[Therapy of prurigo nodularis]

Treatment of prurigo nodularis is a challenge. No specific therapies are approved and data from clinical trials are rare. Based on our experience, case series, randomized controlled trials as well as the S2k guideline on chronic pruritus, we provide general principles and specific recommendations in this review.

[Prurigo. Clinical definition and classification]

BACKGROUND

There is no consistent definition of the term prurigo and a clear classification is unavailable.

OBJECTIVES

Definition of the current forms of prurigo and a new approach to a specific classification.

METHODS

Review of the types of prurigo as presented in current textbooks and publications.

RESULTS

Pruritus is the main symptom of prurigo and shows an intensely pruritic papule or nodule as the main efflorescence. The term prurigo is not only used for secondary lesions, but also for primary dermatoses. The different forms of prurigo obtain their names depending on etiology, onset and duration of lesions or the clinical appearance.

CONCLUSIONS

The term prurigo has not been used consistently. A revision of the classification with a clear distinction between primary dermatoses and secondary lesions seems reasonable. In secondary prurigo, a clinical classification and the cause should be mentioned.

Bipolar disorder and gambling disorder comorbidity: current evidence and implications for pharmacological treatment

BACKGROUND

The co-occurrence of bipolar disorder (BD) and gambling disorder (GD), though of clinical and public health importance, is still scarcely investigated. Comorbid BD-GD subjects experience a more severe course of illness and poorer treatment outcome, due to a range of clinical and psychosocial factors that collectively impede remission and recovery. The aim of our paper is to review the role of pharmacotherapy in the treatment of comorbid BD-GD, in order to support clinical decisions according to the best available evidence.

METHODS

A qualitative systematic review of studies on pharmacological treatment in comorbid BD-GD was performed. A comprehensive literature search of online databases, bibliographies of published articles and gray literature was conducted. Data on efficacy, safety and tolerability were extracted and levels of evidence were assessed. We also provide a brief overview of current epidemiological, neurobiological and clinical findings, with the intention of proposing a dimensional approach to the choice of available drugs.

RESULTS

The only drug with a high level of evidence is lithium. Considering the inclusion of GD in DSM-5 'Substance-related and Addictive Disorders' category, we discuss the use of other drugs with a high level of evidence currently used in BD subjects with co-occurring substance use disorders.

LIMITATIONS

Only few clinical trials are available and the population is limited; therefore no conclusive evidence can be inferred.

CONCLUSIONS

Further randomized controlled trials are required to evaluate the efficacy of pharmacological treatment strategies in large samples of patients with comorbid BD-GD. Also, attempts should be made to identify other shared clinical and psychopathological domains that are amenable to treatment.

Dietary fatty acids affect semen quality: a review

Mammalian spermatozoa are characterized by a high proportion of polyunsaturated fatty acids (PUFA) which play a crucial role in fertilization. This review focuses on analysis of sperm fatty acid profiles and the effects of omega-3, saturated and trans dietary and sperm fatty acids on sperm parameters. Two major points have been pivotal points of investigation in the field of sperm fatty acid profiles: first, the comparison between fatty acid profiles of fertile and infertile men and second, the effect of dietary fatty acids on sperm fatty acid profiles as well as sperm quality and quantity. Docosahexaenoic acid (DHA, C22:6n-3), and palmitic acid (C16:0) are the predominant PUFA and saturated fatty acids, respectively, in human sperm cells. Higher levels of DHA are concentrated on the sperm's head or tail varying among different species. However, the human sperm head contains a higher concentration of DHA. Dietary fatty acids influence on sperm fatty acid profiles and it seems that sperm fatty acid profiles are most sensitive to dietary omega-3 PUFA. Although improvements in sperm parameters are a response to omega-3 sources after more than 4 weeks of supplementation in the male diet, time-dependent and dose-dependent responses may explain the failure in some experiments. In human spermatozoa, elevated saturated or trans fatty acid concentration and a low DHA level is a concern. The regulations of the sperm fatty acid mean melting point as well as expression regulation of peroxisome proliferator-activated receptor gamma (PPARG) alongside with spermatozoon assembly, anti-apoptosis effects, eicosanoid formation, and hormone activity are the putative key factors that induce a response by inclusion of omega-3 PUFA.

Collaborative care for patients with bipolar disorder: randomised controlled trial

BACKGROUND

A substantial number of people with bipolar disorder show a suboptimal response to treatment.

AIMS

To study the effectiveness of a collaborative care programme on symptoms and medication adherence in patients with bipolar disorder, compared with care as usual.

METHOD

A two-armed, cluster randomised clinical trial was carried out in 16 out-patient mental health clinics in The Netherlands, in which 138 patients were randomised. Patient outcomes included duration and severity of symptoms and medication adherence, and were measured at baseline, 6 months and 12 months. Collaborative care comprised contracting, psychoeducation, problem-solving treatment, systematic relapse prevention and monitoring of outcomes. Mental health nurses functioned as care managers in this programme. The trial was registered with The Netherlands Trial Registry (NTR2600).

RESULTS

Collaborative care had a significant and clinically relevant effect on number of months with depressive symptoms, both at 6 months (z = -2.6, P = 0.01, d = 0.5) and at 12 months (z = -3.1, P = 0.002, d = 0.7), as well as on severity of depressive symptoms at 12 months (z = -2.9, P = 0.004, d = 0.4). There was no effect on symptoms of mania or on treatment adherence.

CONCLUSIONS

When compared with treatment as usual, collaborative care substantially reduced the time participants with bipolar disorder experienced depressive symptoms. Also, depressive symptom severity decreased significantly. As persistent depressive symptoms are difficult to treat and contribute to both disability and impaired quality of life in bipolar disorder, collaborative care may be an important form of treatment for people with this disorder.

Retinal blood flow in mild cognitive impairment and Alzheimer's disease

Background

Patients with Alzheimer's disease (AD) demonstrate the narrowing of retinal veins and decreased retinal venous blood flow compared with control subjects. We assessed whether these abnormalities are present in patients with mild cognitive impairment (MCI).

Methods

After the determination of the global clinical dementia rating, 52 subjects (10 AD, 21 MCI, and 21 normal controls) underwent retinal hemodynamic profiling. Blood column diameter, blood speed, and blood flow were measured in a major temporal retinal vein using retinal laser Doppler flowmetry. In addition, peripapillary retinal nerve fiber layer (RNFL) thickness was measured using optical coherence tomography.

Results

Blood column diameter in AD was narrower than in both MCI (P = .004) and controls (P = .002). However, blood speed in both AD (P = .024) and MCI (P = .005) was lower than in controls. As a result, the differences in blood flow between AD and MCI (P = .036), AD and controls (P < .0001), and MCI and controls (P = .009) were significant. Although there were no differences in RNFL thickness among the groups, blood flow was correlated (P = .047) with superior RNFL thickness in the AD group, but not in the MCI (P = .40) or control (P = .84) groups.

Conclusions

Retinal blood flow in MCI is intermediate between what is measured in control subjects and in AD patients. Our findings suggest that blood flow abnormalities may precede the neurodegeneration in AD.

Pain and Personality: Do Individuals with Different Forms of Chronic Pain Exhibit a Mutual Personality?

The role of personality in the experience of chronic pain is a growing field, with endless debate regarding the existence of a "pain personality". This study aims to compare different chronic pain types and consolidate the existence of a common personality. Thirty-two females with chronic orofacial pain and 37 age-matched healthy females were assessed with the Temperament and Character Inventory-Revised. Chronic pain subjects had either trigeminal neuropathy (neuropathic pain) or temporomandibular disorders (nociceptive pain). This study revealed that individuals with different chronic pain types exhibit a mutual personality profile encompassing significantly higher scores in Harm Avoidance and significantly lower scores in Self-Directedness when compared to healthy subjects. In fact, this combination is associated with Cluster C personality disorders. In conclusion, our study reveals that irrespective of type, chronic pain may be associated with Cluster C personality disorders. Indeed, there has never been empirical evidence in the past to suggest that chronic pain as an overall concept is associated with any particular personality disorders. Therefore, a potential future avenue of chronic pain treatment may lie in targeting particular personality aspects and shift the target of pain-relieving treatments from sensory and psychologically state focused to psychologically trait focused.

Meta-analysis of the efficacy and safety of Ginkgo biloba extract for the treatment of dementia

BACKGROUND

The benefit of Ginkgo biloba for the treatment of dementia remains controversial. The aim of this study was to evaluate the efficacy and safety of Ginkgo biloba in patients with dementia in whom administration effects were reported using meta-analysis.

METHODS

We searched MEDLINE, Embase, the Cochrane databases, and Ichushi for controlled trials of Ginkgo biloba for the treatment dementia. Clinical characteristics and outcomes were extracted. Meta-analysis results were expressed as standard mean differences (SMDs) in scores of the Syndrome Kurztest (SKT), Alzheimer's Disease Assessment Scale Cognitive Subscale (ADAS-Cog) for cognition efficacy, or odds ratios (ORs) for dropouts and adverse drug reactions.

RESULTS

Thirteen studies using the extract EGb761 met our inclusion criteria, which were duration of 12 to 52 weeks and daily dose of more than 120 mg, and included a total of 2381 patients. Meta-analysis was performed by using 9 of 13 studies, 7 of which used the SKT and 2 ADAS-Cog (dose 120 mg, 26 weeks) scores as efficacy parameters. In meta-analysis of all patients, SMDs (95% confidence interval [CI]) in the change in SKT scores (7 studies) were in favor of Ginkgo biloba over placebo (SMD = -0.90 [-1.46, -0.34]), but 2 studies that used ADAS-Cog did not show a statistically significant difference from placebo for ADAS-Cog (-0.06 [-0.41, 0.30]). For Alzheimer's disease (AD) and vascular dementia (VaD) subgroups, SMDs [95% CI] in SKT in the combined AD and VaD subgroup (-1.07 [-1.66, -0.47]) and AD subgroup (-1.36 [-2.27, -0.46]) were in favor of Ginkgo biloba over placebo. In terms of daily dose of Ginkgo biloba in the combined AD and VaD subgroup, SMD in SKT score in 240-mg daily dose groups was significantly greater than with placebo (-0.71 [-1.28, -0.14]). Dropout rates for any reason did not differ between two groups, but dropout rates due to side effects were significantly lower in Ginkgo biloba groups compared with placebo groups (OR = 1.72 [1.06, 2.80]).

CONCLUSIONS

Taking a 240-mg daily dose of Ginkgo biloba extract is effective and safe in the treatment of dementia.

Anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders

Alcoholic patients suffer from harmful allostatic neuroplastic changes in the brain causing an acute withdrawal syndrome upon cessation of drinking followed by a protracted abstinence syndrome and an increased risk of relapse to heavy drinking. Benzodiazepines have long been the treatment of choice for detoxifying patients and managing alcohol withdrawal syndrome (AWS). Non-benzodiazepine anticonvulsants (NBACs) are increasingly being used both for alcohol withdrawal management and for ongoing outpatient treatment of alcohol dependence, with the goal of either abstinence or harm reduction. This expert narrative review summarizes the scientific basis and clinical evidence supporting the use of NBACs in treating AWS and for reducing harmful drinking patterns. There is less evidence in support of NBAC therapy for AWS, with few placebo-controlled trials. Carbamazepine and gabapentin appear to be the most promising adjunctive treatments for AWS, and they may be useful as monotherapy in select cases, especially in outpatient settings and for the treatment of mild-to-moderate low-risk patients with the AWS. The body of evidence supporting the use of the NBACs for reducing harmful drinking in the outpatient setting is stronger. Topiramate appears to have a robust effect on reducing harmful drinking in alcoholics. Gabapentin is a potentially efficacious treatment for reducing the risk of relapse to harmful drinking patterns in outpatient management of alcoholism. Gabapentin's ease of use, rapid titration, good tolerability, and efficacy in both the withdrawal and chronic phases of treatment make it particularly appealing. In summary, several NBACs appear to be beneficial in treating AWS and alcohol use disorders.

Heart failure and Alzheimer's disease

It has recently been proposed that heart failure is a risk factor for Alzheimer's disease. Decreased cerebral blood flow and neurohormonal activation due to heart failure may contribute to the dysfunction of the neurovascular unit and cause an energy crisis in neurons. This leads to the impaired clearance of amyloid beta and hyperphosphorylation of tau protein, resulting in the formation of amyloid beta plaques and neurofibrillary tangles. In this article, we will summarize the current understanding of the relationship between heart failure and Alzheimer's disease based on epidemiological studies, brain imaging research, pathological findings and the use of animal models. The importance of atherosclerosis, myocardial infarction, atrial fibrillation, blood pressure and valve disease as well as the effect of relevant medications will be discussed.

Reliability and validity of the Chinese version of the Neurological Disorders Depression Inventory for Epilepsy (C-NDDI-E)

OBJECTIVE

The aim of this study was to evaluate the clinical reliability and validity of the Chinese version of the Neurological Disorders Depression Inventory for Epilepsy (C-NDDI-E).

METHODS

A total of 248 Chinese patients with epilepsy underwent psychometric tests, including the Chinese version of the Mini International Neuropsychiatric Interview (C-MINI), the Chinese version of the Beck Depression Inventory - II (C-BDI-II), and the C-NDDI-E.

RESULTS

None of the patients had difficulties understanding or completing the C-NDDI-E. Cronbach's α coefficient was 0.824. At a cutoff score of ≥14, the C-NDDI-E had a sensitivity of 0.854, a specificity of 0.899, a positive predictive value of 0.625, and a negative predictive value of 0.969. The scores for the C-NDDI-E were positively correlated with those for the C-BDI-II (P<0.001).

CONCLUSION

The C-NDDI-E is a reliable and valid screening tool for the detection of major depression in Chinese patients with epilepsy.

Comparison of common data elements from the Managing Epilepsy Well (MEW) Network integrated database and a well-characterized sample with nonepileptic seizures

INTRODUCTION

Epilepsy and psychogenic nonepileptic seizures (PNES) are both chronic illnesses characterized by similar and overlapping clinical features. A limited number of studies comparing people with epilepsy (PWE) and patients with PNES that address determinants of health outcomes exist. We conducted an analysis using a well-characterized sample of people with PNES and the Managing Epilepsy Well (MEW) Network integrated data, comparing descriptive data on samples with epilepsy and with documented PNES. Based on the pooled data, we hypothesized that people with PNES would have worse QOL and higher depression severity than PWE.

MATERIAL AND METHODS

We used data from the MEW Network integrated database involving select epilepsy self-management studies comprising 182 PWE and 305 individuals with documented PNES from the Rhode Island Hospital Neuropsychiatry and Behavioral Neurology Clinic. We conducted a matched, case-control study assessing descriptive comparisons on 16 common data elements that included gender, age, ethnicity, race, education, employment, income, household composition, relationship status, age at seizure onset, frequency of seizures, seizure type, health status, healthy days, quality of life, and depression. Standardized rating scales for depression and quality of life were used.

RESULTS

Median seizure frequency in the last 30days for PWE was 1, compared to 15 for patients with PNES (p<0.05). People with epilepsy had a QOLIE-10 mean score of 3.00 (SD: 0.91) compared to 3.54 (0.88) (p<0.01) for patients with PNES. Depression severity was moderate to severe in 7.7% of PWE compared to 34.1% (p<0.05) of patients with PNES.

DISCUSSION

People with epilepsy in selected MEW Network programs are fairly well educated, mostly women, with few minorities and low monthly seizure rates. Those with PNES, however, have higher levels of not working/on disability and had more frequent seizures, higher depression severity, and worse QOL. These differences were present despite demographics that are largely similar in both groups, illustrating that other determinants of illness may influence PNES.

Predicting treatment failure in pathological gambling: the role of personality traits

INTRODUCTION

The aim of this study was twofold: First, to assess the personality profile of treatment-seeking adult outpatients with pathological gambling compared to a matched control group under the Alternative Five Factor Model perspective, and second, to determine which personality variables would predict treatment outcome.

METHODS

The final total sample consisted of 44 consecutive treatment-seeking pathological gamblers (PGs) and 88 controls paired by age and sex who completed the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ). Twelve months after starting an open program of individual cognitive-behavioral therapy, PGs were categorized as abstinent or treatment failure.

RESULTS

PGs scored significantly higher on Neuroticism-Anxiety. Those who had relapsed or dropped out showed higher Impulsivity and Sensation Seeking scores. Impulsivity emerged as a significant predictor of treatment failure. Treatment-seeking PGs scored higher on Neuroticism-Anxiety and Impulsivity appeared as a risk factor of relapsing or dropping out.

CONCLUSIONS

Our findings support the importance of individual differences in personality on therapy outcomes. The ZKPQ may constitute a useful tool to identify these individual differences that might be considered when making personalized treatment decisions to improve the effectiveness and quality of treatment interventions.

Co-occurrence of alcohol use disorder and behavioral addictions: relevance of impulsivity and craving

PURPOSE

The aims of the study were to evaluate the occurrence of behavioral addictions (BAs) in alcohol use disorder (AUD) subjects and to investigate the role of impulsivity, personality dimensions and craving.

METHODS

95 AUD outpatients (DSM-5) and 140 homogeneous controls were assessed with diagnostic criteria and specific tests for gambling disorder, compulsive buying, sexual, internet and physical exercise addictions, as well as with the Barratt Impulsiveness Scale (BIS-11) and Temperamental and Character Inventory-Revised (TCI-R). The Obsessive Compulsive Drinking Scale (OCDS) and Visual Analogue Scale for craving (VASc) were also administered to the AUD sample.

RESULTS

28.4% (n=27) of AUD subjects had at least one BA, as compared to 15% (n=21) of controls (χ(2)=6.27; p=.014). In AUD subjects, direct correlations between BIS-11 and Compulsive Buying Scale (CBS), Internet Addiction Disorder test (IAD), Exercise Addiction Inventory-Short Form (EAI-SF) scores (p<.01), between OCDS obsessive and CBS and VASc and CBS, IAD scores (p<.003), were found. BIS-11 (t=-2.36; p=.020), OCDS obsessive (Z=-4.13; p<.001), OCDS compulsive (Z=-2.12; p=.034) and VASc (Z=-4.94; p<.001) scores were higher in AUD subjects with co-occurring BAs. The occurrence of BAs was associated with higher impulsivity traits (BIS-11 scores; OR=1.08; p=.012) and higher craving levels (VASc scores; OR=2.48; p<.001).

CONCLUSIONS

Our findings emphasize a significant rate of co-occurrence of BAs in AUD. High levels of impulsivity and craving for alcohol seem to be associated with other addictive behaviors.

Dissociative experiences in epilepsy: effects of epilepsy-related factors on pathological dissociation

Psychogenic nonepileptic seizures (PNESs) in patients with epilepsy can be categorized as dissociative disorders. The prevalence of PNESs in patients with epilepsy appears to be much higher than that of dissociative experiences in nonclinical subjects. In order to clarify as to whether epilepsy-related factors were associated with pathological dissociation, we conducted a controlled study with 225 patients with epilepsy and 334 nonclinically matched individuals. All participants completed the Japanese version of the Dissociative Experiences Scale (DES). There was no significant difference in the DES score (DES-S) between the group with epilepsy and the control group. The group with epilepsy showed a significantly higher DES taxon (DES-T; a subset of DES-S and an index of pathological dissociation) than the control group. Thirty-one out of the 225 patients with epilepsy (13.8%) had PNESs. Because of its strong association with the DES-S and DES-T, PNESs can be regarded as a symptom of dissociation. With multiple regression analysis, the patients with a shorter duration of epilepsy, higher seizure frequency, or shorter period in education tend to suffer from pathological dissociation. These findings demonstrate that patients with epilepsy are more prone to experiencing pathological dissociation when having certain clinical factors.

One step closer to a global tool for rapid screening of major depression in epilepsy: validation of the French NDDI-E

OBJECTIVE

Depression in people with epilepsy (PWE) is underdiagnosed and undertreated. The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is a screening questionnaire used for detecting major depressive episode (MDE) in PWE, and is already validated in 10 languages. However a version in French, one of the world's widely spoken languages, was, until now, lacking. We aimed to translate and validate the French NDDI-E.

METHODS

This study was performed under the auspices of the ILAE. People with epilepsy >18years of age were recruited from 2 specialist epilepsy units in Marseille, France. Two native French speakers and 2 native English speakers performed a forward-backward translation. The Mini International Neuropsychiatric Interview (MINI) was performed as the gold standard, and the Center for Epidemiological Studies Depression symptoms index (CES-D) was performed for external validity. Data were compared between PWE with MDE and PWE without MDE using the chi-square test and Student's t-test. Internal structural validity, external validity, and receiver operator characteristics were analyzed.

RESULTS

Testing was performed on 116 PWE: mean age=40.39years (SD=13.83, range: [18-81]years old); 58.6% (68) were women; 87.1% had focal epilepsy. Using the MINI, we found that 33 (28.4%) patients had current MDE and that 15 (12.9%) patients had dysthymia; also, we found that 37 (31.9%) patients presented suicidal ideation and/or behavior. Cronbach's alpha coefficient was 0.838, indicating satisfactory internal consistency. Correlation between the NDDI-E and the CES-D scores was high (r(116)=0.817, p<0.0001), indicating good external validity. Receiver operator characteristic analysis showed an area under the curve of 0.958 (95% CI=0.904-0.986), (p<0.0001), indicating good capacity of the NDDI-E to detect MDE (defined by MINI). The cutoff for maximal sensitivity and specificity was 15. The mean NDDI-E score in PWE with MDE was 18.27 (SD=2.28), and the mean NDDI-E score in PWE without MDE was 10.61 (SD=3.63).

SIGNIFICANCE

This study validated the French NDDI-E, with a cutoff score of 15/24 for MDE, similar to previous studies, and reinforces the NDDI-E as a global tool for detection of MDE.

Perceived emotional intelligence is impaired and associated with poor community functioning in schizophrenia and bipolar disorder

Schizophrenia and bipolar disorder have been associated with shared and distinct emotion processing abnormalities. Initial findings indicate that these disorders differ with respect to the domain of emotional intelligence (EI). Individuals with schizophrenia display deficits on performance measures of EI, whereas those with bipolar disorder do not. However, no research has examined patients' subjective beliefs about their own EI (referred to as "perceived EI"). This study examined perceived EI, assessed with the Trait Meta-Mood Scale (TMMS), and its clinical and functional correlates in outpatients with schizophrenia (n=35) or bipolar disorder I (n=38) and matched healthy controls (n=35). The TMMS includes three subscales that assess beliefs about one's ability to attend to (Attention to Feelings), understand (Clarity of Feelings), and repair emotions (Mood Repair). Participants in the clinical groups also completed community functioning and symptom assessments. Both clinical groups reported significantly lower perceived EI than controls, but did not differ from each other. Higher total TMMS correlated with higher levels of independent living in the schizophrenia group (r=.36) and better social functioning in the bipolar group (r=.61). In addition, although higher Attention to Feelings scores correlated with greater psychiatric symptoms in the schizophrenia group, higher scores across all subscales correlated with less manic symptoms in the bipolar group. The findings suggest that perceived EI is impaired and related to community functioning in both disorders.

Depression and cerebrovascular disease: could vortioxetine represent a valid treatment option?

INTRODUCTION

Depression and cerebrovascular atherosclerosis often occur in comorbidity showing neuropsychological impairment and poor response to antidepressant treatment. Objective is to evaluate if new antidepressant vortioxetine may be a potential treatment option. Mechanism of Action : Vortioxetine has 5-HT3, 5-HT7 and 5-HT1D antagonists, 5-HT1B partial agonist and a 5-HT1A agonist and serotonin transporter inhibitor property. Efficacy and safety in Major Depressive Disorders and in cognitive impairment : The majority of trials (one of them in older people) showed efficacy for vortioxetine against placebo and no differences against other active treatments. The Adverse Effects ranged from 15.8% more to 10.8% less than placebo. In the elderly, only nausea was found higher than placebo. Effects on arterial blood pressure and cardiac parameters including the ECG-QT segment were similar to placebo. Elderly depressive patients on vortioxetine showed improvement versus placebo and other active comparators in Auditory Verbal Learning Test and Digit Symbol Substitution Test scores. The inclusion criteria admitted cases with middle cerebrovascular disease. Conclusion : The mechanism of action, the efficacy on depression and safety profile and early data on cognitive impairment make Vortioxetine a strong candidate for use in depression associated with cerebrovascular disease. This information must be supported by future randomized controlled trials.

Vitamin D and the omega-3 fatty acids control serotonin synthesis and action, part 2: relevance for ADHD, bipolar disorder, schizophrenia, and impulsive behavior

Serotonin regulates a wide variety of brain functions and behaviors. Here, we synthesize previous findings that serotonin regulates executive function, sensory gating, and social behavior and that attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and impulsive behavior all share in common defects in these functions. It has remained unclear why supplementation with omega-3 fatty acids and vitamin D improve cognitive function and behavior in these brain disorders. Here, we propose mechanisms by which serotonin synthesis, release, and function in the brain are modulated by vitamin D and the 2 marine omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Brain serotonin is synthesized from tryptophan by tryptophan hydroxylase 2, which is transcriptionally activated by vitamin D hormone. Inadequate levels of vitamin D (∼70% of the population) and omega-3 fatty acids are common, suggesting that brain serotonin synthesis is not optimal. We propose mechanisms by which EPA increases serotonin release from presynaptic neurons by reducing E2 series prostaglandins and DHA influences serotonin receptor action by increasing cell membrane fluidity in postsynaptic neurons. We propose a model whereby insufficient levels of vitamin D, EPA, or DHA, in combination with genetic factors and at key periods during development, would lead to dysfunctional serotonin activation and function and may be one underlying mechanism that contributes to neuropsychiatric disorders and depression. This model suggests that optimizing vitamin D and marine omega-3 fatty acid intake may help prevent and modulate the severity of brain dysfunction.

Efficacy and safety of conversion to monotherapy with eslicarbazepine acetate in adults with uncontrolled partial-onset seizures: a randomized historical-control phase III study based in North America

Objective

To assess the efficacy and safety of eslicarbazepine acetate (ESL) as monotherapy in North American patients with partial‐onset seizures (POS).

Methods

This multicenter, randomized, double‐blind “withdrawal to monotherapy” study used historical control data as the comparator. Adults with POS medically uncontrolled by one to two antiepileptic drugs gradually converted to ESL monotherapy. Following an 8‐week baseline period, patients were randomized 2:1 to receive ESL 1,600 mg (n = 128) or 1,200 mg QD (n = 65) for 18 weeks. The primary end point was the proportion of patients meeting predefined exit criteria (signifying worsening seizure control). Treatment was considered effective if the 95% upper confidence limit (UCL) for the Kaplan‐Meier estimated exit rate was lower than the exit rate threshold calculated from the historical control (65.3%).

Results

Kaplan‐Meier estimated exit rates were: ESL 1,600 mg, 28.7% (95% CI 21.2–38.1%) and 1,200 mg, 44.4% (32.5–58.3%). The difference between doses was not significant (p = 0.07). For both doses, the 95% UCLs for the exit rate were ˂65.3%; ESL monotherapy was considered superior to the historical control. There was no statistically significant increase in the risk of study exit related to carbamazepine use. Nine (7.6%) and five patients (8.3%) remained seizure‐free during the 10‐week monotherapy period, while taking ESL 1,600 and 1,200 mg, respectively. The reductions in median standardized seizure frequency (seizures per 28 days) between baseline and the 18‐week treatment period were: ESL 1,600 mg, 42% and 1,200 mg, 31%. Treatment‐emergent adverse events (TEAEs) occurring in ≥10% of patients were dizziness, headache, fatigue, somnolence, nausea, and nasopharyngitis. The TEAE most frequently leading to discontinuation was hyponatremia (2.1%).

Significance

ESL was efficacious and well tolerated as monotherapy in North American patients, and led to a reduction in seizure frequency. Exit rates for ESL 1,600 and 1,200 mg QD were superior to the historical control; the difference in exit rates between doses was not statistically significant.

Venular degeneration leads to vascular dysfunction in a transgenic model of Alzheimer's disease

Most patients with Alzheimer's disease exhibit accumulation of amyloid-β peptide on leptomeningeal and cortical arterioles, or cerebral amyloid angiopathy, which is associated with impaired vascular reactivity and accelerated cognitive decline. Despite widespread recognition of the significance of vascular dysfunction in Alzheimer's disease aetiology and progression, much uncertainty still surrounds the mechanism underlying Alzheimer's disease vascular injury. Studies to date have focused on amyloid-β-induced damage to capillaries and plaque-associated arterioles, without examining effects across the entire vascular bed. In the present study, we investigated the structural and functional impairment of the feeding arteriolar versus draining venular vessels in a transgenic murine Alzheimer's disease model, with a particular focus on the mural cell populations that dictate these vessels' contractility. Although amyloid-β deposition was restricted to arterioles, we found that vascular impairment extended to the venules, which showed significant depletion of their mural cell coverage by the mid-stage of Alzheimer's disease pathophysiology. These structural abnormalities were accompanied by an abolishment of the normal vascular network flow response to hypercapnia: this functional impairment was so severe as to result in hypercapnia-induced flow decreases in the arterioles. Further pharmacological depletion of mural cells using SU6668, a platelet-derived growth factor receptor-β antagonist, resulted in profound structural abnormalities of the cortical microvasculature, including vessel coiling and short-range looping, increased tortuosity of the venules but not of the arterioles, increased amyloid-β deposition on the arterioles, and further alterations of the microvascular network cerebral blood flow response to hypercapnia. Together, this work shows hitherto unrecognized structural alterations in penetrating venules, demonstrates their functional significance and sheds light on the complexity of the relationship between vascular network structure and function in Alzheimer's disease.

Effects of pregabalin in patients with hypnotic-dependent insomnia

STUDY OBJECTIVES

Long-term use of hypnotics runs the risk of dependency, and subjects usually experience difficulties in withdrawal. The objective of this study was to investigate the success of withdrawal using pregabalin and its efficacy on sleep in patients with hypnotic-dependent insomnia.

METHODS

We enrolled patients with hypnotic-dependent insomnia who were 18 years or older. The starting dosage of pregabalin was 75 mg/day and was increased up to as much as 300 mg/day, depending on the individual patient's condition, while tapering off hypnotics. After 4 weeks of titration, the final dosage amount was maintained for at least another 4 weeks. Sleep and clinical variables were evaluated at baseline and after treatment, using the Korean versions of various sleep questionnaires as well as polysomnography.

RESULTS

Forty subjects were enrolled, with a mean age of 52.0 ± 8.5 years, of whom 28 (70.0%) were women. Twenty-one (52.5%) subjects successfully withdrew from hypnotics. The duration of withdrawal was 42.1 ± 16.0 days (range: 27.0∼84.0). The mean pregabalin dose was 121.4 ± 69.0 mg/day (range: 75.0∼300.0). After pregabalin treatment, there was a significant improvement in the total score of the Pittsburgh Sleep Quality Index (15.0 ± 2.1, 8.9 ± 3.0, p < 0.001), and insomnia severity index (20.9 ± 4.3, 9.6 ± 4.4, p < 0.001); however, most of the sleep variables of the PSG showed no differences. The main adverse effects of pregabalin were nausea and dizziness.

CONCLUSIONS

Our results showed pregabalin may be a promising candidate for withdrawal from hypnotics and improved sleep in patients with hypnotic-dependent insomnia.

Hypoactivation of the ventral and dorsal striatum during reward and loss anticipation in antipsychotic and mood stabilizer-naive bipolar disorder

Increased activity within known reward-processing neurocircuitry (eg, ventral striatum, VS) has been reported among medicated individuals with bipolar disorder (BD) I and II. However, such findings are confounded by the potential ameliorative effects of mood-stabilizing and antipsychotic medications on neural activations. This study tests the hypothesis that a pathophysiological locus of alterations in reward processing is present within the striatum in antipsychotic and lithium-naive individuals with BD. Twenty antipsychotic and lithium-naive individuals with BD II or BD not-otherwise specified (NOS) and 20 matched healthy comparison individuals participated in functional magnetic resonance imaging during the performance of a monetary incentive delay task. Between-group comparisons were conducted using small-volume correction focusing on orthogonal a priori regions of interest centered in the VS and dorsal striatum (DS), respectively. During reward anticipation, unmedicated individuals with BD II/NOS had decreased activity within the DS (but not VS). During loss anticipation, on the other hand, decreased activation within both the VS and DS was observed. Across all participants, DS activity (during reward anticipation) was positively associated with putamen volume. This is the first report of decreased dorsal and ventral striatal activity among unmedicated individuals with BD II/NOS. These data contradict a simple 'reward hypersensitivity' model of BD, and add to a growing body of literature suggesting that blunted reward processing may be a vulnerability factor for both mood- and addiction-related disorders.

BRCA1 and p53 tumor suppressor molecules in Alzheimer's disease

Tumor suppressor molecules play a pivotal role in regulating DNA repair, cell proliferation, and cell death, which are also important processes in the pathogenesis of Alzheimer’s disease. Alzheimer’s disease is the most common neurodegenerative disorder, however, the precise molecular events that control the death of neuronal cells are unclear. Recently, a fundamental role for tumor suppressor molecules in regulating neurons in Alzheimer’s disease was highlighted. Generally, onset of neurodegenerative diseases including Alzheimer’s disease may be delayed with use of dietary neuro-protective agents against oxidative stresses. Studies suggest that dietary antioxidants are also beneficial for brain health in reducing disease-risk and in slowing down disease-progression. We summarize research advances in dietary regulation for the treatment of Alzheimer’s disease with a focus on its modulatory roles in BRCA1 and p53 tumor suppressor expression, in support of further therapeutic research in this field.

Using a single screening question for depressive symptoms in patients with acute coronary syndrome

BACKGROUND

Despite the prevalence of depressive symptoms and increased risk for future cardiovascular events, depressive symptoms frequently go underrecognized in patients hospitalized for acute coronary syndrome (ACS). Identifying an effective approach to depressive symptom screening is imperative in this population.

OBJECTIVE

The purpose of this cross-sectional study was to explore the agreement between Beck Depression Inventory-II (BDI-II) scores and a single screening question for depressive symptoms in 1122 patients hospitalized for ACS.

METHODS

Independent-samples t tests and χ tests were used to compare the groups with BDI-II scores of 14 or higher and lower than 14. Three separate agreement analyses were conducted using categorized BDI-II scores (≥14, ≥20, and ≥29). Agreement of the BDI-II categories with the responses to the single screening question was assessed with the simple κ statistic. Sensitivity and specificity were calculated using the BDI-II categories as the criterion standards for depressive symptom screening.

RESULTS

The agreement analysis revealed a moderate level of agreement (κ coefficient = 0.42) between the BDI-II scores of 14 or higher and the single screening question. Of the participants who reported a BDI-II score of 14 or higher, 61.65% answered yes to the single screening question (sensitivity, 0.62). For those who had BDI-II scores of lower than 14, a total of 82% responded no to the single screening question (specificity, 0.82). When using higher BDI-II scores to define depressive symptoms (≥20 and ≥29), the level of agreement decreased, whereas sensitivity increased to 0.76 and 0.90, with a trade-off in specificity (0.79 and 0.74, respectively).

CONCLUSIONS

These results suggest that the single screening question for depressive symptoms correctly identifies depressive symptoms 62% of the time but inappropriately identifies depressive symptoms 18% of the time in patients hospitalized for ACS. This suggests that the single screening question for depressive symptoms may be used with caution to initially screen patients with ACS, who can then undergo a more thorough assessment for clinical depression.

Ginkgo biloba on focal cerebral ischemia: a systematic review and meta-analysis

Gingko biloba extract (EGB) has been used in traditional medicines for centuries, and although its application to cerebral ischemia has been of great interest in recent years, high quality evidence-based clinical trials have not been carried out. This systematic review and meta-analysis aimed to examine the neuroprotective effect of EGB on focal cerebral ischemia in animal models. A systematic literature search was performed using five databases spanning January 1980-July 2013. The outcome was assessed using the effect size, which was based on infarct size and/or neurological score. A total of 42 studies with 1,232 experimental animals matched our inclusion criteria. The results revealed that EGB improved the effect size by 34% compared to the control group. The animal species, the method and time to measure outcome, and the route and dosage of EGB administration affected the variability of the effect size. Mechanisms of EGB neuroprotection were reported as anti-apoptotic, anti-oxidative, and anti-inflammatory. In conclusion, EGB exerts a significant protective effect on experimental focal cerebral ischemia. However, possible experimental bias should be taken into account in future clinical studies.

Agomelatine beyond borders: current evidences of its efficacy in disorders other than major depression

Agomelatine, a melatonergic antidepressant with a rapid onset of action, is one of the most recent drugs in the antidepressant category. Agomelatine's antidepressant actions are attributed to its sleep-promoting and chronobiotic actions mediated by MT1 and MT2 receptors present in the suprachiasmatic nucleus, as well as to its effects on the blockade of 5-HT2c receptors. Blockade of 5-HT2c receptors causes release of both noradrenaline and dopamine at the fronto-cortical dopaminergic and noradrenergic pathways. The combined actions of agomelatine on MT1/MT2 and 5-HT2c receptors facilitate the resynchronization of altered circadian rhythms and abnormal sleep patterns. Agomelatine appeared to be effective in treating major depression. Moreover, evidence exists that points out a possible efficacy of such drug in the treatment of bipolar depression, anxiety disorders, alcohol dependence, migraines etc. Thus, the aim of this narrative review was to elucidate current evidences on the role of agomelatine in disorders other than major depression.

SERT and NET polymorphisms, temperament and antidepressant response

BACKGROUND

The genetic variations in norepinephrine transporter (NET) and serotonin transporter (SERT) genes have been associated with personality traits, several psychiatric disorders and the efficacy of antidepressant treatment.

AIMS

We investigated the separate effects and possible interactions between NET T-182C (rs2242446) and SERT 5-HTTLPR (rs4795541) polymorphisms on selective serotonin reuptake inhibitors (SSRI) treatment response and temperamental traits assessed by the Temperament and Character Inventory (TCI) in a clinical sample of subjects with major depressive disorder (MDD).

METHODS

Our sample of 97 patients with major depression completed the 107-item TCI temperament questionnaire (version IX) at the initial assessment of the study and after 6 weeks of follow-up. All subjects received selective SSRI medications. Temperament dimension scores at baseline ( 1 ) and endpoint ( 2 ) during antidepressant treatment were analyzed between NET and SERT genotypes.

RESULTS

SS-genotype of 5-HTTLPR was associated with higher baseline Persistence scores than SL- or LL-genotype. A corresponding but weaker association was found at endpoint. No differences were found between 5-HTTLPR genotypes and other temperament dimensions and 5-HTTLPR genotypes had no effect on treatment response.

CONCLUSIONS

Our results suggest that the SS-genotype of 5-HTTLPR is associated with Persistence scores in patients with MDD. Higher Persistence could be viewed as a negative trait when recovering from stress and its association with short and "weaker" S-allele may be related to less efficient serotonin neurotransmission, possibly resulting in less effective coping strategies on a behavioral level.

Aripiprazole adjunct treatment in bipolar I or II disorder, depressed state: a 2-year clinical study

The symptomatic course of bipolar disorder (BPD) is chronic and dominated by depression. As recurrence rates are high, maintenance therapy is required. Although efficacious, mood stabilizers may be hampered by poor adherence, and second-generation antipsychotic medications may be associated with weight gain and metabolic abnormalities. There is evidence to suggest that aripiprazole is beneficial in major depressive disorder and BPD with depression. We therefore investigated 2-year clinical outcomes with aripiprazole adjunct therapy at 5 to 15 mg once daily alongside a mood stabilizer in 40 patients with BPD. All patients experienced marked improvements in Montgomery-Åsberg Depression Rating Scale scores by 6 weeks and substantial reductions in Clinical Global Impressions Scale scores by 6 months. All patients were able to return to optimal or premorbid functioning by 6 months to 1 year. By 1 year, all patients made a complete functional recovery on the Sheehan Disability Scale. Improvements were maintained on all measures up to 2 years. There were minimal adverse events, all of which decreased during therapy. Our findings indicate that aripiprazole adjunct treatment is safe and effective as an acute and maintenance therapy for BPD. However, the findings will need to be replicated by larger studies.

Comparison of the effects of escitalopram and nortriptyline on painful symptoms in patients with major depression

OBJECTIVE

Unexplained painful physical symptoms are commonly reported by depressed patients. The evidence suggests that dual-action antidepressants are potent in relieving pain in depression. However, a direct comparison of the effects of selective serotonergic and selective noradrenergic antidepressants on painful symptoms has not been investigated so far.

METHOD

Sixty patients who participated in the Genome-based Therapeutic Drugs for Depression study with a diagnosis of moderate or severe episodes of depression according to the International Classification of Diseases, 10th Revision, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were involved. All the participants were randomly allocated to receive nortriptyline or escitalopram. The severity of depression was measured using the Montgomery-Åsberg Depression Rating Scale, the Hamilton Depression Rating Scale and the Beck Depression Inventory at weeks 0, 2, 4, 6 and 8. The intensity of pain was measured on the Visual Analog Scale at the same points of the study.

RESULTS

At "week 0," 83.3% of the patients later randomized to treatment with escitalopram and 86.7% of those treated with nortriptyline reported at least one painful symptom. A significant decrease of pain intensity was observed after 2 weeks of treatment. The two groups did not differ in degree of pain reduction at weeks 2, 4, 6 and 8 in comparison to baseline values. A 50% reduction in pain intensity preceded the 50% reduction of depression severity. The intensity of pain at "week 0" did not differ in remitted or nonremitted patients at week 8.

CONCLUSION

Both selective serotonergic and selective noradrenergic antidepressants are equally effective in alleviations of painful physical symptoms of depression. The presence of painful symptoms before the onset of treatment did not determine the final response.

Comorbid bipolar disorder and borderline personality disorder and substance use disorder

Bipolar disorder (BD) and borderline personality disorder (BPD) are disabling and life-threatening conditions. Both disorders share relevant comorbidities, particularly the risk of having a lifetime substance use disorder (SUD). We tested the hypothesis that patients with both BD type I (BDI) or II (BDII) and BPD would have a higher rate of SUD than would patients with either disorder alone. A total of 3651 psychiatric patients were evaluated with semistructured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, axis I and II disorders. A total of 63 patients were diagnosed with both BD and BPD, and these patients were significantly more likely to have a SUD compared with BDII patients without BPD (76% vs. 50%, χ = 9.69, p < 0.01). There were no differences when comparing the comorbid group with BPD patients without BD (76% vs. 71%, χ = 0.519, p = 0.4). The present study shows the importance of taking both BPD and BD into consideration insofar as the co-occurrence of the disorders increased the risk of having a SUD especially when compared with BDII alone.

Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice

More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review.

Validation of the Chinese Version of the Short TEMPS-A and its application in patients with mood disorders

BACKGROUND

The short version of Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego-Auto-questionnaire (TEMPS-A) is a useful instrument to measure affective temperaments. Aims of the present study are to validate the Chinese Version of the Short TEMPS-A, and to explore whether it could be useful to distinguish patients with mood disorders from healthy controls or differentiate patients with bipolar disorder (BPD) from those with major depressive disorder (MDD) in Chinese population.

METHODS

A sample of 715 participants, including 387 patients with MDD, 143 with BPD and 185 healthy controls, was recruited. All participants completed The Chinese Version of the Short TEMPS-A. Standard psychometric tests of reliability and validation were performed. ANOVA, non-parameter test and Multiple Logistic Regression were used to test the association between TEMPS-A scores and mood disorders.

RESULTS

The originally proposed five factors of the Chinese Version of the Short TEMPS-A were upheld. The Chronbach-Alpha coefficients of it varied from 0.70 to 0.89 and test-retest Spearman׳s Correlation Coefficients varied from 0.52 to 0.85. Significant differences were found across the three groups on all five TEMPS-A subscales (P<0.001). Multiple Logistic Regression showed that hyperthymic temperament distinguished patients with BPD from those with MDD (OR 1.28, 95% CI 1.14-1.45, P<0.001) after controlling for age, gender and the severity of depression.

LIMITATIONS

The cross-sectional self-report design, unbalanced demographic characteristics and undifferentiated subtypes of bipolar disorders might limit the generalizability of the results.

CONCLUSION

The Chinese Version of the Short TEMPS-A shows good reliability and validity. It might be used as a screening tool in the general population to identify the vulnerability for developing a mood disorder and the potential risk for bipolar disorder among those who only have depressive symptoms.

Anhedonia in depressed patients on treatment with selective serotonin reuptake inhibitor anti-depressant--A two-centered study in Malaysia

OBJECTIVE

Anhedonia is the reduced ability to experience pleasure. It is a core symptom of depression and is particularly difficult to treat. This study aims to compare the level of anhedonia between depressed patients on anti-depressants and healthy subjects.

METHOD

A total of 111 depressed patients on selective serotonin reuptake inhibitor (SSRI) and 82 healthy subjects were recruited from the outpatient psychiatric services at two major general hospitals in a cross-sectional study. Subjects were assessed using the Mini International Neuropsychiatric Interview 5.0.0 or MINI, Beck's Depression Index (BDI), and Snaith-Hamilton Pleasure Scale (SHAPS). Relevant personal and sociodemographic information were also collected.

RESULTS

There was a significant association between educational level and SHAPS-M scores (P < 0.01) among the participants. Most items in the SHAPS scores were significantly different (P < 0.01) in the depressed subjects treated with anti-depressant compared with the healthy subjects, after adjusting the confounding factors, BDI score, and educational level.

CONCLUSION

Anhedonia often persists in depressed patients despite on SSRI anti-depressant treatment.

Korean Medication Algorithm Project for Bipolar Disorder: third revision

OBJECTIVE

To constitute the third revision of the guidelines for the treatment of bipolar disorder issued by the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP 2014).

METHODS

A 56-item questionnaire was used to obtain the consensus of experts regarding pharmacological treatment strategies for the various phases of bipolar disorder and for special populations. The review committee included 110 Korean psychiatrists and 38 experts for child and adolescent psychiatry. Of the committee members, 64 general psychiatrists and 23 child and adolescent psychiatrists responded to the survey.

RESULTS

The treatment of choice (TOC) for euphoric, mixed, and psychotic mania was the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP); the TOC for acute mild depression was monotherapy with MS or AAP; and the TOC for moderate or severe depression was MS plus AAP/antidepressant. The first-line maintenance treatment following mania or depression was MS monotherapy or MS plus AAP; the first-line treatment after mania was AAP monotherapy; and the first-line treatment after depression was lamotrigine (LTG) monotherapy, LTG plus MS/AAP, or MS plus AAP plus LTG. The first-line treatment strategy for mania in children and adolescents was MS plus AAP or AAP monotherapy. For geriatric bipolar patients, the TOC for mania was AAP/MS monotherapy, and the TOC for depression was AAP plus MS or AAP monotherapy.

CONCLUSION

The expert consensus in the KMAP-BP 2014 differed from that in previous publications; most notably, the preference for AAP was increased in the treatment of acute mania, depression, and maintenance treatment. There was increased expert preference for the use of AAP and LTG. The major limitation of the present study is that it was based on the consensus of Korean experts rather than on experimental evidence.