Functional remediation in bipolar disorder: 1-year follow-up of neurocognitive and functional outcome

BACKGROUND

Few randomised clinical trials have examined the efficacy of an intervention aimed at improving psychosocial functioning in bipolar disorder.

AIMS

To examine changes in psychosocial functioning in a group that has been enrolled in a functional remediation programme 1 year after baseline.

METHOD

This was a multicentre, randomised, rater-masked clinical trial comparing three patient groups: functional remediation, psychoeducation and treatment as usual over 1-year follow-up. The primary outcome was change in psychosocial functioning measured by means of the Functioning Assessment Short Test (FAST). Group×time effects for overall psychosocial functioning were examined using repeated-measures ANOVA (trial registration NCT01370668).

RESULTS

There was a significant group×time interaction for overall psychosocial functioning, favouring patients in the functional remediation group (F = 3.071, d.f. = 2, P = 0.049).

CONCLUSIONS

Improvement in psychosocial functioning is maintained after 1-year follow-up in patients with bipolar disorder receiving functional remediation.

Effects of functional remediation on neurocognitively impaired bipolar patients: enhancement of verbal memory

BACKGROUND

Functional remediation is a novel intervention with demonstrated efficacy at improving functional outcome in euthymic bipolar patients. However, in a previous trial no significant changes in neurocognitive measures were detected. The objective of the present analysis was to test the efficacy of this therapy in the enhancement of neuropsychological functions in a subgroup of neurocognitively impaired bipolar patients.

METHOD

A total of 188 out of 239 DSM-IV euthymic bipolar patients performing below two standard deviations from the mean of normative data in any neurocognitive test were included in this subanalysis. Repeated-measures analyses of variance were conducted to assess the impact of the treatment arms [functional remediation, psychoeducation, or treatment as usual (TAU)] on participants' neurocognitive and functional outcomes in the subgroup of neurocognitively impaired patients.

RESULTS

Patients receiving functional remediation (n = 56) showed an improvement on delayed free recall when compared with the TAU (n = 63) and psychoeducation (n = 69) groups as shown by the group × time interaction at 6-month follow-up [F 2,158 = 3.37, degrees of freedom (df) = 2, p = 0.037]. However, Tukey post-hoc analyses revealed that functional remediation was only superior when compared with TAU (p = 0.04), but not with psychoeducation (p = 0.10). Finally, the patients in the functional remediation group also benefited from the treatment in terms of functional outcome (F 2,158 = 4.26, df = 2, p = 0.016).

CONCLUSIONS

Functional remediation is effective at improving verbal memory and psychosocial functioning in a sample of neurocognitively impaired bipolar patients at 6-month follow-up. Neurocognitive enhancement may be one of the active ingredients of this novel intervention, and, specifically, verbal memory appears to be the most sensitive function that improves with functional remediation.

The neurobiology of autism spectrum disorders

Data is progressively and robustly accumulating regarding the biological basis of autism. Autism spectrum disorders (ASD) are currently considered a group of neurodevelopmental disorders with onset very early in life and a complex, heterogeneous, multifactorial aetiology. A comprehensive search of the last five years of the Medline database was conducted in order to summarize recent evidence on the neurobiological bases of autism. The main findings on genetic influence, neuropathology, neurostructure and brain networks are summarized. In addition, findings from peripheral samples of subjects with autism and animal models, which show immune, oxidative, mitochondrial dysregulations, are reported. Then, other biomarkers from very different systems associated with autism are reported. Finally, an attempt is made to try and integrate the available evidence, which points to a oligogenetic, multifactorial aetiology that converges in an aberrant micro-organization of the cortex, with abnormal functioning of the synapses and abnormalities in very general physiological pathways (such as inflammatory, immune and redox systems).

Evidence for the early clinical relevance of hallucinatory-delusional states in the general population

OBJECTIVE

To analyze, in a general population sample, clustering of delusional and hallucinatory experiences in relation to environmental exposures and clinical parameters.

METHOD

General population-based household surveys of randomly selected adults between 18 and 65 years of age were carried out.

SETTING

52 countries participating in the World Health Organization's World Health Survey were included.

PARTICIPANTS

225 842 subjects (55.6% women), from nationally representative samples, with an individual response rate of 98.5% within households participated.

RESULTS

Compared with isolated delusions and hallucinations, co-occurrence of the two phenomena was associated with poorer outcome including worse general health and functioning status (OR = 0.93; 95% CI: 0.92-0.93), greater severity of symptoms (OR = 2.5 95% CI: 2.0-3.0), higher probability of lifetime diagnosis of psychotic disorder (OR = 12.9; 95% CI: 11.5-14.4), lifetime treatment for psychotic disorder (OR = 19.7; 95% CI: 17.3-22.5), and depression during the last 12 months (OR = 11.6; 95% CI: 10.9-12.4). Co-occurrence was also associated with adversity and hearing problems (OR = 2.0; 95% CI: 1.8-2.3).

CONCLUSION

The results suggest that the co-occurrence of hallucinations and delusions in populations is not random but instead can be seen, compared with either phenomenon in isolation, as the result of more etiologic loading leading to a more severe clinical state.

Neuropsychological evidence for abnormal neurodevelopment associated with early-onset psychoses

BACKGROUND

The longitudinal neuropsychological study of first-episode early-onset psychosis (EOP) patients, whose brain maturation is still in progress at the time of illness onset, provides a unique opportunity to compare their cognitive development with that of healthy subjects, in search of specific patterns resulting from the interaction between neurodevelopmental processes and the presence of psychotic disorders. Method Seventy-five first-episode EOP patients (schizophrenia n = 35; bipolar disorder n = 17; other forms of psychosis n = 23) with a mean age of 15.53 years were assessed with a neuropsychological battery that included measures of attention, working memory, memory and executive functions within 6 months following the onset of the first psychotic symptom (baseline) and 2 years later. Psychotic symptoms were assessed at both times with the Positive and Negative Symptom Scale (PANSS). Seventy-nine healthy subjects matched for age and education served as controls.

RESULTS

EOP patients showed significant cognitive impairment at both baseline and the 2-year follow-up, with no significant differences between diagnostic groups at either time. Both healthy controls and EOP patients improved in all cognitive measures, except for patient working memory. Improvement in patient attention lost significance after controlling for psychotic symptom reduction. No significant time/diagnosis interaction was found among patients (p > 0.405).

CONCLUSIONS

Cognitive impairment in EOP is already present at the first episode, and cognitive development seems to be arrested early in EOP patients compared to their healthy peers, at least for some cognitive functions. These and previous similar results support the neurodevelopmental hypothesis of psychosis.

Psychometric properties of the Spanish version of the diagnostic interview for depressive personality

The aim of this study was to evaluate the reliability and validity of the Spanish-language version of the diagnostic interview for depressive personality (DIDP). The DIDP was administered to 328 consecutive outpatients and the test-retest and inter-rater reliability were assessed. Factor analysis was used in search of factors capable of explaining the scale and a cutoff point was established. The DIDP scales showed adequate Cronbach's α values and acceptable test-retest and inter-rater reliability coefficients. Convergent and discriminant validity were explored, the latter with respect to avoidant and borderline personality disorders. The results of the factor analysis were consistent with the four-factor structure of the DIDP scales. The receiver operating characteristic (ROC) analysis revealed the area under the curve to be 0.848. We found 30 to be a good cutoff point, with a sensitivity of 74.5% and a specificity of 78.5%. The DIDP proved to be a reliable and valid instrument for assessing depressive personality disorder, at least among our outpatients. The psychometric properties of the DIDP support its clinical usefulness in assessing depressive personality.

Longitudinal study of neurological soft signs in first-episode early-onset psychosis

BACKGROUND

In recent decades, the assessment of neurological soft signs (NSS) in patients with psychosis has become a subject of special interest. The study of the progression of NSS during adolescence will provide valuable information about the role of NSS as endophenotypes or biomarkers and about brain development at a stage in which brain maturation has not yet been completed.

METHODS

Neurological soft signs were assessed in a sample of 110 first episodes of early-onset psychosis (EOP) and 98 healthy children and adolescents at two different times in a 2-year follow-up period.

RESULTS

Patients with EOP showed more NSS than controls both at baseline (p < .001) and the 2-year follow-up (p < .001). No differences were found in the number of signs among the different diagnostic subgroups (schizophrenia, bipolar disorder, and other psychoses). When we examined the changes in NSS over the follow-up, the reduction of NSS in the patients was greater than the controls for 'Motor coordination' (p = .032), 'Others' (p < .001), and 'Total score' (p < .001) of the NES.

CONCLUSION

Despite the greater reduction of NSS in patients than in controls along the follow-up, patients still have more neurological signs than healthy controls; therefore, these signs may be considered a trait marker. NSS do not seem to be specific to schizophrenia as they are present in different EOPs.

Neurobiological susbtrates in deficit and non deficit schizophrenia

The deficit syndrome defines a subgroup of schizophrenia patients with prominent and enduring primary negative symptoms (1). Behavioral, structural, and functional neuroimaging studies have implicated mainly the dorsolateral prefrontal - thalamocortical circuit. Deficit syndrome patients seem to have larger ventricles in MRI studies (2). Neurological soft signs suggest parietal involvement with greater sensory integration impairment in deficit syndrome patients (3). On the contrary, some biological markers such as P50 gating have not shown any difference between deficit and non-deficit schizophrenia (4). Finally, no pharmacological treatment has so far proven effective for the treatment of primary enduring negative symptoms (5). In conclusion, deficit pathology in schizophrenia seems to involve the prefrontal and parietal lobes and have different neurobiological substrates than positive symptoms.

Insight correlates in child- and adolescent-onset first episodes of psychosis: results from the CAFEPS study

BACKGROUND

The correlates of insight in early-onset psychosis have received little previous attention.

METHOD

We studied clinical correlates of insight in a sample of 110 adolescent recent-onset psychosis patients (mean age 15.53 years; psychotic symptoms present for <6 months). Insight was measured with the Scale to Assess Unawareness of Mental Disorder (SUMD) at baseline, 6 months and 12 months follow-up.

RESULTS

Insight improved over the early phases of the illness, in parallel with psychopathological improvement. Poor insight at baseline and 6 months correlated with poor functioning at 6 and 12 months respectively. Schizophrenia patients had poorer insight than patients with bipolar disorder at 6 and 12 months but not at baseline. Logistic and linear regressions were used to predict 12-month diagnoses and functioning based on insight measurements. Baseline awareness of illness was a significant predictor for diagnosis [odds ratio (OR) 1.4, 95% confidence interval (CI) 1.05-1.97]. Treatment compliance at 6 months did not correlate with baseline SUMD subscores, but correlated with insight into having a disorder (Spearman's rho=0.21, p=0.039), its consequences (Spearman's rho=0.28, p=0.006) and the need for treatment (Spearman's rho=0.26, p=0.012) at 6 months. The 'attribution of symptoms' dimension of insight is poorly correlated with other insight dimensions and with other clinical variables.

CONCLUSIONS

Poor insight correlates with symptom severity and global functioning but also has some trait value for schizophrenia, which is apparent once acute psychotic symptomatology is not prominent. A multi-dimensional approach to the assessment of insight is necessary, as different dimensions are influenced by different factors.

Violence among schizophrenia out-patients compliant with medication: prevalence and associated factors

OBJECTIVE

Aggressive behaviour has been related to schizophrenia both in in-patient and out-patient samples. In this study, we aimed to assess the prevalence and factors associated with aggressive behaviour in out-patient compliant with their prescribed medication.

METHOD

Eight hundred and ninety-five patients were interviewed at Community-Based Mental Health Services about aggressive-violent behaviour within the week prior to the study visit. Adult patients diagnosed with schizophrenia and receiving stable pharmacological treatment were enrolled. Presence of aggressive episodes, including type of aggression, severity and frequency, was assessed with the Modified Overt Aggression Scale (MOAS). Violence was defined as a score of 3 or more in any of the MOAS subscores.

RESULTS

Prevalence of recent aggressive behaviour was 5.07%, (95% CI 5.04-5.10), where 47% (43 behaviours 91) reached the violent threshold. Among the 91 violent episodes rated, most episodes were verbal (44%), followed by physical violence towards objects (29%), violence towards others (19%) and self-directed violence (8%). Recent episodes of any severity were more likely among patients with a history of violence and also with relapses within the previous year and with low treatment satisfaction.

CONCLUSION

Five per cent of the studied cases showed aggressive behaviour in the week prior to assessment, despite having been compliant with their medication. Most aggressive behaviour was verbal rather than physical.

Association between heroin dependence and 5-HT2A receptor gene polymorphisms

OBJECTIVE

To investigate the association between four polymorphisms of the 5-HT(2A) receptor and 5-HT transporter genes and heroin dependence.

METHODS

113 heroin- dependent patients (DSM-IV criteria) and 420 unrelated healthy controls from Asturias (Northern Spain) were genotyped using standard methods.

RESULTS

There was an apparent difference in the distribution of genotypes for A-1438G polymorphisms (p = 0.024, not significant after Bonferroni correction). The 5-HT(2A) -1438A allele was significantly more common in patients than controls [0.55 and 0.45, respectively; corrected p = 0.042, OR = 1.51 (95% CI = 1.13-2.03)]. An interaction was observed between A-1438G of 5-HT(2A) and 5-HTT polymorphisms. The association between the -1438AA vs. AG/GG genotypes and heroin dependence was enhanced in the presence of 12-repeat 5-HTT VNTR and short 5-HTTLPR alleles [24.8% in heroin-dependent patients vs. 12.6% in controls; corrected p = 0.045, OR = 2.28 (95% CI = 1.36-3.82)].

CONCLUSIONS

Our findings support a contribution of the 5-HT(2A) gene to susceptibility to heroin dependence, as well as a possible synergistic effect of 5-HT(2A) and 5-HTT genes on susceptibility to heroin dependence.

A 6-month prospective, observational, naturalistic, uncontrolled study to evaluate the effectiveness and tolerability of oral ziprasidone in patients with schizophrenia

This multicenter, uncontrolled, naturalistic study evaluated the effectiveness and tolerability of 6 months of treatment with ziprasidone in 1266 patients with a diagnosis of schizophrenia. The percentage of responders (at least 30% reduction in PANSS total score) in the primary analysis sample (n=1022) was 47.3% (95% CI 44.2-50.4) at the end of the study. Patients showed a significant and clinically relevant reduction in the PANSS total, positive, negative and general psychopathology subscales scores (effect size of 1.60, 1.83, 0.62 and 1.40 respectively). Overall, 453 (35.8%) patients withdrew from the study; 9.3% withdrew owing to adverse events. Ziprasidone doses greater than 120 mg/day were associated with a lower risk of discontinuation for any cause (OR 0.46, 95% CI 0.33-0.65) Ziprasidone was well tolerated. Most common side effects were: insomnia, somnolence and nervousness. The effectiveness and tolerability of ziprasidone in clinical practice are consistent to those previously shown in the more restricted and homogeneous populations of clinical trials.

Antidepressants in child and adolescent depression: where are the bugs?

OBJECTIVE

To examine the data on the effect of antidepressant medication in depressed children and adolescents and the causes of the results obtained.

METHOD

A systematic literature search was conducted, supplemented by a manual search, and a search of public online information on paediatric antidepressant trials reviewed by regulatory agencies.

RESULTS

Data gathered from published and unpublished randomized controlled trials vary in their findings, with most of the studies showing a lack of efficacy characterized by a high placebo response rate.

CONCLUSION

Differences from efficacy results with the same drugs in adult depression may be because of neurobiological developmental correlates, developmental differences in pharmacokinetics and pharmacodynamics, high rates of placebo response in children, and a number of methodological influences. There are several areas needing more attention in paediatric antidepressant clinical trials. Judicious use of published and unpublished studies to assess who may benefit from treatment with antidepressants seems warranted.