DSM-5 reviewed from different angles: goal attainment, rationality, use of evidence, consequences—part 2: bipolar disorders, schizophrenia spectrum disorders, anxiety disorders, obsessive-compulsive disorders, trauma- and stressor-related disorders, personality disorders, substance-related and addictive disorders, neurocognitive disorders

Examining Outcomes and Challenges of Telepsychiatry in Australian Elderly: A Scoping Review

Methods

To find relevant articles, we searched PubMed, Scopus, and Web of Science databases. We used a data extraction form to gather information from primary studies. Two researchers followed inclusion and exclusion criteria to select studies and extract data. Disagreements were resolved through discussion with all researchers. Studies needed to be in English, about telepsychiatry for Australian seniors, and use any technology type (synchronous, asynchronous, or both). We excluded nontelepsychiatry articles, books, book chapters, conference abstracts, and editor letters.

Results

Telepsychiatry was effectively employed to manage depression, anxiety, delirium, and cognitive impairments. Among these four disorders, telepsychiatry was mostly used for depression. Videoconference and telephone were mostly used to provide telepsychiatry services. Most telepsychiatry services for Australian seniors included "patient education on disorder control and management," "creating continuous interaction between the patient and the therapist," and "remote patients' assessment." "Reductions in symptoms of disorders," "improving patients' satisfaction with telepsychiatry," and "cost-effectiveness of telepsychiatry" were the most important positive outcomes of using telepsychiatry. We also identified four challenges in using telepsychiatry for elderly individuals in Australia.

Conclusions

This study is the first scoping review in Australia and provides valuable insight into telepsychiatry for elderly individuals.

Increased Serum NSE and S100B Indicate Neuronal and Glial Alterations in Subjects Under 71 Years With Mild Neurocognitive Disorder/Mild Cognitive Impairment

Background

Mild cognitive impairment (MCI) is considered a pre-stage of different dementia syndromes. Despite diagnostic criteria refined by DSM-5 and a new term for MCI – “mild neurocognitive disorder” (mild NCD) – this diagnosis is still based on clinical criteria.

Methods

To link mild NCD to the underlying pathophysiology we assessed the degree of white matter hyperintensities (WMH) in the brain and peripheral biomarkers for neuronal integrity (neuron-specific enolase, NSE), plasticity (brain-derived neurotrophic factor, BDNF), and glial function (S100B) in 158 community-dwelling subjects with mild NCD and 82 healthy controls. All participants (63–79 years old) were selected from the Leipzig-population-based study of adults (LIFE).

Results

Serum S100B levels were increased in mild NCD in comparison to controls (p = 0.007). Serum NSE levels were also increased but remained non-significant after Bonferroni-Holm correction (p = 0.04). Furthermore, age by group interaction was significant for S100B. In an age-stratified sub-analysis, NSE and S100B were higher in younger subjects with mild NCD below 71 years of age. Some effects were inconsistent after controlling for potentially confounding factors. The discriminatory power of the two biomarkers NSE and S100B was insufficient to establish a pathologic threshold for mild NCD. In subjects with mild NCD, WMH load correlated with serum NSE levels (r = 0.20, p = 0.01), independently of age.

Conclusion

Our findings might indicate the presence of neuronal (NSE) and glial (S100B) injury in mild NCD. Future studies need to investigate whether younger subjects with mild NCD with increased biomarker levels are at risk of developing major NCD.

Alpha2-adrenergic dysregulation in congenic DxH recombinant inbred mice selectively bred for a high fear-sensitized (H-FSS) startle response

Patients with anxiety disorders and posttraumatic stress disorder (PTSD) exhibit exaggerated fear responses and noradrenergic dysregulation. Fear-related responses to α₂-adrenergic challenge were therefore studied in DxH C3H/HeJ-like recombinant inbred (C3HLRI) mice, which are a DBA/2J-congenic strain selectively bred for a high fear-sensitized startle (H-FSS). C3HLRI mice showed an enhanced acoustic startle response and immobility in the forced swim test compared to DBA/2J controls. The α₂-adrenoceptor antagonist yohimbine (Yoh; 5.0 mg/kg) induced an anxiogenic and the α₂-adrenoceptor agonist clonidine (Clon; 0.1 mg/kg) an anxiolytic effect in the open field (OF) in C3HLRI but not DBA/2J mice. In auditory fear-conditioning, Yoh (5.0 mg/kg)-treated C3HLRI mice showed higher freezing during fear recall and extinction learning than DBA/2J mice, and a higher ceiling for the Yoh-induced deficit in fear extinction. No strain differences were observed in exploration-related anxiety/spatial learning or the Clon-induced (0.1 mg/kg) corticosterone surge. A global analysis of the behavioral profile of the two mouse strains based on observed and expected numbers of significant behavioral outcomes indicated that C3HLRI mice showed significantly more often fear- and stress-related PTSD-like behaviors than DBA/2J controls. The analysis of the robustness of significant outcomes based on false discovery rate (FDR) thresholds confirmed significant differences for the strain-Yoh-interactions in the OF center and periphery, the Yoh-induced general extinction deficit, strain differences in conditioned fear levels, and at the dose of 5.0 mg/kg for the Yoh-induced ceiling in freezing levels among others. The current findings are consistent with previous observations showing alterations in the central noradrenergic system of C3HLRI mice (Browne et al., 2014, Stress 17:471-83). Based on their behavioral profile and response to α₂-adrenergic stimulation, C3HLRI mice are a valuable genetic model for studying adrenergic mechanisms of anxiety disorders and potentially also of PTSD.

Concordance of genetic variation that increases risk for anxiety disorders and posttraumatic stress disorders and that influences their underlying neurocircuitry

BACKGROUND

There have been considerable recent advances in understanding the genetic architecture of anxiety disorders and posttraumatic stress disorder (PTSD), as well as the underlying neurocircuitry of these disorders. However, there is little work on the concordance of genetic variations that increase risk for these conditions, and that influence subcortical brain structures. We undertook a genome-wide investigation of the overlap between the genetic influences from single nucleotide polymorphisms (SNPs) on volumes of subcortical brain structures and genetic risk for anxiety disorders and PTSD.

METHOD

We obtained summary statistics of genome-wide association studies (GWAS) of anxiety disorders (N_cases= 7016, N_controls= 14,745), PTSD (European sample; N_cases= 2424, N_controls= 7113) and of subcortical brain structures (N = 13,171). SNP Effect Concordance Analysis (SECA) and Linkage Disequilibrium (LD) Score Regression were used to examine genetic pleiotropy, concordance, and genome-wide correlations respectively. SECAs conditional false discovery was used to identify specific risk variants associated with anxiety disorders or PTSD when conditioning on brain related traits.

RESULTS

For anxiety disorders, we found evidence of significant concordance between increased anxiety risk variants and variants associated with smaller amygdala volume. Further, by conditioning on brain volume GWAS, we identified novel variants that associate with smaller brain volumes and increase risk for disorders: rs56242606 was found to increase risk for anxiety disorders, while two variants (rs6470292 and rs683250) increase risk for PTSD, when conditioning on the GWAS of putamen volume.

LIMITATIONS

Despite using the largest available GWAS summary statistics, the analyses were limited by sample size.

CONCLUSIONS

These preliminary data indicate that there is genome wide concordance between genetic risk factors for anxiety disorders and those for smaller amygdala volume, which is consistent with research that supports the involvement of the amygdala in anxiety disorders. It is notable that a genetic variant that contributes to both reduced putamen volume and PTSD plays a key role in the glutamatergic system. Further work with GWAS summary statistics from larger samples, and a more extensive look at the genetics underlying brain circuits, is needed to fully delineate the genetic architecture of these disorders and their underlying neurocircuitry.

Detection Study of Bipolar Depression Through the Application of a Model-Based Algorithm in Terms of Clinical Feature and Peripheral Biomarkers

Objectives: The nature of the diagnostic classification of mood disorder is a typical dichotomous data problem and the method of combining different dimensions of evidences to make judgments might be more statistically reliable. In this paper, we aimed to explore whether peripheral neurotrophic factors could be helpful for early detection of bipolar depression. Methods: A screening method combining peripheral biomarkers and clinical characteristics was applied in 30 patients with major depressive disorder (MDD) and 23 patients with depressive episode of bipolar disorder. By a model-based algorithm, some information was extracted from the dataset and used as a "model" to approach penalized regression model for stably differential diagnosis for bipolar depression. Results: A simple and efficient model of approaching the diagnosis of individuals with depressive symptoms was established with a fitting degree (90.58%) and an acceptable cross-validation error rate. Neurotrophic factors of our interest were successfully screened out from the feature selection and optimized model performance as reliable predictive variables. Conclusion: It seems to be feasible to combine different types of clinical characteristics with biomarkers in order to detect bipolarity of all depressive episodes. Neurotrophic factors of our interest presented its stable discriminant potentiality in unipolar and bipolar depression, deserving validation analysis in larger samples.

Comparison of the DSM-5 and ICD-10: panic and other anxiety disorders

Anxiety disorders are the most prevalent mental disorders and are associated with substantial healthcare costs and a high burden of disease. In this article, changes in the new Diagnostic and Statistical Manual for Mental Disorders (the DSM-5) with respect to panic disorder/agoraphobia, generalized anxiety disorder, social anxiety disorder, specific phobias, and selective mutism are compared with the International Classification of Diseases (ICD-10) system.

Validity of remission and recovery criteria for schizophrenia and major depression: comparison of the results of two one-year follow-up naturalistic studies

The objective of the present study was the application and comparison of common remission and recovery criteria between patients with the diagnosis of schizophrenia and major depressive disorder (MDD) under inclusion of other outcome parameters. Patients with schizophrenia and MDD who were treated as inpatients at the beginning of the study were examined within two naturalistic follow-up trials from admission to discharge of an inpatient treatment period and the one-year follow-up assessment. PANSS criteria of the Remission in Schizophrenia Working Group (RSWG) for schizophrenia and HAMD criteria of the ACNP Task Force in MDD for depressive patients as well as the Clinical Global Impression-Severity Scale (CGI-S) were applied as symptomatic outcome measures additionally to functional outcome parameters. Data of 153 schizophrenia patients and 231 patients with a MDD episode have been included in the analysis. More depressive than schizophrenia patients reached a threshold score of ≤3 on the CGI-S, indicating symptomatic remission at discharge and at the one-year follow-up. In contrast similar proportions of patients reaching symptomatic remission at discharge from inpatient treatment and at the one-year follow-up in the schizophrenia and in the MDD group were found when disease-related consensus criteria (RSWG vs. ACNP Task Force) were used. Functional remission and recovery rates were significantly lower in schizophrenia than in depressive patients at the one-year follow-up visit. Common outcome criteria for remission and recovery in schizophrenia and major depression were not directly comparable. However, our results indicated a significantly poorer outcome in schizophrenia than in depressive patients according to terms of remission and recovery.

How to tell a happy from an unhappy schizotype: personality factors and mental health outcomes in individuals with psychotic experiences

Objective:

It is unclear why some individuals reporting psychotic experiences have balanced lives while others go on to develop mental health problems. The objective of this study was to test if the personality traits of harm avoidance, self-directedness, and self-transcendence can be used as criteria to differentiate healthy from unhealthy schizotypal individuals.

Methods:

We interviewed 115 participants who reported a high frequency of psychotic experiences. The instruments used were the Temperament and Character Inventory (140), Structured Clinical Interview for DSM-IV, and the Oxford-Liverpool Inventory of Feelings and Experiences.

Results:

Harm avoidance predicted cognitive disorganization (β = 0.319; t = 2.94), while novelty seeking predicted bipolar disorder (β = 0.136, Exp [β]. = 1.146) and impulsive non-conformity (β = 0.322; t = 3.55). Self-directedness predicted an overall decrease in schizotypy, most of all in cognitive disorganization (β = -0.356; t = -2.95) and in impulsive non-conformity (β = -0.313; t = -2.83). Finally, self-transcendence predicted unusual experiences (β = 0.256; t = 2.32).

Conclusion:

Personality features are important criteria to distinguish between pathology and mental health in individuals presenting high levels of anomalous experiences (AEs). While self-directedness is a protective factor, both harm avoidance and novelty seeking were predictors of negative mental health outcomes. We suggest that the impact of AEs on mental health is moderated by personality factors.

The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III

OBJECTIVES

To present current, nationally representative US findings on the past-year and lifetime prevalences, sociodemographic correlates, psychiatric comorbidity, associated disability, and treatment of DSM-5 posttraumatic stress disorder (PTSD).

METHODS

Face-to-face interviews with 36,309 adults in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. PTSD, alcohol and drug use disorders, and selected mood, anxiety, and personality disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5.

RESULTS

Past-year and lifetime prevalences were 4.7 and 6.1 %, higher for female, white, Native American, younger, and previously married respondents, those with <high school education and lower incomes, and rural residents. PTSD was significantly associated with a broad range of substance use, mood, anxiety, and personality disorders, and past-month disability. Among respondents with lifetime PTSD, 59.4 % sought treatment; an average of 4.5 years elapsed from disorder onset to first treatment.

CONCLUSIONS

DSM-5 PTSD is prevalent, highly comorbid, disabling, and associated with delayed help seeking. Additional research is needed to elucidate relationships identified herein, estimate PTSD-related costs, investigate hypotheses regarding etiology, course, and treatment, and support decisions about resource allocation to service delivery and research. Initiatives are needed to destigmatize PTSD, educate the public about its treatment, and encourage affected individuals to seek help.

Systems psychopharmacology: A network approach to developing novel therapies

The multifactorial origin of most chronic disorders of the brain, including schizophrenia, has been well accepted. Consequently, pharmacotherapy would require multi-targeted strategies. This contrasts to the majority of drug therapies used until now, addressing more or less specifically only one target molecule. Nevertheless, quite some searches for multiple molecular targets specific for mental disorders have been undertaken. For example, genome-wide association studies have been conducted to discover new target genes of disease. Unfortunately, these attempts have not fulfilled the great hopes they have started with. Polypharmacology and network pharmacology approaches of drug treatment endeavor to abandon the one-drug one-target thinking. To this end, most approaches set out to investigate network topologies searching for modules, endowed with "important" nodes, such as "hubs" or "bottlenecks", encompassing features of disease networks, and being useful as tentative targets of drug therapies. This kind of research appears to be very promising. However, blocking or inhibiting "important" targets may easily result in destruction of network integrity. Therefore, it is suggested here to study functions of nodes with lower centrality for more subtle impact on network behavior. Targeting multiple nodes with low impact on network integrity by drugs with multiple activities ("dirty drugs") or by several drugs, simultaneously, avoids to disrupt network integrity and may reset deviant dynamics of disease. Natural products typically display multi target functions and therefore could help to identify useful biological targets. Hence, future efforts should consider to combine drug-target networks with target-disease networks using mathematical (graph theoretical) tools, which could help to develop new therapeutic strategies in long-term psychiatric disorders.

EPA guidance on improving the image of psychiatry

This paper explores causes, explanations and consequences of the negative image of psychiatry and develops recommendations for improvement. It is primarily based on a WPA guidance paper on how to combat the stigmatization of psychiatry and psychiatrists and a Medline search on related publications since 2010. Furthermore, focussing on potential causes and explanations, the authors performed a selective literature search regarding additional image-related issues such as mental health literacy and diagnostic and treatment issues. Underestimation of psychiatry results from both unjustified prejudices of the general public, mass media and healthcare professionals and psychiatry's own unfavourable coping with external and internal concerns. Issues related to unjustified devaluation of psychiatry include overestimation of coercion, associative stigma, lack of public knowledge, need to simplify complex mental issues, problem of the continuum between normality and psychopathology, competition with medical and non-medical disciplines and psychopharmacological treatment. Issues related to psychiatry's own contribution to being underestimated include lack of a clear professional identity, lack of biomarkers supporting clinical diagnoses, limited consensus about best treatment options, lack of collaboration with other medical disciplines and low recruitment rates among medical students. Recommendations are proposed for creating and representing a positive self-concept with different components. The negative image of psychiatry is not only due to unfavourable communication with the media, but is basically a problem of self-conceptualization. Much can be improved. However, psychiatry will remain a profession with an exceptional position among the medical disciplines, which should be seen as its specific strength.

[Estimation of prevalence and treatment needs of mental disorders. The problem of diagnostic thresholds]

BACKGROUND

Uncertainties in the context of threshold-based diagnostics represent a theoretically unsolved methodological problem that may require multidimensional solutions. Pragmatically, current research focuses on establishing reliable and valid operationalized criteria within the framework of diagnostic systems, such as the International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM).

AIM AND METHODS

By means of model calculations based on epidemiological data we show how exemplified changes in the disorder spectrum and diagnostic criteria influence case numbers. Furthermore, we investigate how threshold-based constructs, such as DSM-IV diagnoses, relate to the general criteria of illness and sickness.

RESULTS

Variations in the disorder spectrum and thresholds lead to slight to moderate changes in case numbers. Regarding distress and impairment, mental disorders are associated with significantly reduced health-related quality of life and an increased number of days out of role (due to mental and/or physical problems). With increasing distress and impairment, the percentage of mental disorders increases significantly; in the 5 % of the general population with the highest distress and impairment, the proportion is nearly 80 %.

DISCUSSION

Despite fuzzy boundaries, threshold-based diagnoses (DSM-IV) represent a satisfactory and reproducible disease classification (in terms of illness and sickness) for estimation of prevalence. There is a lack of definitions and instruments to assess treatment needs. It is still debated whether diagnostic symptom criteria always represent pathological disorders (i. e. disease).

MK-801 treatment affects glycolysis in oligodendrocytes more than in astrocytes and neuronal cells: insights for schizophrenia

Schizophrenia is a debilitating mental disorder, affecting more than 30 million people worldwide. As a multifactorial disease, the underlying causes of schizophrenia require analysis by multiplex methods such as proteomics to allow identification of whole protein networks. Previous post-mortem proteomic studies on brain tissues from schizophrenia patients have demonstrated changes in activation of glycolytic and energy metabolism pathways. However, it is not known whether these changes occur in neurons or in glial cells. To address this question, we treated neuronal, astrocyte, and oligodendrocyte cell lines with the NMDA receptor antagonist MK-801 and measured the levels of six glycolytic enzymes by Western blot analysis. MK-801 acts on the glutamatergic system and has been proposed as a pharmacological means of modeling schizophrenia. Treatment with MK-801 resulted in significant changes in the levels of glycolytic enzymes in all cell types. Most of the differences were found in oligodendrocytes, which had altered levels of hexokinase 1 (HK1), enolase 2 (ENO2), phosphoglycerate kinase (PGK), and phosphoglycerate mutase 1 after acute MK-801 treatment (8 h), and HK1, ENO2, PGK, and triosephosphate isomerase (TPI) following long term treatment (72 h). Addition of the antipsychotic clozapine to the cultures resulted in counter-regulatory effects to the MK-801 treatment by normalizing the levels of ENO2 and PGK in both the acute and long term cultures. In astrocytes, MK-801 affected only aldolase C (ALDOC) under both acute conditions and HK1 and ALDOC following long term treatment, and TPI was the only enzyme affected under long term conditions in the neuronal cells. In conclusion, MK-801 affects glycolysis in oligodendrocytes to a larger extent than neuronal cells and this may be modulated by antipsychotic treatment. Although cell culture studies do not necessarily reflect the in vivo pathophysiology and drug effects within the brain, these results suggest that neurons, astrocytes, and oligodendrocytes are affected differently in schizophrenia. Employing in vitro models using neurotransmitter agonists and antagonists may provide new insights about the pathophysiology of schizophrenia which could lead to a novel system for drug discovery.