[Anti-NMDA-receptor encephalitis: a new axis-III disorder in the differential diagnosis of childhood disintegrative disorder, early onset schizophrenia and late onset autism]

Childhood disintegrative disorder (CDD), early onset schizophrenia (EOS), and late onset autism (LOA) often follow a similar course: initially, development is normal, then there is a sudden neuropsychiatric deterioration of social interaction and communication skills, which is combined with a decline in intelligence and reduction in daily activities. A 9-year-old boy was admitted to the paediatric ward with acute onset of secondary epileptic seizures. It was not long until the boy's symptoms resembled that of patients with cdd, eos and loa. Intensive tests led to the diagnosis of anti-NMDA-receptor encephalitis. Anti-NMDA-receptor encephalitis should be regarded as a possible organic cause underlying the syndromal presentation of CDD, EOS and LOA.

[Psychotic disorders: the need for staging]

BACKGROUND

In psychotic disorders it is the stage of development of the disease which mainly determines the prognosis and the effectiveness of treatment.

AIM

To describe and to refine the current staging and profiling of psychotic disorders and to propose a way in which to describe the course of dimensions of psychoses.

METHOD

We searched the literature for articles relating to the staging of psychotic disorders.

RESULTS

McGorry e.a. developed a simple classification into stages which is currently applicable to research and clinical practice. We propose a further refinement in the form of a graph from which one can see in a glance the history of clinically relevant variation.

CONCLUSION

Research into the prodromal stages of diseases is needed in order to elucidate the pathophysiological mechanisms that the stages have in common and to reveal the pathways of differential development.

The relationship between coping and subclinical psychotic experiences in adolescents from the general population--a longitudinal study

BACKGROUND

Subclinical psychotic experiences during adolescence may represent liability for developing psychotic disorder. Both coping style and the degree of persistence of psychotic experiences may play a role in the progression to clinical psychotic disorder, but little is known about the causal relationship between the two.

METHOD

Path modelling was used to examine longitudinal relationships between subclinical positive psychotic experiences and three styles of coping (task-, emotion- and avoidance-oriented) in an adolescent general population sample (n=813) assessed three times in 3 years. Distinct developmental trajectories of psychotic experiences, identified with growth mixture modelling, were compared on the use of these coping styles.

RESULTS

Over time, emotion-oriented coping in general was bi-directionally related to psychotic experiences. No meaningful results were found for task- or avoidance-oriented coping. Females reported using a wider range of coping styles than males, but the paths between coping and psychotic experiences did not differ by gender. Persistence of psychotic experiences was associated with a greater use of emotion-oriented coping, whereas a decrease in experiences over time was associated with an increased use of task-orientated coping.

CONCLUSIONS

Emotion-oriented coping is the most important coping style in relation to psychotic experiences, as it may contribute to a 'vicious cycle' and is associated with persistence of experiences. In addition, more task-oriented coping may result in a decrease in psychotic experiences. Results suggest that opportunities for intervention may already be present at the level of subclinical psychosis.

Evidence for a persistent, environment-dependent and deteriorating subtype of subclinical psychotic experiences: a 6-year longitudinal general population study

BACKGROUND

Research suggests that subclinical psychotic experiences during adolescence represent the behavioral expression of liability for psychosis. Little is known, however, about the longitudinal trajectory of liability in general population samples.

METHOD

Growth mixture modeling was used to examine longitudinal trajectories of self-reported positive psychotic experiences in the Youth Self Report (YSR), completed three times over a period of 6 years by a general population cohort of adolescents aged 10-11 years at baseline (n=2230).

RESULTS

Four groups with distinct developmental trajectories of low, decreasing, increasing and persistent levels of mild positive psychotic experiences were revealed. The persistent trajectory was associated strongly with cannabis use, childhood trauma, developmental problems and ethnic minority status, and consistently displayed strong associations with factors known to predict transition from subclinical psychotic experience to clinical psychotic disorder (severity of and secondary distress due to psychotic experiences, social and attentional problems and affective dysregulation) and also with high levels of parental-reported psychotic experiences and use of mental health care at the end of the follow-up period. Progressively weaker associations were found for the increasing, decreasing and low trajectories respectively.

CONCLUSIONS

The results suggest that the outcome of early developmental deviation associated with later expression of psychotic experiences is contingent on the degree of later interaction with environmental risks inducing, first, persistence of psychotic experiences and, second, progression to onset of need for care and service use. Insight into the longitudinal dynamics of risk states in representative samples may contribute to the development of targeted early intervention in psychosis.

Daily cortisol, stress reactivity and psychotic experiences in individuals at above average genetic risk for psychosis

BACKGROUND

Hypothalamic-pituitary-adrenocortical (HPA) axis abnormalities have been found in patients with a psychotic disorder and first-degree relatives of patients with a psychotic disorder react with subtle increases in non-clinical psychotic experiences and negative emotions in the face of everyday stress. The current study investigated whether HPA axis functioning is altered in individuals at above average genetic risk for psychotic disorder, examining diurnal cortisol profiles, cortisol reactivity to daily stressors and the association between HPA axis activity and subclinical psychotic experiences.

METHOD

Participants included siblings of patients with a psychotic disorder (n=60) and a healthy comparison group (n=63). The Experience Sampling Method (a structured diary technique) was employed to assess stress, psychotic experiences, negative affect and salivary cortisol repeatedly in the flow of daily life.

RESULTS

Multi-level analyses revealed higher diurnal cortisol levels and heightened cortisol reactivity to negative daily events in siblings compared with controls. Diurnal cortisol slope did not differ between the two groups, but momentary increases in psychotic experiences and negative affect were associated with increased cortisol in the sibling group.

CONCLUSIONS

Findings support altered HPA axis activity in individuals at above average genetic risk for psychotic disorder, as evidenced by higher diurnal cortisol levels and increased cortisol reactivity to daily stress. Results also suggest a dynamic association between cortisol secretion and the intensity of psychotic-like experiences and negative emotions in daily life, although the direction of this association remains to be elucidated.

Momentary assessment technology as a tool to help patients with depression help themselves

OBJECTIVE

Given high relapse rates and residual symptoms in depression, new strategies to increase treatment effectiveness are required. A promising avenue is to investigate how electronic momentary assessment technology may contribute to clinical assessment and interventions in depression.

METHOD

A literature search was conducted focusing on the potential contribution of momentary assessments to clinical applications in depression.

RESULTS

Momentary assessments are able to reveal subtle, small but repetitive and relevant patterns of emotional expression that predict future course of depression. A momentary assessment tool may expose manageable pieces of daily life behaviour contributing to the depressive experience that patients can influence. The use of this explicit knowledge of daily life experience is understudied with regard to its contribution to diagnostic assessment, monitoring of treatment effects and feedback interventions in depressed patients. The clinical application of momentary assessments may stimulate a shift from passive consumption of treatment to an active role for patients in their recovery and increased patient ownership.

CONCLUSION

The precise, prospective and fine-grained information that momentary assessment technology provides may contribute to clinical practice in various ways. Future studies should examine the clinical impact of its use and the feasibility of its implementation in mental health care.

Do cannabis and urbanicity co-participate in causing psychosis? Evidence from a 10-year follow-up cohort study

BACKGROUND

Cannabis use is considered a component cause of psychotic illness, interacting with genetic and other environmental risk factors. Little is known, however, about these putative interactions. The present study investigated whether an urban environment plays a role in moderating the effects of adolescent cannabis use on psychosis risk.

METHOD

Prospective data (n=1923, aged 14-24 years at baseline) from the longitudinal population-based German Early Developmental Stages of Psychopathology cohort study were analysed. Urbanicity was assessed at baseline and defined as living in the city of Munich (1562 persons per km2; 4061 individuals per square mile) or in the rural surroundings (213 persons per km2; 553 individuals per square mile). Cannabis use and psychotic symptoms were assessed three times over a 10-year follow-up period using the Munich version of the Composite International Diagnostic Interview.

RESULTS

Analyses revealed a significant interaction between cannabis and urbanicity [10.9% adjusted difference in risk, 95% confidence interval (CI) 3.2-18.6, p=0.005]. The effect of cannabis use on follow-up incident psychotic symptoms was much stronger in individuals who grew up in an urban environment (adjusted risk difference 6.8%, 95% CI 1.0-12.5, p=0.021) compared with individuals from rural surroundings (adjusted risk difference -4.1%, 95% CI -9.8 to 1.6, p=0.159). The statistical interaction was compatible with substantial underlying biological synergism.

CONCLUSIONS

Exposure to environmental influences associated with urban upbringing may increase vulnerability to the psychotomimetic effects of cannabis use later in life.

Psychotic exacerbation and emotional dampening in the daily life of patients with schizophrenia switched to aripiprazole therapy: a collection of standardized case reports

BACKGROUND

Blockade of the dopamine D2 receptor is a key mechanism in the antipsychotic treatment of patients with a psychotic disorder, but may also induce emotional deficits. The partial D2 agonistic profile of aripiprazole has, therefore, been suggested to favor emotional wellbeing compared with the pure dopamine antagonistic properties of traditional antipsychotics.

METHOD

The current study used the experience sampling method (a structured diary technique) to assess the effects of switching from treatment with traditional dopamine antagonist antipsychotics to treatment with the partial dopamine agonist aripiprazole on emotional wellbeing in the daily life of 13 patients with a diagnosis of schizophrenia.

RESULTS

More than half of all patients experienced exacerbation of psychotic symptoms after they had switched to the aripiprazole medication regime, consequently resulting in dropout of the study. Furthermore, switching to aripiprazole treatment, when effective in terms of symptom reduction, was accompanied by decreased feelings of both positive and negative affect in daily life, suggestive of a general state of emotional dampening.

CONCLUSIONS

Although the scale of the current study and the 54% dropout rate call for careful interpretation of the data, implementation of ecological monitoring in psychopharmacological research may open up new avenues for untangling the working mechanisms of compounds with regard to their impact on mental states.

The size and burden of mental disorders and other disorders of the brain in Europe 2010

AIMS

To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU.

METHOD

Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY).

RESULTS

Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165m vs. 2005: 82m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (>4%), ADHD (5%) in the young, and dementia (1-30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment. Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke.

CONCLUSION

In every year over a third of the total EU population suffers from mental disorders. The true size of "disorders of the brain" including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past. Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for disorders of the brain as the core health challenge of the 21st century.

Better theory-of-mind skills in children hearing voices mitigate the risk of secondary delusion formation

OBJECTIVE

To examine the social cognitive vulnerabilities mediating delusion formation in children presenting with hallucinatory experiences.

METHOD

A sample of 259 12- and 13-year-old children, from a baseline case-control sample of children with and without auditory hallucinations (AH), were re-assessed after 5 years for presence of AH. Presence of delusions and theory of mind (ToM) were also assessed, to examine the hypothesized moderating role of ToM in delusion formation in children hearing voices.

RESULTS

In children with AH at age 7-8 and/or 12-13 years, the risk of delusion formation was significantly higher (P interaction = 0.027) in those with lower ToM skills (OR = 4.3, 95% CI 1.9-9.9, P = 0.000), compared to those with higher ToM skills (OR 1.6, 95% CI 0.7-3.7, P = 0.26), independently from secondary school level.

CONCLUSION

The results suggest that better mentalizing abilities confer protection against delusion formation in children experiencing perceptual anomalies, not reducible to general cognitive ability.

Subclinical psychosis and depression: co-occurring phenomena that do not predict each other over time

BACKGROUND

The path from subclinical psychotic experiences to clinical disorder is thought to be mediated by the persistence of subclinical psychotic experiences. One of the factors that is likely associated with this persistence is depression. Although commonly viewed as interrelated concepts, the exact relationship between subclinical psychosis and depression is not clear.

METHODS

Cross-lagged path modeling was used to explore the relationship between subclinical psychosis and depression across and over time in an adolescent population seeking assistance for non-psychotic disorders (N=138), measured at four occasions over a two-year period.

RESULTS

Subclinical psychosis and depression were related to each other at every cross-sectional measurement, but did not predict each other over time. Subclinical psychotic experiences and depressive symptom levels were highest at baseline, when participants presented to the clinical service for help. In addition, the relationship between them was also strongest at baseline and decreased significantly over time.

CONCLUSION

The results suggest that psychosis and depression are interrelated phenomena that strongly co-occur in time, but longitudinally, one does not predict change in the other. Both psychopathological dimensions should be addressed when treatment is provided to adolescent help-seekers.

Neuroticism explained? From a non-informative vulnerability marker to informative person-context interactions in the realm of daily life

OBJECTIVES

Despite the well-replicated finding that neuroticism is associated with increased susceptibility for psychopathology, it remains unclear what 'vulnerability as indexed by neuroticism' represents in terms of everyday life emotional processes. This study examined the association between neuroticism and six phenotypes of daily life emotional responses: positive affect (PA), negative affect (NA), PA variability, NA variability, stress sensitivity, and reward experience, and investigated the contribution of genetic and environmental factors to these associations.

DESIGN

A prospective cohort study in a population-based sample of 416 adult female twins.

METHOD

A momentary assessment approach (experience sampling method) was used to collect multiple assessments of affect in daily life. Neuroticism was assessed with the Eysenck Personality Scale. Multi-level regression analyses were carried out to examine the association between neuroticism and the phenotypes of daily life emotional responses. Cross-twin, cross-trait analyses, and bivariate structural equation modelling (SEM) were performed in order to investigate the nature of these associations.

RESULTS

A high neuroticism score was associated with lower momentary PA levels and increased NA variability, independent of momentary NA, PA variability, stress sensitivity, and reward experience. Both the cross-twin, cross-trait analyses, and the bivariate SEM showed that unique, non-shared environmental factors drive the association between neuroticism and PA and that the association between neuroticism and increased NA variability is based on shared genetic factors as well as individual-specific environmental factors.

CONCLUSIONS

Neuroticism as measured by Eysenck questionnaire may index an environmental risk for decreased daily life PA levels and a genetic as well as an environmental risk for increased NA variability. Decomposing the broad measure of neuroticism into measurable persons-context interactions increases its 'informative' value in explaining psychopathology.

Caloric restriction attenuates age-related changes of DNA methyltransferase 3a in mouse hippocampus

Recent studies have suggested that DNA methylation is implicated in age-related changes in gene expression as well as in cognition. DNA methyltransferase 3a (Dnmt3a), which catalyzes DNA methylation, is essential for memory formation and underlying changes in neuronal and synaptic plasticity. Because caloric restriction (CR) and upregulation of antioxidants have been suggested as strategies to attenuate age-related alterations in the brain, we hypothesized that both a diet restricted in calories and transgenic overexpression of normal human Cu/Zn superoxide dismutase 1 (SOD) attenuate age-related changes in Dnmt3a in the aging mouse hippocampus. For this purpose, we performed qualitative and quantitative analyses of Dnmt3a-immunoreactivity (IR) for the hippocampal dentate gyrus (DG), CA3 and CA1-2 regions in 12- and 24-month-old mice from 4 groups, i.e. (1) wild-type (WT) mice on a control diet (WT-CD), (2) SOD-CD mice, (3) WT mice on CR (WT-CR), and (4) SOD-CR. Qualitative analyses revealed two types of Dnmt3a immunoreactive cells: type I cells--present throughout all hippocampal cell layers showing moderate levels of nuclear Dnmt3a-IR, and type II cells--a subpopulation of hippocampal cells showing very intense nuclear Dnmt3a-IR, and colocalization with Bromodeoxyuridine. Quantitative analyses indicated that the age-related increase in Dnmt3a-IR within the CA3 and CA1-2 in type I cells was attenuated by CR, but not by SOD overexpression. In contrast, the density of type II Dnmt3a immunoreactive cells showed an age-related reduction, without significant effects of both CR and SOD. These changes in Dnmt3a levels in the mouse hippocampus may have a significant impact on gene expression and associated cognitive functioning.

Adolescent development of psychosis as an outcome of hearing impairment: a 10-year longitudinal study

BACKGROUND

It has long been acknowledged that hearing impairment may increase the risk for psychotic experiences. Recent work suggests that young people in particular may be at risk, indicating a possible developmental mechanism.

METHOD

The hypothesis that individuals exposed to hearing impairment in early adolescence would display the highest risk for psychotic symptoms was examined in a prospective cohort study of a population sample of originally 3021 adolescents and young adults aged 14-24 years at baseline, in Munich, Germany (Early Developmental Stages of Psychopathology Study). The expression of psychosis was assessed at multiple time points over a period of up to 10 years, using a diagnostic interview (Munich Composite International Diagnostic Interview; CIDI) administered by clinical psychologists.

RESULTS

Hearing impairment was associated with CIDI psychotic symptoms [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.10-3.81], particularly more severe psychotic symptoms (OR 5.66, 95% CI 1.64-19.49). The association between hearing impairment and CIDI psychotic symptoms was much stronger in the youngest group aged 14-17 years at baseline (OR 3.28, 95% CI 1.54-7.01) than in the older group aged 18-24 years at baseline (OR 0.82, 95% CI 0.24-2.84).

CONCLUSIONS

The finding of an age-specific association between hearing impairment and psychotic experiences suggests that disruption of development at a critical adolescent phase, in interaction with other personal and social vulnerabilities, may increase the risk for psychotic symptoms.

A 2-year naturalistic study on cognitive functioning in bipolar disorder

OBJECTIVE

Cognitive alterations in bipolar disorder may reflect genetic influence. However, to what degree mood, medication, thyroid function and other factors impact on longitudinal cognitive functioning remains unclear.

METHOD

A group of patients with bipolar (spectrum) disorder (n = 76) underwent two monthly cognitive assessments over a 2-year period in a prospective, repeated measures design. Regression models were used to investigate associations with predictors, corrected for multiple testing.

RESULTS

Patients with bipolar disorder performed worse than healthy controls (n = 61) on all cognitive domains tested. Effect sizes were small, with a maximum of -0.36 for sustained attention. However, cognitive performance varied substantially over the 2-year follow-up, co-varying with subjective cognitive complaints and impacting on functioning. Alterations in sustained attention and motor speed were the only impairments that were invariant over time. Predictors had very limited explanatory power on temporal variation in cognition. Use of second-generation antipsychotics was associated with the largest negative effects on cognition, which were evident in the areas of motor speed and basic information processing (-0.35 < β < -0.5).

CONCLUSION

Cognitive function in bipolar disorder varies significantly over time, largely independent of clinical factors. The temporal stability of sustained attention is the exception, suggesting it may represent a possible candidate intermediary phenotype.

Can obsessions drive you mad? Longitudinal evidence that obsessive-compulsive symptoms worsen the outcome of early psychotic experiences

OBJECTIVE

Although there is substantial comorbidity between psychotic disorder and obsessive-compulsive disorder (OCD), little is known about how these clinical phenotypes, and their subclinical extended phenotypes, covary and impact on each other over time. This study examined cross-sectional and longitudinal associations between both (extended) phenotypes in the general population.

METHOD

Data were obtained from the three waves of the NEMESIS-study. A representative population sample of 7076 participants were assessed using the composite international diagnostic interview (CIDI) at baseline (T(0)), 1 year later at T(1) and again 2 years later at T(2).

RESULTS

At T(0), a lifetime diagnosis of psychotic disorder was present in 1.5% of the entire sample, in 11.5% of the people with any OC symptom and in 23.0% of individuals diagnosed with OCD. OC symptoms at T(0) predicted incident psychotic symptoms at T(2). Similarly, T(0) psychotic symptoms predicted T(2) OC symptoms. The likelihood of persistence of psychotic symptoms or transition to psychotic disorder was higher if early psychosis was accompanied by co-occurring OC symptoms, but not the other way around.

CONCLUSION

OCD and the psychosis phenotype cluster together and predict each other at (sub)clinical level. The co-occurrence of subclinical OC and psychosis may facilitate the formation of a more 'toxic' form of persistent psychosis.

[Rapid tranquillisation; review of the literature and recommendations]

BACKGROUND

In The Netherlands, no guidelines exist for rapid tranquillisation in the context of acute agitation, excitement or aggression secondary to a psychiatric disorder.

AIM

To generate an overview of medication regimes suitable for rapid tranquillisation.

METHOD

A literature search was conducted focussing on the effect of medical interventions in acute excitement, agitation or aggression. Primary outcome measurements were tranquillity, being calm, sedation, or asleep within two hours. Secondary outcome measures were frequency of re-administration and adverse side effects.

RESULTS

Haloperidol appears as effective as lorazepam; haloperidol in combination with lorazepam does not have added value to lorazepam or haloperidol alone. Dehydrobenzperidol, risperidone, olanzapine and aripiprazole are comparable in effectiveness to lorazepam or haloperidol. Haloperidol in combination with promethazine is associated with a more rapid onset of effect than lorazepam, haloperidol or olanzapine. Midazolam is faster than the combination of haloperidol and promethazine, but requires more frequent re-administration of medication and increases the risk for respiratory depression. The literature on quetiapine was insufficient. The level of evidence, however, is modest.

CONCLUSION

Haloperidol in combination with promethazine, and olanzapine, are effective in psychotic agitation, although haloperidol plus promethazine has a more rapid onset of effect faster; lorazepam is effective in non-psychotic agitation, aggression or excitement as well as in acute agitation of unknown origin.

Evidence for a familial correlation between increased reactivity to stress and positive psychotic symptoms

OBJECTIVE

This study tested the hypothesis that stress-reactivity may represent an intermediary phenotype underlying positive psychotic symptoms. It was examined whether: (i) stress-reactivity clusters within families of psychotic patients and (ii) stress-reactivity in relatives cosegregates with positive symptoms in patients.

METHOD

The sample consisted of 40 patients and 47 siblings of these patients. The Experience Sampling Method (ESM - a structured diary technique) was used to measure stress-reactivity. Positive symptoms in patients were measured with the Comprehensive Assessment of Symptoms and History.

RESULTS

Within-trait, cross-sib associations showed a significant association between stress-reactivity in the patient and stress-reactivity in their siblings. Significant cross-trait, cross-sib associations were established showing a significant association between positive psychotic symptoms in the patient and stress-reactivity in the sibling.

CONCLUSION

The findings show familial clustering of increased stress-reactivity, suggesting common aetiological influences, probably both genetic and environmental, underlying stress-reactivity in the siblings and patients. In addition, the results underscore the hypothesis that increased stress-reactivity is an unconfounded mechanism of risk underlying the positive symptoms of psychotic disorders.

No major role for X-inactivation in variations of intelligence and behavioral problems at middle childhood

Although members of monozygotic (MZ) twin pairs are identical in genomic sequence, epigenetic mechanisms may occasion difference in gene expression and, consequently, twin discordance in complex traits. Recent work suggests that the epigenetic process of X-inactivation in female individuals may impact on intelligence and child behavioral problems. The timing of X-inactivation has been linked to chorionic splitting in MZ twins. Dichorionic monozygotic (DC-MZ) twinning, unlike monochorionic monozygotic (MC-MZ) twinning, occurs prior to the time of X-inactivation in female organisms. Therefore, the hypothesis of a causal role of X-inactivation in intelligence and behavioral problems can be analyzed by modeling the statistical interaction between sex and chorion type for within-pair differences in these traits in MZ twins. In this study, the effect of X-inactivation on childhood behavioral problems, measured with the CBCL, was studied in a sample of 324 MZ twin pairs from the EFPTS and the effect of X-inactivation on IQ was studied in a sample of 272 twin pairs from the same twin survey. Information on chorion type, gestational age, and birth weight was additionally collated. No significant statistical interaction was found between sex and chorion type, indicating that X-inactivation is not likely involved in variations in intelligence or behavioral problems in middle childhood. Further studies are required to replicate these findings and may explore the role of X-inactivation at different ages or at the extreme scores in the spectrum of intelligence and behavioral problems or may focus on other epigenetic mechanisms.

Gene-environment interaction research and transgenic mouse models of Alzheimer's disease

The etiology of the sporadic form of Alzheimer's disease (AD) remains largely unknown. Recent evidence has suggested that gene-environment interactions (GxE) may play a crucial role in its development and progression. Whereas various susceptibility loci have been identified, like the apolipoprotein E4 allele, these cannot fully explain the increasing prevalence of AD observed with aging. In addition to such genetic risk factors, various environmental factors have been proposed to alter the risk of developing AD as well as to affect the rate of cognitive decline in AD patients. Nevertheless, aside from the independent effects of genetic and environmental risk factors, their synergistic participation in increasing the risk of developing AD has been sparsely investigated, even though evidence points towards such a direction. Advances in the genetic manipulation of mice, modeling various aspects of the AD pathology, have provided an excellent tool to dissect the effects of genes, environment, and their interactions. In this paper we present several environmental factors implicated in the etiology of AD that have been tested in transgenic animal models of the disease. The focus lies on the concept of GxE and its importance in a multifactorial disease like AD. Additionally, possible mediating mechanisms and future challenges are discussed.

Meeting risk with resilience: high daily life reward experience preserves mental health

OBJECTIVE

To examine prospectively whether high reward experience (the ability to generate positive affect boosts from pleasurable daily events) protects against affective symptoms and whether environmental or genetic risk factors moderate protective effects.

METHOD

At baseline, 498 female twins participated in an experience sampling study measuring reward experience in daily life. They also completed questionnaires on childhood adversity and recent stressful life events (SLE). Affective symptoms were measured at baseline and at four follow-ups using SCL-90 anxiety and depression subscales. Co-twin affective symptoms were used as indicators of genetic risk.

RESULTS

Baseline reward experience did not predict follow-up affective symptoms, regardless of level of genetic risk. However, high reward experience was associated with reduced future affective symptoms after previous exposure to childhood adversity or recent SLE.

CONCLUSION

High daily life reward experience increases resilience after environmental adversity; modification of reward experience may constitute a novel area of therapeutic intervention.

Incidence and persistence of tardive dyskinesia and extrapyramidal symptoms in schizophrenia

Although it has been suggested that second-generation antipsychotics (SGA) may reduce the rate of prevalent tardive dyskinesia (TD), little is known about the incidence and outcome of TD in those exposed exclusively to SGA. The incidence and subsequent persistence of TD and extrapyramidal symptoms (EPS) was calculated in a cohort of patients with schizophrenia treated predominantly with SGA. This cohort of more than 10,000 patients with schizophrenia was seen six times over a period of two years. Dichotomous measures of EPS and TD were used to calculate the yearly incidence rates of TD and EPS as well as their subsequent cumulative persistence rate in a subset of 9104 and 6285 patients at risk for TD and EPS, respectively. Of 9104 individuals who did not present with TD at baseline, 138 developed TD, yielding a TD incidence rate of 0.74% (95% CI: 0.62, 0.87) and a subsequent cumulative persistence rate of 80%. Of 6285 individuals without EPS at baseline, 464 developed EPS yielding an incidence rate of 3.7% (95% CI: 3.4, 4.0) and a subsequent cumulative persistence rate of 82%. Incidence rates of TD and EPS may be low in the SGA era. However, once emerged, these disorders prove persistent, suggesting strong moderators effects of underlying predisposing factors.

Unveiling patterns of affective responses in daily life may improve outcome prediction in depression: a momentary assessment study

OBJECTIVE

Daily life affective responses are closely linked to vulnerability and resilience in depression. Prediction of future clinical course may be improved if information on daily life emotional response patterns is taken into account.

METHOD

Female subjects with a history of major depression (n=83), recruited from a population twin register, participated in a longitudinal study using momentary assessment technology with 4 follow-up measurements. The effect of baseline daily life emotional response patterns (affect variability, stress-sensitivity and reward experience) on follow-up depressive symptomatology was examined.

RESULTS

Both reward experience (B=-0.30, p=0.001) and negative affect variability (B=0.46, p=0.001) predicted future negative affective symptoms independent of all other dynamic emotional patterns and conventional predictors.

CONCLUSION

Daily life information on dynamic emotional patterns adds to the prediction of future clinical course, independent of severity of symptoms and neuroticism score. Better prediction of course may improve decision-making regarding quantitative and qualitative aspects of treatment.

Scars in depression: is a conceptual shift necessary to solve the puzzle?

Although clinical findings suggest that in the aftermath of depression a process of 'scarring' may ensue, research examining the issue of 'scars' (including biological, psychological and cognitive changes) has remained largely inconclusive. This paper proposes a new approach to the concept of 'scars' that is (i) based on a dimensional view of depression, (ii) uses methods that take into account the dynamic interplay between the person and his context, (iii) differentiates between scars following depression and scars following the factor that actually caused the depression such as stress and (iv) introduces a dynamic view of the concept of 'scars' in that it hypothesizes that scars can wax and wane. This approach may stimulate the discovery of new entries in the puzzle underlying the ontogenesis of vulnerability and resilience. Furthermore, it may provide insights that help to develop new therapies for depression.

Evidence that bipolar disorder is the poor outcome fraction of a common developmental phenotype: an 8-year cohort study in young people

BACKGROUND

Reported rates of bipolar syndromes are highly variable between studies because of age differences, differences in diagnostic criteria, or restriction of sampling to clinical contacts.

METHOD

In 1395 adolescents aged 14-17 years, DSM-IV (hypo)manic episodes (manic and hypomanic episodes combined), use of mental health care, and five ordinal subcategories representing the underlying continuous score of (hypo)manic symptoms ('mania symptom scale') were measured at baseline and approximately 1.5, 4 and 10 years later using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI).

RESULTS

Incidence rates (IRs) of both (hypo)manic episodes and (hypo)manic symptoms (at least one DSM-IV core symptom) were far higher (714/105 person-years and 1720/10(5) person-years respectively) than traditional estimates. In addition, the risk of developing (hypo)manic episodes was very low after the age of 21 years [hazard ratio (HR) 0.031, 95% confidence interval (CI) 0.0050-0.19], independent of childhood disorders such as attention deficit hyperactivity disorder (ADHD). Most individuals with hypomanic and manic episodes were never in care (87% and 62% respectively) and not presenting co-morbid depressive episodes (69% and 60% respectively). The probability of mental health care increased linearly with the number of symptoms on the mania symptom scale. The incidence of the bipolar categories, in particular at the level of clinical morbidity, was strongly associated with previous childhood disorders and male sex.

CONCLUSIONS

This study showed, for the first time, that experiencing (hypo)manic symptoms is a common adolescent phenomenon that infrequently predicts mental health care use. The findings suggest that the onset of bipolar disorder can be elucidated by studying the pathway from non-pathological behavioural expression to dysfunction and need for care.

[The influence of cannabis on the course of bipolar disorder: a longitudinal analysis]

BACKGROUND

Research shows that the use of cannabis has a negative impact on the onset and outcome of schizophrenia, but little is known about possible effects on mood disorders.

AIM

To study the influence of cannabis use on clinical and social treatment outcomes in patients with bipolar disorders who had been treated for a period of 12 months.

METHOD

3459 bipolar patients were enrolled in an observational study. The influence of cannabis on various clinical and social treatment outcomes was examined over a period of one year. In addition, tests were applied in order to find out whether third, mediating variables had effects on possible associations between cannabis use and treatment outcomes.

RESULTS

During 12 months of treatment cannabis users showed less compliance and higher levels of illness severity, mania and psychosis than did non-users. In addition, cannabis users were less satisfied with their lives and had less chance of forming relationships than non-users. There was little evidence that associations between cannabis use and treatment outcomes were mediated by third variables.

CONCLUSION

Cannabis use clearly had an independent impact on clinical treatment outcomes in patients with bipolar disorder, but the impact on social outcomes was only modest.

[Routine Outcome Monitoring for patients with severe mental illness: a consensus document]

BACKGROUND

Routine outcome monitoring (ROM) means the assessment of the patient's condition on a routine basis using instruments. So far there is no consensus about which instruments should be used for ROM with severely mentally ill patients (ROM-SMI).

AIM

To reach a consensus about instruments for ROM-SMI in the Netherlands and Belgium and to create possibilities for comparison of ROM data.

METHOD

This article discusses the consensus document of the National Remission Working Group for ROM in patients with smi and covers the following topics: reasons for ROM-SMI, domains for ROM-SMI and appropriate instruments, logistics and analyses of the data.

RESULTS

Patients with SMI have problems in several domains. These can be assessed by collecting information about psychiatric symptoms, addiction, somatic problems, general functioning, needs, quality of life and care satisfaction. Potential instruments for ROM-SMI are short, valid, reliable and assess several domains, taking the patient's perspective into account, and have been used in national and international research. The working group advises institutions to choose from a limited set of instruments. After the scores have been aggregated and standardised, comparisons can be drawn. ROM-SMI data can be interpreted more meaningfully, if outcome data are supplemented with data regarding patient characteristics and the treatment interventions already applied.

CONCLUSION

It should be possible to reach a consensus about instruments for ROM-SMI and the way in which they should be used. The use of identical instruments will lead to improvements in mental health care and create possibilities for comparison (benchmarking) and research.

The psychoses: cluster 3 of the proposed meta-structure for DSM-V and ICD-11

BACKGROUND

In an effort to group mental disorders on the basis of etiology, five clusters have been proposed. Here we consider the validity of the cluster comprising selected psychotic and related disorders.

METHOD

A group of diagnostic entities classified under schizophrenia and other psychotic disorders in DSM-IV-TR were assigned to this cluster and the bordering disorders, bipolar (BD) and schizotypal personality disorders (SPD), were included. We then reviewed the literature in relation to 11 validating criteria proposed by the DSM-V Task Force Study Group.

RESULTS

Relevant comparisons on the 11 spectrum criteria are rare for the included disorders except for schizophrenia and the two border conditions, BD and SPD. The core psychosis group is congruent at the level of shared psychotic psychopathology and response to antipsychotic medication. BD and SPD are exceptions in that psychosis is not typical in BD-II disorder and frank psychosis is excluded in SPD. There is modest similarity between schizophrenia and BD relating to risk factors, neural substrates, cognition and endophenotypes, but key differences are noted. There is greater support for a spectrum relationship of SPD and schizophrenia. Antecedent temperament, an important validator for other groupings, has received little empirical study in the various psychotic disorders.

CONCLUSIONS

The DSM-IV-TR grouping of psychotic disorders is supported by tradition and shared psychopathology, but few data exist across these diagnoses relating to the 11 spectrum criteria. The case for including BD is modest, and the relationship of BD to other mood disorders is addressed elsewhere. Evidence is stronger for inclusion of SPD, but the relationship with other personality disorders along the 11 criteria is not addressed and the absence of psychosis presents a conceptual problem. There are no data along the 11 spectrum criteria that are decisive for a cluster based on etiology, and inclusion of BD and SPD is questionable.

'Salience syndrome' replaces 'schizophrenia' in DSM-V and ICD-11: psychiatry's evidence-based entry into the 21st century?

OBJECTIVE

Japan was the first country to abandon the 19th century term of 'mind-splitting disease' (schizophrenia). Revisions of DSM and ICD are forthcoming. Should the rest of the world follow Japan's example?

METHOD

A comprehensive literature search was carried out in order to review the scientific evidence for the validity, usefulness and acceptability of current concepts of psychotic disorder.

RESULTS

The discussion about re-classifying and renaming schizophrenia and other psychotic disorders is clouded by conceptual confusion. First, it is often misunderstood as a misguided attempt to change societal stigma instead of an attempt to change iatrogenic stigma occasioned by the use of misleading and mystifying terminology. Second, the debate is misunderstood as purely semantic, whereas in actual fact it is about the core concepts underlying psychiatric nosology. Third, it has been suggested that the debate is political. However, solid scientific evidence pointing to the absence of nosological validity of diagnostic categories lies at the heart of the argument. Fourth, there is confusion about what constitutes a syndrome (a group of symptom dimensions that cluster in different combinations in different people and for which one or more underlying diseases may or may not be found) and a disease (a nosologically valid entity with specific causes, symptoms, treatment and course).

CONCLUSION

Scientific evidence favours a syndromal system of classification combining categorical and dimensional representations of psychosis. The concept of 'salience' has the potential to make the public recognize psychosis as relating to an aspect of human mentation and experience that is universal. It is proposed to introduce, analogous to the functional-descriptive term 'Metabolic syndrome', the diagnosis of 'Salience syndrome' to replace all current diagnostic categories of psychotic disorders. Within Salience syndrome, three subcategories may be identified, based on scientific evidence of relatively valid and specific contrasts, named Salience syndrome with affective expression, Salience syndrome with developmental expression and Salience syndrome not otherwise specified.

Early adversity and 5-HTT/BDNF genes: new evidence of gene-environment interactions on depressive symptoms in a general population

BACKGROUND

Adverse childhood experiences have been described as one of the major environmental risk factors for depressive disorder. Similarly, the deleterious impact of early traumatic experiences on depression seems to be moderated by individual genetic variability. Serotonin transporter (5-HTT) and brain-derived neurotrophic factor (BDNF) modulate the effect of childhood adversity on adult depression, although inconsistencies across studies have been found. Moreover, the gene x environment (GxE) interaction concerning the different types of childhood adversity remains poorly understood. The aim of this study was to analyse the putative interaction between the 5-HTT gene (5-HTTLPR polymorphism), the BDNF gene (Val66Met polymorphism) and childhood adversity in accounting for adult depressive symptoms.

METHOD

A sample of 534 healthy individuals filled in self-report questionnaires of depressive symptomatology [the Symptom Check List 90 Revised (SCL-90-R)] and different types of childhood adversities [the Childhood Trauma Questionnaire (CTQ)]. The 5-HTTLPR polymorphism (5-HTT gene) and the Val66Met polymorphism (BDNF gene) were genotyped in the whole sample.

RESULTS

Total childhood adversity (beta=0.27, p<0.001), childhood sexual abuse (CSA; beta=0.17, p<0.001), childhood emotional abuse (beta=0.27, p<0.001) and childhood emotional neglect (beta=0.22, p<0.001) had an impact on adult depressive symptoms. CSA had a greater impact on depressive symptoms in Met allele carriers of the BDNF gene than in the Val/Val group (F=5.87, p<0.0001), and in S carriers of the 5-HTTLPR polymorphism (5-HTT gene) (F=5.80, p<0.0001).

CONCLUSIONS

Childhood adversity per se predicted higher levels of adult depressive symptoms. In addition, BDNF Val66Met and 5-HTTLPR polymorphisms seemed to moderate the effect of CSA on adult depressive symptoms.

Experience sampling research in psychopathology: opening the black box of daily life

A growing body of research suggests that momentary assessment technologies that sample experiences in the context of daily life constitute a useful and productive approach in the study of behavioural phenotypes and a powerful addition to mainstream cross-sectional research paradigms. Momentary assessment strategies for psychopathology are described, together with a comprehensive review of research findings illustrating the added value of daily life research for the study of (1) phenomenology, (2) aetiology, (3) psychological models, (4) biological mechanisms, (5) treatment and (6) gene-environment interactions in psychopathology. Overall, this review shows that variability over time and dynamic patterns of reactivity to the environment are essential features of psychopathological experiences that need to be captured for a better understanding of their phenomenology and underlying mechanisms. The Experience Sampling Method (ESM) allows us to capture the film rather than a snapshot of daily life reality of patients, fuelling new research into the gene-environment-experience interplay underlying psychopathology and its treatment.

The role of dopamine D3, 5-HT2A and 5-HT2C receptor variants as pharmacogenetic determinants in tardive dyskinesia in African-Caribbean patients under chronic antipsychotic treatment: Curacao extrapyramidal syndromes study IX

Tardive dyskinesia (TD) is associated with polymorphisms of the dopamine D(3), serotonin 2A and 2C receptors (DRD3, HTR2A and HTR2C, respectively). This study investigated the possible relationship between TD and the polymorphisms Ser9Gly (DRD3), 102T>C (HTR2A), -1438G>A(HTR2A) and Cys23Ser (HTR2C) in African-Caribbean inpatients. One hundred and twenty-six patients under chronic antipsychotic treatment were genotyped. The assessment of TD was carried out with the abnormal involuntary movement scale (AIMS). The relationships between the carriership of the least frequent alleles and the respective orofaciolingual dyskinesia (TDof) (sum of the items 1-4 of the AIMS), limb-truncal dyskinesia (TDlt) (sum of items 5-7 of the AIMS) and TD (sum of items 1-7 of the AIMS) were analyzed with ANCOVA, comparing means with age as a covariate and stratification for carriers and non-carriers of the mutations. In addition, we conducted pre-planned t-tests to compare AIMS values of carriers of the combinations of alleles versus the corresponding non-carriers. In the study population, females with 9Ser carriership exhibited higher AIMS values than non-carriers. Male subjects with 9Ser carriership in combination with 23Ser or -1438A carriership exhibited higher AIMS values. In male patients also, the combination of 23Ser and -1438A carriership increased TD. The study clearly shows that the African-Caribbean population differs from the Caucasian population with regard to the association of TD with the polymorphisms studied and suggests that the association of TD with the studied polymorphisms of the 5-HT(2C) and probably of the 5-HT(2A) receptor are the result of a changed susceptibility of the patients, independent of the action of the antipsychotics on these receptors.

Mechanisms of gene-environment interactions in depression: evidence that genes potentiate multiple sources of adversity

BACKGROUND

Previous work suggests that daily life stress-sensitivity may be an intermediary phenotype associated with both genetic risk for depression and developmental stress exposures. In the current analysis we hypothesized that genetic risk for depression and three environmental exposures over the course of development [prenatal stress, childhood adversity and adult negative life events (NLEs)] combine synergistically to produce the phenotype of stress-sensitivity.

METHOD

Twin pairs (n=279) participated in a momentary assessment study using the Experience Sampling Method (ESM), collecting appraisals of stress and negative affect (NA) in the flow of daily life. Prospective data on birthweight and gestational age, questionnaire data on childhood adversity and recent NLEs, and interview data on depression were used in the analyses. Daily life stress-sensitivity was modelled as the effect of ESM daily life stress appraisals on ESM NA.

RESULTS

All three developmental stress exposures were moderated by genetic vulnerability, modelled as dizygotic (DZ) or monozygotic (MZ) co-twin depression status, in their effect on daily life stress-sensitivity. Effects were much stronger in participants with MZ co-twin depression and a little stronger in participants with DZ co-twin depression status, compared to those without co-twin depression. NLE main effects and NLE genetic moderation were reducible to birthweight and childhood adversity.

CONCLUSIONS

The findings are consistent with the hypothesis that adult daily life stress-sensitivity is the result of sensitization processes initiated by developmental stress exposures. Genes associated with depression may act by accelerating the process of stress-induced sensitization.

Cognition as predictor of current and follow-up depressive symptoms in the general population

OBJECTIVE

Previous studies have reported an association between depression and poor cognitive functioning. Unknown is to what degree such associations are merely state-related or reflect an enduring depression vulnerability. This study examined whether cognitive deficits predict current and/or follow-up (sub)clinical depressive symptoms in the general population.

METHOD

A population-based sample of 569 female twins and 43 of their sisters completed a neuropsychological battery. Cross-sectional and prospective associations between depressive symptoms measured at the subclinical [Symptom Checklist-90 (SCL-90)] and clinical level (Structured Clinical Interview for DSM-IV disorders) and neuropsychological factors (episodic memory and information processing speed) were examined.

RESULTS

Structured Clinical Interview for DSM-IV disorders baseline depressive symptoms were significantly associated with information processing speed but not with episodic memory. Episodic memory was significantly associated with follow-up SCL-90 depressive symptoms.

CONCLUSION

Being depressed is accompanied by slower information processing. Poor memory functioning may be a predictor for the onset of subclinical depressive symptoms.

Reduced stress-sensitivity or increased reward experience: the psychological mechanism of response to antidepressant medication

Depression has often been associated with increased negative affect reactivity to stress (Stress-Sensitivity) and reduced capacity to experience pleasure or positive affect (Reward Experience). To date, no studies have prospectively examined changes in Stress-Sensitivity and Reward Experience following antidepressant treatment. The sample included 83 depressed patients and 22 healthy controls. A randomized controlled trial was carried out with patients receiving either imipramine or placebo for 6 weeks. At baseline and 6 weeks, patients and controls participated in an Experience Sampling procedure, prospectively measuring ecologically valid daily life appraisals of activities and mood states. The course of depression was assessed with the Hamilton Depression Rating Scale (HDRS). Multilevel linear regression analyses showed that patients had higher negative and lower positive appraisals of activities than controls. In addition, patients showed increased Stress-Sensitivity (negative affect reactivity to negatively appraised activities). Treatment with imipramine decreased Stress-Sensitivity and increased Reward Experience (positive affect reactivity to positively appraised activities). Changes in Stress-Sensitivity and Reward Experience were in part reducible to changes in the process of activity appraisal itself. However, increase in Reward Experience, but not decrease in Stress-Sensitivity, discriminated between patients who responded and those who did not, independent of changes in the process of activity appraisal itself. Response to treatment in depression may be conditional on restoration of hedonic capacity, the cerebral substrate of which requires further study in relation to antidepressant response. A search for (synergistic) antidepressant therapies specifically targeting ability to experience reward may be warranted.

A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder

A systematic review of all reported incidence and prevalence studies of population rates of subclinical psychotic experiences reveals a median prevalence rate of around 5% and a median incidence rate of around 3%. A meta-analysis of risk factors reveals associations with developmental stage, child and adult social adversity, psychoactive drug use, and also male sex and migrant status. The small difference between prevalence and incidence rates, together with data from follow-up studies, indicates that approximately 75-90% of developmental psychotic experiences are transitory and disappear over time. There is evidence, however, that transitory developmental expression of psychosis (psychosis proneness) may become abnormally persistent (persistence) and subsequently clinically relevant (impairment), depending on the degree of environmental risk the person is additionally exposed to. The psychosis proneness-persistence-impairment model considers genetic background factors impacting on a broadly distributed and transitory population expression of psychosis during development, poor prognosis of which, in terms of persistence and clinical need, is predicted by environmental exposure interacting with genetic risk.

COMT ValMet moderation of cannabis-induced psychosis: a momentary assessment study of 'switching on' hallucinations in the flow of daily life

OBJECTIVE

A functional polymorphism in the catechol-o-methyltransferase gene (COMT Val(158)Met) may moderate the psychosis-inducing effects of cannabis. In order to extend this finding to dynamic effects in the flow of daily life, a momentary assessment study of psychotic symptoms in response to cannabis use was conducted.

METHOD

The experience sampling technique was used to collect data on cannabis use and occurrence of symptoms in daily life in patients with a psychotic disorder (n = 31) and healthy controls (n = 25).

RESULTS

Carriers of the COMT Val(158)Met Val allele, but not subjects with the Met/Met genotype, showed an increase in hallucinations after cannabis exposure, conditional on prior evidence of psychometric psychosis liability.

CONCLUSION

The findings confirm that in people with psychometric evidence of psychosis liability, COMT Val(158)Met genotype moderates the association between cannabis and psychotic phenomena in the flow of daily life.

Schizophrenia treatment: content versus delivery

OBJECTIVE

To review the evidence supporting the importance of ensuring that patients with psychiatric disorders receive an optimal and appropriate level of non-pharmacological treatment, and how Assertive Community Treatment (ACT) may be able to contribute to this aim.

METHOD

Analysis of data from selected individual published studies on ACT, in addition to reviews from the Cochrane Library, and other study groups.

RESULTS

Treatment management using ACT appears to offer benefits in terms of reduction in hospitalisation, although there is some debate as to whether this is the most representative outcome measure. Preliminary indications using remission as an outcome measure have also shown promising results in favour of ACT.

CONCLUSION

While further investigation and validation are necessary, current data indicate that ACT may be an appropriate strategy to facilitate the delivery of treatment to patients with psychotic disorders.

[Stress and psychosis: is sensitisation the underlying mechanism?]

Epidemiological research has shown that stressful environmental factors can play an aetiological role in the development of psychosis. However, the mechanism underlying the link between stress and psychosis is still not fully understood. In this article it is argued that the interaction between stressful environmental factors and epigenetic factors can bring about psychological and biological changes. Both types of change can be referred to as 'sensitisation'. The underlying mechanism of sensitisation can be interpreted on the one hand as cognitive misinterpretations (psychological sensitisation) and on the other hand as altered dopaminergic neurotransmission (biological sensitisation). Both of these deviations can facilitate the onset and persistence of psychotic symptoms. With the help of epidemiological research at psychometric level sensitisation can be quantified as (i) stress-induced persistence (indicating continuous sensitisation) of the normally transient expression of subclinical psychotic experiences during adolescence and early adulthood and as (ii) the increased risk of transition from gradually more persistent subclinical psychotic experiences to a clinical psychotic disorder.

Exploring the Causal Relationship Between Cannabis and Schizophrenia: What is the Role of Genes and Environment?

Frequent use of cannabis has been associated with poor outcome in patients with psychosis or schizophrenia, and research has become more and more interested in the question whether cannabis may actually cause psychosis or schizophrenia. Since only a minority of cannabis users eventually develops psychosis or schizophrenia, cannabis is suggested to be a component cause, potentially interacting with environmental as well as genetic factors. However, little is known about this putative interaction. Recent research in our group has therefore focused on differential sensitivity to cannabis and its psychosis-inducing effects. Experimental and observational work for instance showed that a functional polymorphism within the COMT gene moderates the acute effects of cannabis on psychosis outcome. In this presentation new evidence from epidemiological work is presented, showing gene-environment interactions within the cannabis-psychosis association. These results point to a moderating role for both age of onset of cannabis use and childhood trauma. Also a certain haplotype within the COMT gene was found to increase the risk of developing schizophrenia after adolescent cannabis use. Complex gene-environment interactions as well as interactions between cannabis and other environmental risk factors seem to underlie the cannabis-psychosis relationship. Possible biological mechanisms such as sensitization processes that may underlie these interactions will be discussed.

[Serotonin-noradrenalin reuptake inhibitors in the treatment of non-malignant pain syndromes; a systematic review]

BACKGROUND

Chronic pain and depressive symptoms are often comorbid. Antidepressants seem to influence not only the symptoms of depression but also the perception of pain.

AIM

To give a systematic overview of the efficacy and safety of serotonin-noradrenalin reuptake inhibitors (SNRI) in the treatment of chronic non-malignant pain syndromes.

METHODS

We reviewed the literature by means of PubMed and PsycInfo using combinations of the words 'pain' 'venlafaxine' and 'duloxetine'. We selected clinical studies that investigated the influence of SNRIs on pain perception.

RESULTS

Fourteen articles met our selection criteria. Medical conditions involved were fibromyalgia, diabetic neuropathy and post mastectomy pain. Twelve studies demonstrated the efficacy and safety of venlafaxine and duloxetine in the treatment of non-malignant pain.

CONCLUSION

The results revealed that SNRIs are effective in reducing pain particularly in the treatment of diabetic neuropathy. Results with regard to the other medical conditions are less clear. More research is needed to find out in which medical conditions SNRIs have a significant pain reducing effect and why this effect does not hold in the case of other medical conditions.

Mood changes after delivery: role of the serotonin transporter gene

BACKGROUND

Polymorphic variations in the serotonin transporter gene (5-HTT) moderate the depressogenic effects of tryptophan depletion. After childbirth there is a sharp reduction in brain tryptophan availability, thus polymorphic variations in 5-HTT may play a similar role in the post-partum period.

AIMS

To study the role of 5-HTT polymorphic variations in mood changes after delivery.

METHOD

One thousand, eight hundred and four depression-free Spanish women were studied post-partum. We evaluated depressive symptoms at 2-3 days, 8 weeks and 32 weeks post-partum. We used diagnostic interview to confirm major depression for all probable cases. Based on two polymorphisms of 5-HTT (5-HTTLPR and STin2 VNTR), three genotype combinations were created to reflect different levels of 5-HTT expression.

RESULTS

One hundred and seventy-three women (12.7%) experienced major depression during the 32-week post-partum period. Depressive symptoms were associated with the high-expression 5-HTT genotypes in a dose-response fashion at 8 weeks post-partum, but not at 32 weeks.

CONCLUSIONS

High-expression 5-HTT genotypes may render women more vulnerable to depressive symptoms after childbirth.

Evidence that the Two-Way Communication Checklist identifies patient-doctor needs discordance resulting in better 6-month outcome

OBJECTIVE

To assess an intervention aimed at reducing patient-professional carer needs discordance.

METHOD

In a group of 460 patients with schizophrenia, the Two-Way Communication Checklist (2-COM), an instrument to rate needs, was completed at baseline, 2 months and 6 months by both the patient and the professional carer, allowing for the quantification of patient-carer needs discordance.

RESULTS

Reduction in patient-reported 2-COM needs in the group with low baseline needs discordance was much greater at 2 and 6 months (2 months: beta = -0.65, P < 0.001; 6 months: beta = -1.00, P < 0.001) than in the group with high baseline discordance (2 months: beta = -0.35, P < 0.001; 6 months: beta = -0.49, P < 0.001). Reduction in needs discordance between baseline and 2 months (beta = -0.07, P = 0.004) as well between 2 and 6 months (beta = -0.05, P = 0.020) was associated with greater levels of CGI clinical improvement.

CONCLUSION

The fact that patient-carer needs discordance impacts negatively, and its reduction positively, on 6-month outcome suggests that systematic inventory of patient-carer views on needs is necessary.