbances of language, at a syntactic, prosodic and pragmatic level, have significant impact on communicative interaction.

Thus, conversation analysis might be a promising method to quantify objectively communicative impairment with the benefit of representing an ecological assessment, examining the performance of patients in the real situation of language use, which is social interaction.

No significant relationships.

The spectrum of suicidal behavior is a core factor of the prognosis and care of Borderline Personality Disorder (BPD).

Identify possible BPD specific personality traits that could act as protective factors of nonsuicidal self-injuries (NSSI).

We performed a cross-sectional, observational and retrospective study of a sample of 134 BPD patients aged from 18 to 56. We assessed the presence or absence of suicidal behavior and NSSI as well as different sociodemographic variables. Millon, Zuckerman-Kuhlman and Structured Clinical Interview for DSM personality questionnaires were also applied. The analysis of the association between variables was carried out with a multivariate negative binomial logistic regression model.

A statistically significant association between NSSI and suicidal behavior was found. Elseways, statistically significant differences were also found in the association between NSSI and the SCID variables for Narcissistic Disorder, which appears as protective variables. These results provide an idea of the dynamic relationship between NSSI and suicidal behavior in a BPD population with particularly severe characteristics.

The role of narcissistic personality traits appears to be important in identifying protective factors for NSSI and suicidal behavior in BPD patients and could be the subject of further research projects.

No significant relationships.

The use of Electroconvulsive therapy (ECT) during pregnancy and in the post-partum period is a critical decision for both providers and their patients. ECT utilization during this critical period needs to be better understood to assess the need and allocate resources for this valuable treatment option.

1) To evaluates baseline characteristics and analyze ECT utilization trends for pregnant and post-partum patients hospitalized in the US. 2) To provide insight into ECT use among inpatient pregnant women with different age groups with various comorbid psychiatric disorders.

The study used the 2002-2015 National (Nationwide) Inpatient Sample (NIS) data. Descriptive statistical and trend analyses were conducted to evaluate data.

A study found that a total of 924 pregnancy-related hospitalizations required ECT treatment; 92.2% of these ECTs were conducted in urban hospitals. The mean age of women was 30.3 years, and the majority (71%) were of the White race. Mood disorders (major depressive disorder- 51.9% and bipolar disorder- 37.9%) accounted for the most common comorbid psychiatric illnesses. The payer source (Medicare/Medicaid vs. Private Insurance) was almost equal (47.9 vs. 46.8). Though not statistically significant, the trend analysis showed that the proportion of ECTs during pregnancy out of the total ECT performed for the year almost doubled (0.24% to 0.47%) from 2008 to 2015.

Though not statistically significant, the use of ECT in pregnant women has increased in 2015 compared to 2002. Results will help clinicians, policymakers, and various stakeholders to optimize ECT utilization, reimbursement and ultimately improve clinical outcomes.

No significant relationships.

Impairment in decision-making capacity is a serious consequence of executive dysfunction secondary to serious mental disorders like schizophrenia. Functional mental capacity (FMC) refers to an individual’s ability to make and communicate legally competent decisions autonomously. Studies have shown that FMC is dependent on severity of psychosis and can improve with treatment.

To ascertain the correlation between the scores on a structured judgement tool, namely the Dundrum Capacity Ladders (DCL) with level of acuity of treatment setting and length of stay in a secure forensic hospital.

Sixty-two patients were interviewed using the DCL across three domains – healthcare, welfare and finances. Correlation between DCL scores, length of hospital stay and level of acuity of treatment setting was assessed.

As patients moved from higher to lower dependency wards, mean DCL score increased, indicating a higher level of capacity. Patients in high dependency wards were most impaired while those in the low dependency wards performed significantly better (rs=0.472, p<0.001). The longer the patients stayed in the hospital, up until five years, the higher the mean welfare domain score (rs=0.402, p=0.011) and mean DCL score (rs=0.376, p=0.018). Beyond five years of hospital stay, those who had lower DCL scores and did not improve had longer length of stay.

Patients’ FMC improve as they progress from high to low level of acuity of treatment setting. However, this is dependent on the length of hospital stay. FMC may be a measure of recovery in the forensic setting.

No significant relationships.

The WHO would increase diagnosis and treatment of viral hepatitis in the world by 2030, based on the high efficacy of direct-acting-antivirals against HCV, extended vaccination programs in HBC, and epidemiological data. Diagnostic of HCV/HBV infection has been simplified by point-of-care (POC) devices (cheap/easy-to-use/interprete/qick-results), detecting anti-HCV-antibodies or HBV-antigen in capillary blood at the patients´site. The current seroprevalence of viral hepatitis B/C in general population in Spain is 0.5%/1% and would be higher (3-17%) in people with severe-mental-disorder due to risk factors and traditionally less access to health care.

To design a screening protocol for HCV eradication and HBV-detection, and risk factors among severe-mental-disorder patients in a CommunityMentalHealthCenter. To guarantee equal access to viral hepatitis screening and therapy among this population.

Outpatients visited along one-year who accepts participate. Using POC-device for qualitative detection of anti-HCV-antibodies (Quickview-of-Lumiquick-Diagnostics®)/HBsAG (Abbott-Rapid-Diagnostics®). Socio-demographic data; mental disorder(ICD-10); HCV/HBV risk-factors; Neurotoxicity-scale (mood/cognition/sleep/gastrointestinal/sickness/motor); SF-12; Patient-satisfaction. Subjects with positive HCV/HBV POC-test will have a on-site venopuncture to assess hemograme/liver tests, and HCV-RNA (Cobas-TaqMan-RocheDiagnostics)/HBsAg-ELISA (Atellica-Siemens). In positive HCV-RNA (active infection) the psychiatric-team will inform the hepatology-team for non-invasive liver fibrosis assessment and DAA prescription. The patient will receive 8-12-weeks on-site treatment, and assessed (Neurotoxicity/SF-12).HCV cure will be confirmed by HCV-RNA in blood. Chronic-cases will be managed at Hepatology-Unit.

We will present the results of the implementation of the programme and their ability to detect viral-hepatitis-positive cases among patients with severe-mental-disorders and to treat them effectively.

Our results may support the generalisation of the programme in among CMHC’s.

No significant relationships.

Managing healthcare data is a major challenge for today’s medicine. The use of artificial intelligence and big data tools has allowed solving questions related to this topic. However, the wide heterogeneity in the psychiatric consultation record makes the retrospective analysis of these data limited due to a lack of information or differences between specialists.

We aim to develop a platform that allows the structured record of medical care data (based on dementia) while maintaining flexibility and format for its usefulness during clinical practice in psychiatry.

We developed a web-based platform for the structured and semi-structured record of psychiatric evaluation. The instrument is diagnosed-oriented (for our version we used dementia). We used Core outcome sets and expert opinion to identify the relevant outcomes for the attention.

A web-based platform is presented for the care of people with suspected dementia at different levels of care designed with the potential to record information of interest in research but also of clinical utility for closer follow-up.

This strategy allows developing the proposal towards other pathologies of interest. Also, with the integration of recommendation algorithms, a monitoring and recommendation system could be achieved to promote knowledge of psychiatric illness from routine practice. This proposal intends to have an impact by increasing the quality of care, reducing care times, and providing better approaches from primary care systems.

No significant relationships.

Identifying the factors that mediate treatment response to rTMS in MDD patients can guide clinicians to administer more appropriate, reliable, and personalized interventions.

The present study aimed to investigate sex differences in response to repetitive transcranial magnetic stimulation (rTMS) in Major Depressive Disorder (MDD) patients.

In this paper, we developed a novel pipeline based on convolutional LSTM-based deep learning (DL) to classify 25 female and 25 male subjects based on their rTMS treatment response.

Five different classification models were generated, namely pre/post-rTMS female (model 1), pre/post-rTMS male (model 2), pre-rTMS female responder vs. pre-rTMS female non-responders (model 3), pre-rTMS male responder vs. pre-rTMS male non-responder (model 4), and pre-rTMS responder vs. non-responder of both sexes (model 5), achieving 93.3%, 98%, 95.2%, 99.2%, and 96.6% overall test accuracy, respectively.

These results indicate the potential of our approach to be used as a response predictor especially regarding sex-specific antidepressant effects of rTMS in MDD patients.

No significant relationships.

Age at onset of type-I bipolar disorder (BD-I) typically averages 12-24 years, is older among patients with type-II-BD (BD-II), even though generally before 50-years-old (EOBD). Clinical observation of late-onset BD (LOBD) posed some questions regarding a differential phenotypic/psychopathological manifestations and affective temperaments between LOBD vs EOBD.

A case-control pilot-study was carried out to investigate psychopathological, clinical and temperamental features of a psychogeriatric cohort of LOBD and EOBD subjects.

Out of 74 enrolled patients, 64 patients (31 EOBD, 33 LOBD) were included and administered an ad hoc socio-demographic datasheet, BPRS, CGI, GAF, HAM-D, GDS, MSRS, MRS, MOCA and TEMPS-M.

LOBD is significantly associated with higher rates of BD-II diagnosis (X2 = 26.1, p<.001), depressive (p=0.05) and mixed states (p=0.011), higher comorbid anxiety levels and depressive affective temperament (p<.001); while clinical manifestations of geriatric EOBD is significantly associated with higher endocrinological (X2 = 7.815, p=.005) and metabolic comorbidity (X2 = 6.896, p=.009), a diagnosis of BD-I, manic episodes and hyperthymic (p=.001) affective temperaments. GDS and MSRS total scores were significantly higher in LOBD (respectively, p<.001 and p=.008).

Further studies with larger sample sizes and a control group should verify whether LOBD is a distinct psychopathological entity from EOBD and evaluate differences (if any) in terms of prognosis and treatment between EOBD and LOBD.

No significant relationships.

In schizophrenia research, little is known about the relationship of environmental exposures with social cognition deficits.

We aimed to investigate the relationship between social cognitive performance and well-defined environmental risk factors (childhood adversities, birth season, paternal age, obstetric complications, urban living i.e.) in schizophrenia.

54 schizophrenia patients and 37 healthy controls (HCs) were included in our study. Participants in both groups were of similar age, gender, and educational level. Two theory of mind (ToM) tests (DEZIKÖ and RMET), and the Childhood Trauma Questionnaire (CTQ) were applied. ToM test scores among groups (patients with/ without risk factors, and HC) were compared using analysis of variance.

Overall, the schizophrenia group scored higher on the CTQ and performed worse on ToM tests than the HCs. Patients were more likely to report obstetric complications, advanced paternal age, winter and rural birth. Both the patients having high and low CTQ scores performed poorer on the RMET and false belief test than HCs. However, there was no significant difference in DEZİKÖ-total scores of patients with low CTQ scores and HCs. Patients with advanced paternal age at birth achieved lower faux pas sub-scores. Urban birth and RMET scores were positively correlated in patients.

Our findings suggest the environmental factors such as childhood traumas, advanced paternal age, and rural birth seem to negatively affect the social cognitive performance of schizophrenia patients.

No significant relationships.

While psychotherapy is an essential aspect of the treatment of depression, there are few studies focusing on the effectiveness of psychoanalytic and psychodynamic group therapies for depressed patients.

In this presentation, we will study the effects of a brief, 4-session psychodynamic intervention (BPI) led by a group of therapists, as inspired by the Lausanne model.

The patients were recruited in a therapeutic setting. A free consent form was completed and the ethics of research explained to each participant. Our sample consisted of 32 patients (average age = 43.81 years, sex ratio: 1M/ 4F). The therapists gathered data by completing several assessment scales after each therapy session: MADRS, ESM, EFP, HAQ-IT, EDICODE, Counter-Transfer Scale. The SPPS software (V21) was used to analyze the data.

The patients’ mean MADRS score dropped by more than 11 after the four sessions. This improvement matches a more positive and committed self-reported counter-transference of the therapists towards the patients. As their insight increases, patients show greater behavioral and psychic activity. We name this exit of the depressive inhibition the “unfreezing” process. It enables more satisfactory human interactions and a more focused and structured self-narrative.

BPI led by a group of therapists seem to be an effective therapeutic adjuvant in the “unfreezing” of the psychic processes in depressive patients. Our results point out the importance of jointly aiming at symptomatic improvement and therapeutic alliance.

No significant relationships.