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Schofield P, Thisted Horsdal H, Das-Munshi J, Thygesen M, Pedersen C, Morgan C, Agerbo E. A comparison of neighbourhood level variation and risk factors for affective versus non-affective psychosis. Schizophr Res 2023; 256:126-132. [PMID: 35697569 PMCID: PMC10259518 DOI: 10.1016/j.schres.2022.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 01/11/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies typically highlight area level variation in the incidence of non-affective but not affective psychoses. We compared neighbourhood-level variation for both types of disorder, and the specific effects of neighbourhood urbanicity and ethnic density, using Danish national registry data. METHODS Population based cohort (2,224,464 people) followed from 1980 to 2013 with neighbourhood exposure measured at age 15 and incidence modelled using multilevel Poisson regression. RESULTS Neighbourhood variation was similar for both disorders with an adjusted median risk ratio of 1.37 (95% CI 1.34-1.39) for non-affective psychosis and 1.43 (1.38-1.49) for affective psychosis. Associations with neighbourhood urbanicity differed: living in the most compared to the least urban quintile at age 15 was associated with a minimal increase in subsequent affective psychosis, IRR 1.13 (1.01-1.27) but a substantial increase in rates of non-affective psychosis, IRR 1.66 (1.57-1.75). Mixed results were found for neighbourhood ethnic density: for Middle Eastern migrants there was an increased average incidence of both affective, IRR 1.54 (1.19-1.99), and non-affective psychoses, 1.13 (1.04-1.23) associated with each decrease in ethnic density quintile, with a similar pattern for African migrants, but for European migrants ethnic density appeared to be associated with non-affective psychosis only. CONCLUSIONS While overall variation and the effect of neighbourhood ethnic density were similar for both types of disorder, associations with urbanicity were largely confined to non-affective psychosis. This may reflect differences in aetiological pathways although the mechanism behind these differences remains unknown.
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Affiliation(s)
- Peter Schofield
- School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.
| | - Henriette Thisted Horsdal
- Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus, Denmark; National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark; CIRRAU - Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - Jayati Das-Munshi
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom; South London & Maudsley NHS Trust; ESRC Centre for Society and Mental Health, Kings College London
| | - Malene Thygesen
- Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus, Denmark; National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark; CIRRAU - Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - Carsten Pedersen
- Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus, Denmark; National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark; CIRRAU - Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - Craig Morgan
- ESRC Centre for Society and Mental Health, Kings College London; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London
| | - Esben Agerbo
- Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus, Denmark; National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark; CIRRAU - Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
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Watson M, Filia K, Stevens A, Cotton S, Nelson B, Ratheesh A. A systematic review and meta-analysis of global and social functioning among people at risk of bipolar disorder. J Affect Disord 2023; 321:290-303. [PMID: 36306929 DOI: 10.1016/j.jad.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 10/04/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD. METHODS We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible. RESULTS 7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples. LIMITATIONS Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms. CONCLUSIONS Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state.
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Affiliation(s)
- M Watson
- The University of Melbourne, Centre for Youth Mental Health, Parkville 3052, Australia; The University of Melbourne, Melbourne Medical School, Parkville 3052, Australia
| | - K Filia
- Orygen, Parkville 3052, Australia
| | | | - S Cotton
- Orygen, Parkville 3052, Australia
| | - B Nelson
- Orygen, Parkville 3052, Australia
| | - A Ratheesh
- Orygen, Parkville 3052, Australia; The University of Melbourne, Centre for Youth Mental Health, Parkville 3052, Australia.
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3
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Grunze H, Cetkovich-Bakmas M. "Apples and pears are similar, but still different things." Bipolar disorder and schizophrenia- discrete disorders or just dimensions ? J Affect Disord 2021; 290:178-187. [PMID: 34000571 DOI: 10.1016/j.jad.2021.04.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/14/2021] [Accepted: 04/25/2021] [Indexed: 02/05/2023]
Abstract
Starting with the dichotomous view of Kraepelin, schizophrenia and bipolar disorder have traditionally been considered as separate entities. More recent, this taxonomic view of illnesses has been challenged and a continuum psychosis has been postulated based on genetic and neurobiological findings suggestive of a large overlap between disorders. In this paper we will review clinical and experimental data from genetics, morphology, phenomenology and illness progression demonstrating what makes schizophrenia and bipolar disorder different conditions, challenging the idea of the obsolescence of the categorical approach. However, perhaps it is also time to move beyond DSM and search for more refined clinical descriptions that could uncover clinical invariants matching better with molecular data. In the future, computational psychiatry employing artificial intelligence and machine learning might provide us a tool to overcome the gap between clinical descriptions (phenomenology) and neurobiology.
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Affiliation(s)
- Heinz Grunze
- Paracelsus Medical University, Nuremberg & Psychiatrie Schwäbisch Hall, Ringstrasse 1, 74523 Schwäbisch Hall, Germany.
| | - Marcelo Cetkovich-Bakmas
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
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4
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Post F, Buchta M, Kemmler G, Pardeller S, Frajo-Apor B, Hofer A. Resilience Predicts Self-Stigma and Stigma Resistance in Stabilized Patients With Bipolar I Disorder. Front Psychiatry 2021; 12:678807. [PMID: 34093288 PMCID: PMC8176112 DOI: 10.3389/fpsyt.2021.678807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022] Open
Abstract
The identification of factors that prevent self-stigma and on the other hand promote stigma resistance are of importance in the long-term management of bipolar disorder. Accordingly, the aim of the current study was to investigate the association of factors deemed relevant in this context, i.e., resilience, premorbid functioning, and residual mood symptoms, with self-stigma/stigma resistance. Sixty patients diagnosed with bipolar I disorder were recruited from a specialized outpatient clinic. Self-stigma and stigma resistance were measured by the Internalized Stigma of Mental Illness (ISMI) Scale. The presence and severity of symptoms were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS). Resilience and premorbid functioning were measured by the Resilience Scale (RS-25) and the Premorbid Adjustment Scale (PAS), respectively. Resilience correlated negatively with self-stigma and positively with stigma resistance and was a predictor for self-stigma/stigma resistance in multiple linear regression analysis. Residual depressive symptoms correlated positively with self-stigma and negatively with stigma resistance. There were no significant correlations between sociodemographic variables, premorbid functioning as well as residual manic symptoms and self-stigma/stigma resistance. The findings of this study implicate that resilience may be considered as an important component of self-stigma reduction interventions.
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Affiliation(s)
- Fabienne Post
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Melanie Buchta
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Kemmler
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Silvia Pardeller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Beatrice Frajo-Apor
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
| | - Alex Hofer
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
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Abstract
PURPOSE OF REVIEW Emil Kraepelin, in 1899, proposed a dichotomy of psychiatric disorders into "dementia praecox," further called schizophrenia, and "manisch-depressives Irresein," now conceptualized as a bipolar disorder. The purpose of the review is to show both similarities and differences between disorders involved in this dichotomy, speaking for and against the idea. RECENT FINDINGS On the molecular genetic side, there are data for both a genetic overlap and genetic differences between these two illnesses. Among pharmacological treatment, lithium, valproates, and carbamazepine present evidence for Kraepelinian dichotomy while atypical antipsychotics speak against this. The recent results for similarities and differences in the immune system, cognitive functions, and neurodevelopmental mechanisms have also been presented and discussed. As of 2019, the Kraepelinian dichotomy has been still partly valid although the results of recent clinical, neurobiological, and pharmacological studies provided a large number of data for an intermediate space between schizophrenia and bipolar disorder.
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Affiliation(s)
- Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Szpitalna 27/33, 60-572, Poznan, Poland.
- Department of Psychiatric Nursing, Poznan University of Medical Sciences, Poznan, Poland.
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6
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Chan CC, Shanahan M, Ospina LH, Larsen EM, Burdick KE. Premorbid adjustment trajectories in schizophrenia and bipolar disorder: A transdiagnostic cluster analysis. Psychiatry Res 2019; 272:655-662. [PMID: 30616137 PMCID: PMC6441475 DOI: 10.1016/j.psychres.2018.12.169] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/10/2018] [Accepted: 12/30/2018] [Indexed: 11/17/2022]
Abstract
Despite the overlap between schizophrenia and bipolar disorder, neurodevelopmental abnormalities are thought to be associated primarily with schizophrenia. Transdiagnostic and empirical identification of subgroups based on premorbid adjustment (PMA) may enhance understanding of illness trajectories. 160 patients with bipolar I or II disorder (BD; n = 104) or schizophrenia or schizoaffective disorder (SZ; n = 56) were assessed on PMA course from childhood to late adolescence and current symptoms and functioning. A hierarchical cluster analysis was performed using social and academic PMA scores, resulting in three optimal clusters. Cluster 1 (n = 28 SZ, 65 BD) had normal social and academic PMA, the most education, and mildest current symptoms. Cluster 2 (n = 15 SZ, 24 BD) had normal social PMA but an impaired-declining academic course and had a greater proportion of males than Cluster 1. Cluster 3 (n = 13 SZ, 15 BD) had an impaired-stable social PMA and an impaired-declining academic course and the most severe current negative symptoms and childhood trauma. The proportions of SZ and BD diagnoses, current neurocognition, and functioning did not differ between clusters. These findings suggest shared neurodevelopmental abnormalities between SZ and BD, with subgroups exhibiting distinct PMA trajectories that cut across disorders.
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Affiliation(s)
- Chi C Chan
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 2 Mental Illness Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Megan Shanahan
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Luz H Ospina
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emmett M Larsen
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine E Burdick
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; VISN 2 Mental Illness Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Brigham and Women's Hospital, Boston, MA, USA.
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7
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Torrent C, Reinares M, Martinez-Arán A, Cabrera B, Amoretti S, Corripio I, Contreras F, Sarró S, González-Pinto A, Lobo A, Cuesta MJ, Sánchez-Torres A, Bergé D, Castro-Fornieles J, Moreno C, Bernardo M, Vieta E. Affective versus non-affective first episode psychoses: A longitudinal study. J Affect Disord 2018; 238:297-304. [PMID: 29902733 DOI: 10.1016/j.jad.2018.06.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This study aimed to assess (1) whether there were clinical, neuropsychological and functional differences between and within affective and non-affective psychoses at baseline and two years-follow-up and (2) to explore clinical and neuropsychological predictors of psychosocial functioning in the whole sample. METHOD This is a subanalysis from a multicentre, naturalistic, longitudinal prospective study ('Phenotype-genotype and environmental interaction. Application of a predictive model in first psychotic episodes'). The sample consisted of 192 patients with a first psychotic episode (FEP): 142 with non-affective psychoses and 50 with affective psychoses. Student t-tests, paired t-tests, Pearson correlations, ANOVAs and regression analyses were performed. RESULTS At baseline, the groups differed in perseverative errors (WCST), Premorbid Adjustment Scale (PAS), family history of psychiatric disorder, negative (PANSS) and manic symptoms (YMRS). At two years follow-up, the groups differed in all the PANSS subscales and in depressive symptoms assessed by the MADRS. When the whole sample was considered, the regression model which best explained the estimated variance in functioning at follow-up (41%) was composed by PANSS total score and verbal fluency assessed by the FAS (COWAT). CONCLUSIONS We found clinical and neurocognitive differences at baseline which decreased in the follow-up. Reduced performances at baseline in executive functions in combination with symptom severity (PANSS) were predictors of FEP patients' poor functional outcome.
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Affiliation(s)
- C Torrent
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - M Reinares
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - A Martinez-Arán
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - B Cabrera
- Barcelona Clínic Schizophrenia Unit, Hospital Clinic de Barcelona, CIBERSAM, Barcelona, Spain
| | - S Amoretti
- Barcelona Clínic Schizophrenia Unit, Hospital Clinic de Barcelona, CIBERSAM, Barcelona, Spain
| | - I Corripio
- Department of Psychiatry, Biomedical Research Institute Sant Pau (IIB-SANT PAU), Santa Creu and Sant Pau Hospital; Autonomous University of Barcelona (UAB), CIBERSAM, Barcelona, Spain
| | - F Contreras
- Psychiatry Department, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - S Sarró
- FIDMAG Research Foundation Germanes Hospitalàries, CIBERSAM, Barcelona, Spain
| | - A González-Pinto
- Department of Psychiatry, University Hospital of Alava-Santiago, Vitoria, Spain
| | - A Lobo
- Department of Medicine and Psychiatry. Universidad de Zaragoza. Instituto de Investigación Aragón, CIBERSAM, Zaragoza, Spain
| | - M J Cuesta
- Department of Psychiatry, Complejo Hospitalario of Navarra, Pamplona, Spain. Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain, IdiSNA
| | - A Sánchez-Torres
- Department of Psychiatry, Complejo Hospitalario of Navarra, Pamplona, Spain. Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain, IdiSNA
| | - D Bergé
- Hospital del Mar Medical Research Institute (IMIM), Autonomous University of Barcelona and CIBERSAM, Barcelona, Spain
| | - J Castro-Fornieles
- Department of Child and Adolescent Psychiatry and Psychology. Institut Clínic of Neurosciences, IDIBAPS, Hospital Clínic de Barcelona, CIBERSAM, Barcelona, Spain
| | - C Moreno
- Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM. Madrid, Spain
| | - M Bernardo
- Barcelona Clínic Schizophrenia Unit, Hospital Clinic de Barcelona, CIBERSAM, Barcelona, Spain
| | - E Vieta
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain.
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8
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Velthorst E, Fett AKJ, Reichenberg A, Perlman G, van Os J, Bromet EJ, Kotov R. The 20-Year Longitudinal Trajectories of Social Functioning in Individuals With Psychotic Disorders. Am J Psychiatry 2017; 174:1075-1085. [PMID: 27978770 PMCID: PMC5474222 DOI: 10.1176/appi.ajp.2016.15111419] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Social impairment is a long-recognized core feature of schizophrenia and is common in other psychotic disorders. Still, to date the long-term trajectories of social impairment in psychotic disorders have rarely been studied systematically. METHODS Data came from the Suffolk County Mental Health Project, a 20-year prospective study of first-admission patients with psychotic disorders. A never-psychotic comparison group was also assessed. Latent class growth analysis was applied to longitudinal data on social functioning from 485 respondents with schizophrenia spectrum disorders and psychotic mood disorders, and associations of the empirically derived trajectories with premorbid social adjustment, diagnosis, and 20-year outcomes were examined. RESULTS Four mostly stable trajectories of preserved (N=82; 59th percentile of comparison group sample distribution), moderately impaired (N=148; 17th percentile), severely impaired (N=181; 3rd percentile), and profoundly impaired (N=74; 1st percentile) functioning best described the 20-year course of social functioning across diagnoses. The outcome in the group with preserved functioning did not differ from that of never-psychotic individuals at 20 years, but the other groups functioned significantly worse. Differences among trajectories were already evident in childhood. The two most impaired trajectories started to diverge in early adolescence. Poorer social functioning trajectories were strongly associated with other real-world outcomes at 20 years. Multiple trajectories were represented within each disorder. However, more participants with schizophrenia spectrum disorders had impaired trajectories, and more with mood disorders had better functioning trajectories. CONCLUSIONS The results highlight substantial variability of social outcomes within diagnoses-albeit overall worse social outcomes in schizophrenia spectrum disorders-and show remarkably stable long-term impairments in social functioning after illness onset across all diagnoses.
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Affiliation(s)
- Eva Velthorst
- Departments of Psychiatry, Icahn School of Medicine at Mount Sinai,
NY, USA,Departments of Preventive Medicine, Icahn School of Medicine at
Mount Sinai, NY, USA,Department of Psychiatry, Academic Medical Center, University of
Amsterdam, the Netherlands
| | - Anne-Kathrin J. Fett
- Department of Educational Neuroscience & Research Institute
LEARN! Faculty of Behavioural and Movement Sciences, VU University, Amsterdam, the
Netherlands,Department of Psychosis Studies, Institute of Psychiatry, Psychology
and Neuroscience, King's College London, London, UK
| | - Abraham Reichenberg
- Departments of Psychiatry, Icahn School of Medicine at Mount Sinai,
NY, USA,Departments of Preventive Medicine, Icahn School of Medicine at
Mount Sinai, NY, USA,Department of Psychosis Studies, Institute of Psychiatry, Psychology
and Neuroscience, King's College London, London, UK
| | - Greg Perlman
- Department of Psychiatry, Stony Brook University, Putnam Hall-South
Campus, Stony Brook, New York
| | - Jim van Os
- Department of Psychosis Studies, Institute of Psychiatry, Psychology
and Neuroscience, King's College London, London, UK,Department of Psychiatry and Neuropsychology, School for Mental
Health and Neuroscience, EURON, Maastricht University Medical Centre, Maastricht,
the Netherlands
| | - Evelyn J. Bromet
- Department of Psychiatry, Stony Brook University, Putnam Hall-South
Campus, Stony Brook, New York
| | - Roman Kotov
- Department of Psychiatry, Stony Brook University, Putnam Hall-South
Campus, Stony Brook, New York
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9
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Social and academic premorbid adjustment domains predict different functional outcomes among youth with first episode mania. J Affect Disord 2017; 219:133-140. [PMID: 28550765 DOI: 10.1016/j.jad.2017.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/21/2017] [Accepted: 05/19/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Premorbid characteristics may help predict the highly variable functional and illness outcomes of young people with early stage Bipolar Disorder (BD). We sought to examine the relationships between premorbid adjustment and short to medium-term outcomes after a first treated episode of mania. METHODS We examined the baseline and 18-month follow-up characteristics of 117 participants with first episode of mania, treated at two tertiary early intervention services in Melbourne, Australia. The baseline demographic, family history, diagnoses, comorbidity and clinical features were determined using unstructured questionnaires and structured diagnostic interviews. Premorbid adjustment was determined using the Premorbid Adjustment Scale (PAS), the components of which were identified using a principal component analysis. Eighteen-month follow-up outcome measures included the Clinical Global Impressions scale, Social and Occupational Functioning Assessment Scale and the Heinrichs' Quality of Life Scale (QLS). Correlations and linear regressions were utilised to examine the relationships between component scores and outcomes, while controlling for baseline and follow-up confounders. RESULTS The social adjustment component of the PAS correlated with the interpersonal relations (rs = -0.46, p<0.001) domain of QLS while the academic adjustment component of the PAS correlated with the vocational functioning domain of QLS (rs =-0.39, p = 0.004). Premorbid adjustment did not predict illness severity or objective functioning. LIMITATIONS Lack of information on cognition, personality factors and prodromal symptoms limited the assessment of their impact on outcomes. CONCLUSIONS Impairments in domains of premorbid adjustment may be early markers of persistent difficulties in social and vocational functioning and may benefit from targeted interventions.
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10
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Okkenhaug A, Tanem T, Johansen A, Romild UK, Nordahl HM, Gjervan B. Physical activity in adolescents who later developed schizophrenia: A prospective case-control study from the Young-HUNT. Nord J Psychiatry 2016; 70:111-5. [PMID: 26121012 DOI: 10.3109/08039488.2015.1055300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Adults suffering from schizophrenia and other psychiatric disorders report low levels of physical activity. In addition, these patients have an increased risk of overweight and poor nutritional habits. Less is known about patterns and levels of physical activity before the onset of disease. AIMS The purpose of the study was to investigate whether there were specific patterns of physical activity in the premorbid phase of schizophrenia and whether these participants differed from those with bipolar disorder (BD). A group of healthy controls (HC) was also included. METHODS The study was a prospective, longitudinal, comparative cohort design in which 15 adolescents who later developed schizophrenia and 18 with later BD were compared with HC. Data were analysed using non-parametric statistical tests. RESULTS Patients with a diagnosis of schizophrenia were less physically active with fewer days per week (p < 0.05) and fewer hours per week (p < 0.05) in the premorbid phase than both BD and HC. They also participated less in team sports than HC (p < 0.05). CONCLUSION Our results suggest that individuals who develop schizophrenia in their teens may be at risk of establishing a lifestyle harmful to health. From a preventive perspective it is important to gain more knowledge about the connections between health habits and later development of disease.
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Affiliation(s)
- Arne Okkenhaug
- a Arne Okkenhaug, Department of Psychiatry , Levanger Hospital, North Troendelag Health Trust , Norway
| | - Torbjørn Tanem
- b Torbjørn Tanem, Department of Psychiatry , Outpatient Unit, Levanger Hospital, North Troendelag Health Trust , Norway
| | - Asbjørn Johansen
- c Asbjørn Johansen, Department of Psychiatry , Unit of Psychosis, Levanger Hospital, North Troendelag Health Trust , Norway
| | - Ulla Kristina Romild
- d Ulla Kristina Romild, Scientific Unit, Levanger Hospital, North Troendelag Health Trust, Norway and Folkhälsomyndigheten, Drog- och spelprevention , Østersund , Sweden
| | - Hans Morten Nordahl
- e Hans Morten Nordahl, Department of Psychology , Norwegian University of Science and Technology (NTNU) , Trondheim , Norway
| | - Bjørn Gjervan
- f Bjørn Gjervan, Department of Psychiatry , Levanger Hospital, North Troendelag Health Trust , Norway , Institute of Neuromedicine, Norwegian University of Technology and Science, NTNU
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11
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Ibrahim, A W, Pindar, S K, Yerima, M M, Rabbebe, I B, Shehu, S, Garkuwa, H A, Bashir, I Y, Wakil, M A, Yahya, S J. Medication-related factors of non adherence among patients with schizophrenia and bipolar disorder: Outcome of a cross-sectional survey in Maiduguri, North-eastern Nigeria. ACTA ACUST UNITED AC 2015. [DOI: 10.5897/jnbh2015.0128] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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12
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Kirkbride JB, Jones PB, Ullrich S, Coid JW. Social deprivation, inequality, and the neighborhood-level incidence of psychotic syndromes in East London. Schizophr Bull 2014; 40:169-80. [PMID: 23236081 PMCID: PMC3885290 DOI: 10.1093/schbul/sbs151] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although urban birth, upbringing, and living are associated with increased risk of nonaffective psychotic disorders, few studies have used appropriate multilevel techniques accounting for spatial dependency in risk to investigate social, economic, or physical determinants of psychosis incidence. We adopted Bayesian hierarchical modeling to investigate the sociospatial distribution of psychosis risk in East London for DSM-IV nonaffective and affective psychotic disorders, ascertained over a 2-year period in the East London first-episode psychosis study. We included individual and environmental data on 427 subjects experiencing first-episode psychosis to estimate the incidence of disorder across 56 neighborhoods, having standardized for age, sex, ethnicity, and socioeconomic status. A Bayesian model that included spatially structured neighborhood-level random effects identified substantial unexplained variation in nonaffective psychosis risk after controlling for individual-level factors. This variation was independently associated with greater levels of neighborhood income inequality (SD increase in inequality: Bayesian relative risks [RR]: 1.25; 95% CI: 1.04-1.49), absolute deprivation (RR: 1.28; 95% CI: 1.08-1.51) and population density (RR: 1.18; 95% CI: 1.00-1.41). Neighborhood ethnic composition effects were associated with incidence of nonaffective psychosis for people of black Caribbean and black African origin. No variation in the spatial distribution of the affective psychoses was identified, consistent with the possibility of differing etiological origins of affective and nonaffective psychoses. Our data suggest that both absolute and relative measures of neighborhood social composition are associated with the incidence of nonaffective psychosis. We suggest these associations are consistent with a role for social stressors in psychosis risk, particularly when people live in more unequal communities.
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Affiliation(s)
- James B Kirkbride
- To whom correspondence should be addressed; Department of Psychiatry, Herchel Smith Building University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SZ, UK; tel: 01223 336966, fax: 01223 336 968, e-mail:
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Owoeye O, Kingston T, Scully PJ, Baldwin P, Browne D, Kinsella A, Russell V, O’Callaghan E, Waddington JL. Epidemiological and clinical characterization following a first psychotic episode in major depressive disorder: comparisons with schizophrenia and bipolar I disorder in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS). Schizophr Bull 2013; 39:756-65. [PMID: 23716714 PMCID: PMC3686464 DOI: 10.1093/schbul/sbt075] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 12/29/2022]
Abstract
While recent research on psychotic illness has focussed on the nosological, clinical, and biological relationships between schizophrenia and bipolar disorder, little attention has been directed to the most common other psychotic diagnosis, major depressive disorder with psychotic features (MDDP). As this diagnostic category captures the confluence between dimensions of psychotic and affective psychopathology, it is of unappreciated heuristic potential to inform on the nature of psychotic illness. Therefore, the epidemiology and clinical characteristics of MDDP were compared with those of schizophrenia and bipolar disorder within the Cavan-Monaghan First Episode Psychosis Study (n = 370). Epidemiologically, the first psychotic episode of MDDP (n = 77) was uniformly distributed across the adult life span, while schizophrenia (n = 73) and bipolar disorder (n = 73) were primarily disorders of young adulthood; the incidence of MDDP, like bipolar disorder, did not differ between the sexes, while the incidence of schizophrenia was more common in males than in females. Clinically, MDDP was characterized by negative symptoms, executive dysfunction, neurological soft signs (NSS), premorbid intellectual function, premorbid adjustment, and quality of life similar to those for schizophrenia, while bipolar disorder was characterized by less prominent negative symptoms, executive dysfunction and NSS, and better quality of life. These findings suggest that what we currently categorize as MDDP may be more closely aligned with other psychotic diagnoses than has been considered previously. They indicate that differences in how psychosis is manifested vis-à-vis depression and mania may be quantitative rather than qualitative and occur within a dimensional space, rather than validating categorical distinctions.
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Affiliation(s)
- Olabisi Owoeye
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tara Kingston
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul J. Scully
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patrizia Baldwin
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Browne
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anthony Kinsella
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vincent Russell
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Department of Psychiatry, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | | | - John L. Waddington
- Cavan-Monaghan Mental Health Service, Cavan General Hospital & St Davnet’s Hospital, Monaghan, Ireland
- Molecular & Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Schoeyen HK, Melle I, Sundet K, Aminoff SR, Hellvin T, Auestad BH, Morken G, Andreassen OA. Occupational outcome in bipolar disorder is not predicted by premorbid functioning and intelligence. Bipolar Disord 2013; 15:294-305. [PMID: 23527993 DOI: 10.1111/bdi.12056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 01/23/2013] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Bipolar disorder (BD), over the long term, can manifest a variety of outcomes depending on a number of different conditions. There is a need for further knowledge regarding preventive factors as well as predictors of the disabling course of the disorder. Studies regarding the impact on functional outcome of premorbid and current general intellectual function [intelligence quotient (IQ)] and premorbid functioning in BD patients are sparse. The present study addressed the role of premorbid functioning [assessed with the Premorbid Adjustment Scale (PAS)], intelligence, course of illness, and sociodemographics on occupational outcome in BD. METHODS Bipolar disorder patients were recruited consecutively from psychiatric units (outpatient and inpatient) in four major hospitals in Oslo, Norway [(N = 226: 64.4% bipolar I disorder (BD-I); 30.1% bipolar II disorder (BD-II); 5.5% bipolar disorder not otherwise specified (BD-NOS); 38.6% males]. The associations between current IQ, premorbid IQ [assessed using the National Adult Reading Test (NART)], PAS, clinical and sociodemographic characteristics, and receipt of disability benefit were analysed using descriptive statistics and logistic regression analyses. RESULTS The number of hospitalizations for depressive episodes and illness duration was associated with a higher risk of receipt of disability benefit. PAS, premorbid and current IQ, as well as decline in IQ, did not explain the higher risk of receipt of disability benefits. CONCLUSIONS Severe clinical course of BD was associated with receipt of disability benefit. Occupational outcome was unrelated to PAS, premorbid and current IQ, as well as decline in IQ. This suggests that the persistence of severe clinical symptoms, rather than global cognitive functioning, determines occupational outcome in BD and emphasizes the protective potential of early and continuous clinical treatment.
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Affiliation(s)
- Helle K Schoeyen
- Moodnet Research Group, Division of Psychiatry, Stavanger University Hospital, Stavanger, Norway.
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Payá B, Rodríguez-Sánchez JM, Otero S, Muñoz P, Castro-Fornieles J, Parellada M, Gonzalez-Pinto A, Soutullo C, Baeza I, Rapado-Castro M, Sáenz-Herrero M, Moreno D, Arango C. Premorbid impairments in early-onset psychosis: differences between patients with schizophrenia and bipolar disorder. Schizophr Res 2013; 146:103-10. [PMID: 23465966 DOI: 10.1016/j.schres.2013.01.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 01/08/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite the large body of research on premorbid impairments in schizophrenia, studies comparing different early-onset psychoses are scarce. AIMS To examine premorbid impairments in first episodes of early-onset bipolar and schizophrenia disorders. METHOD We compared premorbid adjustment and other premorbid variables such as IQ and developmental abnormalities in a cohort of children and adolescents (N=69) with bipolar disorder (BP) or schizophrenia (SZ) experiencing their first psychotic episode and in a healthy control group (N=91). RESULTS Schizophrenia patients showed more social impairment in childhood than bipolar patients (p<0.05) and healthy controls (p<0.001) and had higher rates of developmental abnormalities (p<0.05) than healthy controls. Between childhood and early adolescence, schizophrenia and bipolar patients showed a greater decline in academic adjustment than healthy controls, more specifically in adaptation to school (p<0.01). CONCLUSIONS Early-onset schizophrenia patients show more early social impairment than early-onset bipolar patients. Intellectual premorbid abnormalities are less specific and probably more linked to early-onset psychosis.
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Affiliation(s)
- Beatriz Payá
- Child and Adolescent Psychiatry and Psychology Unit, Hospital Universitario Marques de Valdecilla, Santander, Spain.
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16
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Moro MF, Colom F, Floris F, Pintus E, Pintus M, Contini F, Carta MG. Validity and Reliability of the Italian Version of the Functioning Assessment Short Test (FAST) in Bipolar Disorder. Clin Pract Epidemiol Ment Health 2012; 8:67-73. [PMID: 22905035 PMCID: PMC3419862 DOI: 10.2174/1745017901208010067] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 06/20/2012] [Accepted: 06/21/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Functioning Assessment Short Test (FAST) is a brief instrument designed to assess the main functioning problems experienced by psychiatric patients, specifically bipolar patients. It includes 24 items assessing impairment or disability in six domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships and leisure time. The aim of this study is to measure the validity and reliability of the Italian version of this instrument. METHODS Twenty-four patients with DSM-IV TR bipolar disorder and 20 healthy controls were recruited and evaluated in three private clinics in Cagliari (Sardinia, Italy). The psychometric properties of FAST (feasibility, internal consistency, concurrent validity, discriminant validity (patients vs controls and eutimic patients vs manic and depressed), and test-retest reliability were analyzed. RESULTS The internal consistency obtained was very high with a Cronbach's alpha of 0.955. A highly significant negative correlation with GAF was obtained (r = -0.9; p < 0.001) pointing to a reasonable degree of concurrent validity. FAST show a good test-retest reliability between two independent evaluation differing of one week (mean K =0.73). The total FAST scores were lower in controls as compared with Bipolar Patients and in Euthimic patients compared with Depressed or Manic. CONCLUSION The Italian version of the FAST showed similar psychometrics properties as far as regard internal consistency and discriminant validity of the original version and show a good test retest reliability measure by means of K statistics.
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Affiliation(s)
- Maria Francesca Moro
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari Italy and Centro di Psichiatria di Consultazione e Psicosomatica, University Hospital, Cagliari
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Demjaha A, MacCabe JH, Murray RM. How genes and environmental factors determine the different neurodevelopmental trajectories of schizophrenia and bipolar disorder. Schizophr Bull 2012; 38:209-14. [PMID: 21857009 PMCID: PMC3283142 DOI: 10.1093/schbul/sbr100] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The debate endures as to whether schizophrenia and bipolar disorder are separate entities or different manifestations of a single underlying pathological process. Here, we argue that this sterile argument obscures the fact that the truth lies somewhere in between. Thus, recent studies support a model whereby, on a background of some shared genetic liability for both disorders, patients with schizophrenia have been subject to additional genetic and/or environmental factors that impair neurodevelopment; for example, copy number variants and obstetric complications are associated with schizophrenia but not with bipolar disorder. As a result, children destined to develop schizophrenia show an excess of neuromotor delays and cognitive difficulties while those who later develop bipolar disorder perform at least as well as the general population. In keeping with this model, cognitive impairments and brain structural abnormalities are present at first onset of schizophrenia but not in the early stages of bipolar disorder. However, with repeated episodes of illness, cognitive and brain structural abnormalities accumulate in both schizophrenia and bipolar disorder, thus clouding the picture.
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Affiliation(s)
- Arsime Demjaha
- Department of Psychosis Studies, Biomedical Research Centre, Institute of Psychiatry, King’s College, London, UK.
| | - James H. MacCabe
- Department of Psychosis Studies, Biomedical Research Centre, Institute of Psychiatry, King’s College, London, UK
| | - Robin M. Murray
- Department of Psychosis Studies, Biomedical Research Centre, Institute of Psychiatry, King’s College, London, UK
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Levy B, Manove E. Functional outcome in bipolar disorder: the big picture. DEPRESSION RESEARCH AND TREATMENT 2011; 2012:949248. [PMID: 21961062 PMCID: PMC3180778 DOI: 10.1155/2012/949248] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 06/23/2011] [Indexed: 12/12/2022]
Abstract
Previous research on functional outcome in bipolar disorder (BD) has uncovered various factors that exacerbate psychosocial disability over the course of illness, including genetics, illness severity, stress, anxiety, and cognitive impairment. This paper presents an integrated view of these findings that accounts for the precipitous decline in psychosocial functioning after illness onset. The proposed model highlights a number of reciprocal pathways among previously studied factors that trap people in a powerful cycle of ailing forces. The paper discusses implications to patient care as well as the larger social changes required for shifting the functional trajectory of people with BD from psychosocial decline to growth.
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Affiliation(s)
- Boaz Levy
- Mental Health Counseling, Department of Counseling and School Psychology, University of Massachusetts, Boston, MA 02125, USA
| | - Emily Manove
- Mental Health Counseling, Department of Counseling and School Psychology, University of Massachusetts, Boston, MA 02125, USA
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Hennessy RJ, Baldwin PA, Browne DJ, Kinsella A, Waddington JL. Frontonasal dysmorphology in bipolar disorder by 3D laser surface imaging and geometric morphometrics: comparisons with schizophrenia. Schizophr Res 2010; 122:63-71. [PMID: 20554158 PMCID: PMC2941027 DOI: 10.1016/j.schres.2010.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/22/2010] [Accepted: 05/05/2010] [Indexed: 11/22/2022]
Abstract
Any developmental relationship between bipolar disorder and schizophrenia engenders continuing debate. As the brain and face emerge in embryological intimacy, brain dysmorphogenesis is accompanied by facial dysmorphogenesis. 3D laser surface imaging was used to capture the facial surface of 13 male and 14 female patients with bipolar disorder in comparison with 61 male and 75 female control subjects and with 37 male and 32 female patients with schizophrenia. Surface images were analysed using geometric morphometrics and 3D visualisations to identify domains of facial shape that distinguish bipolar patients from controls and bipolar patients from those with schizophrenia. Both male and female bipolar patients evidenced significant facial dysmorphology: common to male and female patients was overall facial widening, increased width of nose, narrowing of mouth and upward displacement of the chin; dysmorphology differed between male and female patients for nose length, lip thickness and tragion height. There were few morphological differences in comparison with schizophrenia patients. That dysmorphology of the frontonasal prominences and related facial regions in bipolar disorder is more similar to than different from that found in schizophrenia indicates some common dysmorphogenesis. Bipolar disorder and schizophrenia might reflect similar insult(s) acting over slightly differing time-frames or slightly differing insult(s) acting over a similar time-frame.
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Affiliation(s)
- Robin J. Hennessy
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland
| | - Patrizia A. Baldwin
- Cavan-Monaghan Mental Health Service, St. Davnet's Hospital, Monaghan, Ireland
| | - David J. Browne
- Cavan-Monaghan Mental Health Service, St. Davnet's Hospital, Monaghan, Ireland
| | - Anthony Kinsella
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland
| | - John L. Waddington
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland,Cavan-Monaghan Mental Health Service, St. Davnet's Hospital, Monaghan, Ireland,Corresponding author. Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin 2, Ireland. Tel.: + 353 1 402 2129; fax: + 353 1 402 2453.
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