Duration of illness and duration of untreated illness in relation to drug response in psychiatric disorders

A New Intervention for Implementation of Pharmacogenetics in Psychiatry: A Description of the PSY-PGx Clinical Study

(1) Background Pharmacological treatment for psychiatric disorders has shown to only be effective in about one-third of patients, as it is associated with frequent treatment failure, often because of side effects, and a long process of trial-and-error pharmacotherapy until an effective and tolerable treatment is found. This notion emphasizes the urgency for a personalized medicine approach in psychiatry. (2) Methods This prospective patient- and rater-blinded, randomized, controlled study will investigate the effect of dose-adjustment of antidepressants escitalopram and sertraline or antipsychotics risperidone and aripiprazole according to the latest state-of-the-art international dosing recommendations for CYP2C19 and CYP2D6 metabolizer status in patients with mood, anxiety, and psychotic disorders. A total sample of N = 2500 will be recruited at nine sites in seven countries (expected drop-out rate of 30%). Patients will be randomized to a pharmacogenetic group or a dosing-as-usual group and treated over a 24-week period with four study visits. The primary outcome is personal recovery using the Recovery Assessment Scale as assessed by the patient (RAS-DS), with secondary outcomes including clinical effects (response or symptomatic remission), side effects, general well-being, digital phenotyping, and psychosocial functioning. (3) Conclusions This is, to our knowledge, the first international, multi-center, non-industry-sponsored randomized controlled trial (RCT) that may provide insights into the effectiveness and utility of implementing pharmacogenetic-guided treatment of psychiatric disorders, and as such, results will be incorporated in already available dosing guidelines.

Short-term Clinical Outcome of Previously Untreated and Treated Schizophrenia and Impact of Duration of Untreated Psychosis

Background

Duration of untreated psychosis (DUP) is an important modifiable factor affecting schizophrenia outcomes. A dearth of research in India on untreated versus treated schizophrenia warrants further research.

Methods

This was a longitudinal study in a tertiary hospital over 2 years. Inpatients diagnosed with schizophrenia (N = 116), aged 18-45, were divided into untreated and treated groups. Diagnostic confirmation, severity assessment, and clinical outcome were done using ICD-10 criteria, Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression (CGI) scale. Follow-up was done at 12 and 24 weeks. DUP was measured, and its association with the outcome was assessed.

Results

Final analysis included 100 patients, 50 each of previously untreated and treated. Untreated patients had lower age and duration of illness (DOI), but higher DUP (p < .001). Treated patients showed much improvement on CGI-I at 12 weeks (p = .029), with no difference at 24 weeks. PANSS severity comparison showed no difference, and both groups followed a declining trend. In untreated patients, age of onset (AoO) was negatively correlated with severity (except general symptoms at baseline) at all follow-ups ('r' range = -0.32 to -0.49, p < .05), while DOI showed a positive correlation with negative and general symptoms at 12 weeks (r ~ 0.3, p < .05). Treated patients showed inconsistent and lower negative correlation between AoO and PANSS, with no correlation between severity and DOI. The mean sample DUP was 17.9 ± 31.6 weeks; it negatively correlated with education (r = -0.25, p = .01) and positively with PANSS severity ('r' range = 0.22 to 0.30, p < .05) at all follow-ups, especially negative symptoms. Patients with no or minimal improvement on CGI at 24 weeks had higher DUP (Quade's ANOVA F[1,98] = 6.24, p = .014).

Conclusion

Illness variables in untreated schizophrenia affect severity, which has delayed improvement than treated schizophrenia. Higher DUP is associated with negative symptoms of schizophrenia.

Criteria for detection of possible risk factors for mental health problems in undergraduate university students

Introduction

Developing approaches for early detection of possible risk clusters for mental health problems among undergraduate university students is warranted to reduce the duration of untreated illness (DUI). However, little is known about indicators of need for care by others. Herein, we aimed to clarify the specific value of study engagement and lifestyle habit variables in predicting potentially high-risk cluster of mental health problems among undergraduate university students.

Methods

This cross-sectional study used a web-based demographic questionnaire [the Utrecht Work Engagement Scale for Students (UWES-S-J)] as study engagement scale. Moreover, information regarding life habits such as sleep duration and meal frequency, along with mental health problems such as depression and fatigue were also collected. Students with both mental health problems were classified as high risk. Characteristics of students in the two groups were compared. Univariate logistic regression was performed to identify predictors of membership. Receiver Operating Characteristic (ROC) curve was used to clarify the specific values that differentiated the groups in terms of significant predictors in univariate logistic analysis. Cut-off point was calculated using Youden index. Statistical significance was set at p < 0.05.

Results

A total of 1,644 students were assessed, and 30.1% were classified as high-risk for mental health problems. Significant differences were found between the two groups in terms of sex, age, study engagement, weekday sleep duration, and meal frequency. In the ROC curve, students who had lower study engagement with UWES-S-J score < 37.5 points (sensitivity, 81.5%; specificity, 38.0%), <6 h sleep duration on weekdays (sensitivity, 82.0%; specificity, 24.0%), and < 2.5 times of meals per day (sensitivity, 73.3%; specificity, 35.8%), were more likely to be classified into the high-risk group for mental health problems.

Conclusion

Academic staff should detect students who meet these criteria at the earliest and provide mental health support to reduce DUI among undergraduate university students.

Toward staging differentiation for posttraumatic stress disorder treatment

OBJECTIVES

Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD.

METHODS

State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD.

RESULTS

We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations.

CONCLUSION

A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.

Longer illness duration is associated with greater individual variability in functional brain activity in Schizophrenia, but not bipolar disorder

BACKGROUND

Individuals with schizophrenia exhibit greater inter-patient variability in functional brain activity during neurocognitive task performance. Some studies have shown associations of age and illness duration with brain function; however, the association of these variables with variability in brain function activity is not known. In order to better understand the progressive effects of age and illness duration across disorders, we examined the relationship with individual variability in brain activity.

METHODS

Neuroimaging and behavioural data were extracted from harmonized datasets collectively including 212 control participants, 107 individuals with bipolar disorder, and 232 individuals with schizophrenia (total n = 551). Functional activity in response to an N-back working memory task (2-back vs 1-back) was examined. Individual variability was quantified via the correlational distance of fMRI activity between participants; mean correlational distance of one participant in relation to all others was defined as a 'variability score'.

RESULTS

Greater individual variability was found in the schizophrenia group compared to the bipolar disorder and control groups (p = 1.52e-09). Individual variability was significantly associated with aging (p = 0.027), however, this relationship was not different across diagnostic groups. In contrast, in the schizophrenia sample only, a longer illness duration was associated with increased variability (p = 0.027).

CONCLUSION

An increase in variability was observed in the schizophrenia group related to illness duration, beyond the effects of normal aging, implying illness-related deterioration of cognitive networks. This has clinical implications for considering long-term trajectories in schizophrenia and progressive neural and cognitive decline which may be amiable to novel treatments.

COVID-19-Related Perceived Threat Following a Second Dose Vaccination in Adults with Chronic Illness: A Mixed-Method Study

Background

In patients with comorbidities such as chronic illness, the severity and mortality risk of the disease (COVID-19) are high. Even if they are fully vaccinated, they should follow all precautions for unvaccinated people because the vaccine may not provide them complete protection. As a result, understanding their response to a threat is essential because knowing their threat level can be a good predictor of behavioral changes and health-protective behaviors.

Methods

An institution-based cross-sectional mixed-method study design was used at the University of Gondar specialized hospital from May 1 to June 30, 2021. An interviewer-administered questionnaire was used for the quantitative, and tape recorders, field notes, and memos were properly taken during the in-depth interviews for the qualitative data. Multivariable logistic regression with consideration of adjusted odds ratio of 95% confidence interval and p-value of 0.05% was used for statistical significance.

Results

The study enrolled 239 people, with a 96% response rate, ranging from 24 to 67 years, with the majority (57.9%) male. Even after receiving the second dose of AstraZeneca, nearly half (46.5%) of participants with a chronic illness perceived a threat to COVID-19. The participant’s age ranges from 24 to 34 years [3.24 (AOR= 3.24 (95% CI: 1.08, 9.68))], patients who are student [2.38 (AOR= 2.38 (95% CI: 1.12, 5.06))], participants applying the recommended behavioral response [2.36 (AOR=2.36 (95% CI: 1.16, 4.81))] and duration of illness ranged from four to six-year [3.17 (AOR=3.17 (95% CI (1.05, 9.58))] were statistically associated with perceived threat.

Conclusion

Most people with chronic illnesses do not see the disease as a threat. Particular emphasis should be placed on creating awareness programs and disseminating information through media on prevention, and ongoing health education is strongly advisable.

Mindfulness meditation for Chinese patients with psychosis: A systematic review and meta-analysis

Mindfulness meditation (MM) and its alignment with the mind-body perspective of health in Chinese cultures indicate its potential to benefit Chinese patients with psychosis. This is the first systematic review and meta-analysis to address the following questions: (1) Does MM improve clinical, well-being, and third-wave outcomes (i.e., mindfulness, acceptance, and compassion levels) among Chinese patients with psychosis? (2) What are the patient- and/or intervention-specific factors that moderate the efficacy of MM? (3) Are improvements on third-wave outcomes associated with improvements on clinical and well-being outcomes? (4) What are the mechanisms underlying the effects of MM? Evidence synthesized from 23 relevant articles (20 studies) involving 1749 patients showed that (1) MM improved a wide range of patients' outcomes, most consistently and sustainably for insight, rehospitalization duration, recovery rate, and social functioning; (2) age and duration of illness, but not the cumulated intervention hours, moderated the overall efficacy of MM; (3) post-MM improvements on mindfulness and on clinical and well-being outcomes were related, and (4) the effects of MM on patients' outcomes may be driven by its ability to promote positive changes in personal growth and enhance one's coping with the illness and its symptoms. Our data showed preliminary support for the benefits of MM in Chinese patients with psychosis. However, results should be considered in light of the varying quality of included studies and their heterogeneity in multiple aspects. Further research is needed to deduce the sustainability of MM's effects, its active ingredients, underlying mechanisms, and additional moderators of its efficacy.

Early Improvement of Psychiatric Symptoms with Long-Acting Injectable Antipsychotic Predicts Subsequent Social Functional Remission in Patients with Schizophrenia

PURPOSE

The aim of this study was to clarify whether early symptomatic improvement in response to a long-acting injectable antipsychotic (LAI) contributes to subsequent social functional remission in patients with schizophrenia using the previous clinical trial data (EudraCT registration number: 2011-004889-15). Associations between other factors and social functional remission were also explored.

PATIENTS AND METHODS

We analyzed 428 patients with schizophrenia in which the personal and social performance scale (PSP) and the involvement evaluation questionnaire (IEQ) at the time of the base line were recorded. Social functional remission was defined as participants who scored PSP >70 at the end of 65 weeks. Logistic regression analyses were done to examine associations between social functional remission and clinical and demographic characteristics including early symptomatic response evaluated by Positive and Negative Syndrome Scale (PANSS) at week one.

RESULTS

One hundred out of 428 patients showed social functional remission at the end of the observation period. Shorter duration of illness, higher baseline score of supervision evaluated by IEQ and higher baseline PSP were significantly associated with the social functional remission. Improvement of positive subscale of PANSS at one week was significantly associated with later social functional remission when baseline PSP scores were excluded from predictive variables.

CONCLUSION

Shorter duration of illness, residual type of schizophrenia, higher baseline score of supervision and higher baseline social functioning were predictors of subsequent social functional remission. Although its effect seems to be limited, early symptomatic improvement could be also was a predictor of social functional remission.

Safety and effectiveness of oral blonanserin for schizophrenia: A review of Japanese post-marketing surveillances

Schizophrenia significantly limits social functioning with positive and negative symptoms and cognitive dysfunction. Blonanserin (LONASEN®), a novel second-generation antipsychotic approved for treating schizophrenia in Japan in 2008, reportedly shows beneficial effects on cognitive function as well as positive and negative symptoms, with potential for improving social functioning. To understand the safety and effectiveness of blonanserin in the real clinical practice, five Japanese post-marketing surveillances have been conducted and published to date. In this article, we reviewed all the Japanese post-marketing surveillances and discussed the clinical usefulness of blonanserin in patients with schizophrenia having diverse clinical characteristics. Adverse drug reactions, such as akathisia and extrapyramidal symptoms, were common in all surveillances. However, those specific to second-generation antipsychotics, such as weight gain and abnormalities in glycometabolism or lipid metabolism, were rarely observed. In addition, no adverse drug reactions apart from clinical trial results were found. Brief Psychiatric Rating Scale total scores in all surveillances significantly lowered at the last evaluation than at baseline. These results were consistent through 1-year of treatment, suggesting that effectiveness is maintained even after long-term use. In conclusion, blonanserin is considered a beneficial drug in real clinical practice for patients with schizophrenia having diverse characteristics.

Paliperidone LAI and Aripiprazole LAI Plasma Level Monitoring in the Prophylaxis of Bipolar Disorder Type I with Manic Predominance

Introduction The objective of this study was the evaluation of utility of plasma level monitoring in the clinical stabilizing efficacy and tolerability of paliperidone palmitate (PP) vs. aripiprazole monohydrate (AM) in bipolar disorder I (BD I) with manic predominance.

Methods Fifty-six outpatients of both sexes, age ranging from 18 to 65 years, affected by BD I with manic predominance, orally treated and stabilized after acute episode for at least 2 weeks with paliperidone or aripiprazole (n=31, paliperidone; n=25, aripiprazole) underwent a prospective observational study of switching to the corresponding long-acting injection (LAI) on the basis of clinical evaluation. The efficacy and tolerability of the 2 treatments were assessed by BPRS, PANSS, HAMD21, and MRS rating scales and a check list every month for 12 months. Drug plasma levels determinations (PLs) were performed at the same times.

Results A good clinical stability and tolerability of both drugs were reported. Lower mean PLs of PP showed a positive effect on depressive symptoms. AM PLs variability was associated with greater instability of manic symptoms whereas intermediate PLs seem to have more influence on depressive symptomatology.

Discussion PLs drug monitoring has been proven to be useful, and further investigations to identify optimal therapeutic ranges for LAI formulations are needed.

Psychotic versus non-psychotic bipolar disorder: Socio-demographic and clinical profiles in an Italian nationwide study

OBJECTIVE

Psychotic versus non-psychotic patients with bipolar disorder have been traditionally associated with different unfavorable clinical features. In this study on bipolar Italian patients, we aimed to compare clinical and demographic differences between psychotic and non-psychotic individuals, exploring clinical factors that may favor early diagnosis and personalized treatment.

METHODS

A total of 1671 patients (males: n = 712 and females: n = 959; bipolar type 1: n = 1038 and bipolar type 2: n = 633) from different psychiatric departments were compared according to the lifetime presence of psychotic symptoms in terms of socio-demographic and clinical variables. Chi-square tests for qualitative variables and Student's t-tests for quantitative variables were performed for group comparison, and a multivariable logistic regression was performed, considering the lifetime psychotic symptoms as dependent variables and socio-demographic/clinical characteristics as independent variables.

RESULTS

Psychotic versus non-psychotic bipolar subjects resulted to: be more frequently unemployed (p < 0.01) and never married/partnered (p < 0.01); have an earlier age at onset (p < 0.01); more frequently receive a first diagnosis different from a mood disorder (p < 0.01); have a shorter duration of untreated illness (p < 0.01); have a more frequently hypomanic/manic prevalent polarity (p < 0.01) and a prevalent manic-depressive type of cycling (p < 0.01); present a lower lifetime number of depressive episodes (p < 0.01), but have more manic episodes (p < 0.01); and less insight (p < 0.01) and more hospitalizations in the last year (p < 0.01). Multivariable regression analysis showed that psychotic versus non-psychotic bipolar patients received more frequently a first diagnosis different from bipolar disorder (odds ratio = 0.64, 95% confidence interval = [0.46, 0.90], p = 0.02) or major depressive disorder (odds ratio = 0.66, 95% confidence interval = [0.48, 0.91], p = 0.02), had more frequently a prevalent manic polarity (odds ratio = 1.84, 95% confidence interval = [1.14, 2.98], p < 0.01) and had a higher number of lifetime manic episodes (more than six) (odds ratio = 8.79, 95% confidence interval = [5.93, 13.05], p < 0.01).

CONCLUSION

Lifetime psychotic symptoms in bipolar disorder are associated with unfavorable socio-demographic and clinical features as well as with a more frequent initial misdiagnosis.

Is trazodone more effective than clomipramine in major depressed outpatients? A single-blind study with intravenous and oral administration

OBJECTIVE

Some antidepressants, such as trazodone or clomipramine, can be administered intravenously in patients with major depressive disorder (MDD), with potential benefits compared to the standard oral treatment, but available data about their efficacy are limited. The present study was aimed to compare the effectiveness of trazodone and clomipramine (intravenous [i.v.] followed by oral administration).

METHODS

Some 42 patients with a diagnosis of MDD according to the DSM-5 were selected and treated with i.v. trazodone or clomipramine according to clinical judgment. The Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Montgomery-Åsberg Depression Rating Scale were administered at baseline, after 2 weeks, and after 6 weeks, as well as after 1 week of intravenous antidepressant administration. Raters were blinded to type of treatment.

RESULTS

No significant differences were found between treatment groups in terms of effectiveness at endpoint. Borderline statistical significance was found in terms of number of responders in favor of trazodone. In addition, patients treated with trazodone reported fewer total side effects than those treated with clomipramine.

CONCLUSION

Both i.v. trazodone and clomipramine are rapid and effective options for improving depressive symptoms, although trazodone appears to be tolerated better. Further studies with larger samples and double-blind conditions are warranted to confirm our results.

Clinical characterization of rapid cycling bipolar disorder: Association with attention deficit hyperactivity disorder

BACKGROUND

Rapid cycling (RC) bipolar disorder (BD) is associated with more disability and worse global functioning than non-rapid cycling BD (NRC) and is understudied. This study aims to investigate clinical characteristics associated to RC in a Latin-American sample and secondarily, to generate a clinical model to test the likelihood of RC in BD.

METHODS

250 BD patients were enrolled between 2007 and 2015. All patients met DSM-IV criteria for BD type I, II or NOS. The sample was dichotomized into RC and NRC subgroups, and compared in terms of sociodemographic and clinical variables by bivariate analyses. A binary logistic regression was performed to generate a model and explain variance associated with the likelihood of presenting RC.

RESULTS

Final sample included 235 patients, of which forty-four (18.7%) met RC criteria. When compared to NRC, a significantly higher proportion of RC patients were female (81.4% vs. 58.9% p = 0.006), BD type II (58.1% vs. 29.7% p = 0.002), presented more manic/hypomanic episodes (43.6 ± 35.8 vs. 12.8 ± 58.9, p = 0.001), and had less psychotic symptoms (20.9% vs. 42.2%, p = 0.010). Attention deficit hyperactivity disorder (ADHD) was a significant comorbidity in RC (23.7% vs. 8.3%, p = 0.007). No differences were found in suicidality, mixed symptoms, and seasonal pattern. After logistic regression, variables significantly associated with RC were presence of ADHD (OR 4.6 [95% CI 1.54-13.93] p = 0.006) and female gender (OR 3.55 [95% CI, 1.32-9.56] p = 0.012).

LIMITATIONS

It is a cross-sectional study.

CONCLUSIONS

Findings suggest that ADHD comorbidity, and female gender are risk factors for RC in BD.

Is there a link between air pollution and mental disorders?

Several studies have demonstrated the association between air pollution and different medical conditions including respiratory and cardiovascular diseases. Air pollutants might have a role also in the etiology of mental disorders in the light of their toxicity on central nervous system. Purpose of the present manuscript was to review and summarize available data about an association between psychiatric disorders and air pollution. A research in the main database sources has been conducted to identify relevant papers about the topic. Different air pollutants and in particular PM and nitric oxides have been associated with poor mental health; long exposition to PM_2.5 has been associated with an increased risk of new onset of depressive symptoms (Cohen's effect size d: 0.05-0.81), while increased concentration of nitric dioxide in summer with worsening of existing depressive conditions (Cohen's effect size d: 0.05-1.77). However, the interpretation of these finding should take into account the retrospective design of most of studies, different periods of observations, confounding factors such as advanced age or medical comorbidity. Further studies with rigorous methodology are needed to confirm the results of available literature about this topic.

Gray matter bases of psychotic features in adult bipolar disorder: A systematic review and voxel-based meta-analysis of neuroimaging studies

Psychotic bipolar disorder (P-BD) is a specific subset that presents greater risk of relapse and worse outcomes than nonpsychotic bipolar disorder (NP-BD). To explore the neuroanatomical bases of psychotic dimension in bipolar disorder (BD), a systematic review was carried out based on the gray matter volume (GMV) among P-BD and NP-BD patients and healthy controls (HC). Further, we conducted a meta-analysis of GMV differences between P-BD patients and HC using a whole-brain imaging approach. Our review revealed that P-BD patients exhibited smaller GMVs mainly in the prefronto-temporal and cingulate cortices, the precentral gyrus, and insula relative to HC both qualitatively and quantitatively. Qualitatively the comparison between P-BD and NP-BD patients suggested inconsistent GMV alterations mainly involving the prefrontal cortex, while NP-BD patients showed GMV deficits in local regions compared with HC. The higher proportions of female patients and patients taking psychotropic medication in P-BD and P-BD type I were associated with smaller GMV in the right precentral gyrus, and the right insula, respectively. In conclusions, psychosis in BD might be associated with specific cortical GMV deficits. Gender and psychotropic medication might have effects on the regional GMVs in P-BD patients. It is necessary to distinguish psychotic dimension in neuroimaging studies of BD.

Socio-demographic and clinical characterization of patients with Bipolar Disorder I vs II: a Nationwide Italian Study

Bipolar disorders (BDs) are prevalent, comorbid and disabling conditions, associated with the highest suicide risk among psychiatric illnesses. In the last few years, new efforts to better characterize the socio-demographic and clinical profiles of BD type I vs II have been documented by several reports, with novel and insightful findings in the field. The present multicenter study aimed to provide a comprehensive and reliable representation of the Italian reality, through the analysis of the largest national sample of bipolar patients collected so far. A total of 1500 patients (BD I n = 963 and BD II n = 537) from different psychiatric departments, participating in the Italian Chapter of the "International Society of Bipolar Disorders" (ISBD), were assessed and divided into two groups on the basis of their diagnostic subtype, and different socio-demographic and clinical variables were compared between the two subgroups. Chi-squared tests for categorical variables and t tests for continuous variables were performed for group comparison. Furthermore, a multivariable logistic regression was performed, considering diagnostic bipolar subtype (type I or II) as dependent variable, and socio-demographic/clinical characteristics as independent variables. BD I vs II patients showed an overall less favorable socio-demographic and clinical profile. In addition, the multivariable logistic regression showed that BD II vs BD I was predicted by the absence of lifetime suicide attempts (OR = 1.58, p = 0.01), a later age of diagnosis (OR = 1.03, p < 0.01), less hypomanic episodes in the last year (OR = 2.29, p < 0.0001) and absence of psycho-educational interventions in the last year (OR = 0.51, p < 0.01). BD I and II patients were found to significantly differ in relation to specific clinical variables, which should be considered within updated diagnostic-therapeutic algorithms.

Have antipsychotics a different speed of action in the acute treatment of mania? A single-blind comparative study

Available antipsychotics show different efficacy on manic symptoms of bipolar patients, but few studies have investigated the speed of action of the various compounds. For this reason, purpose of the present paper was to compare antipsychotic mono-therapies in terms of speed of action in a sample of manic bipolar patients. In total, 155 bipolar patients, treated with antipsychotic mono-therapy and followed-up in Inpatient Psychiatry Clinic of University of Milan, were included in this single-blind comparative study. Clinical response was defined as a reduction of Young Mania Rating Scale (YMRS) scores ⩾50%, while remission as a YMRS score <10. After 4 days patients who had been treated with asenapine, were more likely to have achieved a clinical response than those in treatment with haloperidol ( p = 0.001). After 7 days, a more frequent clinical response was achieved by patients treated with asenapine than those who had been treated with haloperidol ( p < 0.001) or olanzapine ( p = 0.047). Asenapine appears to be faster in determining treatment response in manic patients compared with haloperidol and less markedly with olanzapine.

Impaired prefrontal activity to regulate the intrinsic motivation-action link in schizophrenia

A core feature of schizophrenia (SCZ) is impairment in intrinsic motivation. Although intrinsic motivation plays an important role in enhancing improvement of the social functioning, its neural mechanisms of impairment have yet to be clarified. We hypothesized that abnormal function of the frontostriatal loop consisting of the striatum and lateral prefrontal cortex (LPFC) may be related to impaired intrinsic motivation in SCZ. We tested this by comparing the brain activity measured by functional magnetic resonance imaging and behavioral parameters associated with movement, motivation, and cognitive control between 18 stable SCZ patients and 17 healthy control (HC) participants during a task that elicits intrinsic motivation. We also compared the functional connectivity during resting-state and the fractional anisotropy using diffusion tensor imaging analysis between the two groups. We adopted an enjoyable timing task to stop a stopwatch at an exact time, which in our previous study has demonstrated to elicit intrinsic motivation. Although the performance level in general was not different between groups, the SCZ group performed worse than the HC group in trials following “overshoot” errors (i.e., the response was too late). SCZ participants showed lower intrinsic motivation to the task than the HC group in an inventory report. The striatal activity during the prediction at the task cue period was consistently lower in SCZ participants than in HC. The LPFC activity at the task cue period positively correlated with intrinsic motivation and also with the rate of success following overshoot errors in the HC group, but not in the SCZ group. The LPFC activity at the task cue period was also positively correlated with the striatal activity in both groups. The striatal activity during the feedback period was not significantly different between groups. These results suggest that, unlike HC, the neural activity in the LPFC fails to mediate between prediction of hedonic events and cognitive control of action plans in SCZ, whereas the hedonic response is retained.

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The neural basis of impaired motivation in schizophrenia is examined using fMRI.

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The hedonic response to a feedback in the striatum is retained in schizophrenia.

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Translating hedonic events to action plans is impeded by poor cognitive control.

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The cognitive control impairment is associated with altered prefrontal function.

Fitness to stand trial evaluation challenges in the United States: Some comparisons with South Africa

Like the Republic of South Africa, the United States faces serious challenges regarding fitness to stand trial evaluations, including long waitlists for individuals awaiting such evaluations. Some similarities exist between the RSA and US evaluation systems, including an increasing number of referrals for fitness to stand trial evaluations, limited evaluator resources, and concerns about the significant restrictions on civil liberties for those awaiting evaluation. Recently, the United States has implemented several different solutions to address these issues. These have included broadening the eligibility requirements for fitness to stand trial evaluators, utilizing localized and short-term settings for fitness to stand trial evaluations, and a host of other ideas. This article examines these different solutions, discusses their relevance and potential effectiveness for the RSA evaluation system, and makes recommendations for consideration by policy makers and mental health professionals.

Biological aspects and candidate biomarkers for psychotic bipolar disorder: A systematic review

AIM

We carried out a systematic review of the available literature about potential biomarkers of psychotic bipolar disorder (BD-P), a specific subset presenting worse outcome and greater risk of relapse than non-psychotic bipolar disorder (BD-NP).

METHODS

We searched the main psychiatric databases (PubMed, ISI Web of Knowledge, PsychInfo). Only original articles with the main topic of BD-P compared to schizophrenia/BD-NP/healthy controls (HC) written in English from 1994 to 2015 were included.

RESULTS

BD-P patients presented higher kynurenic acid levels in the cerebrospinal fluid, elevated anti- S accharomyces cerevisiae antibodies levels, and lower serum levels of dehydroepiandrosterone sulfate and progesterone than BD-NP/HC. Event-related potentials abnormalities have been identified in BD-P with respect to BD-NP. BD-P patients also presented bigger ventricles but similar hippocampal volumes compared to BD-NP/HC. Although the results are contrasting, some cognitive deficits seemed to be related to the psychotic dimension of bipolar affective disorder, such as impairment in verbal/logical memory, working memory, verbal and semantic fluency and executive functioning. Finally, polymorphisms of genes, such as NRG1, 5HTTLPR (s), COMT, DAOA and some chromosome regions (16p12 and 13q), were positively associated with BD-P.

CONCLUSION

Data about the identification of specific biomarkers for BD-P are promising, but most of them have not yet been replicated. They could lead the clinicians to an early diagnosis and proper treatment, thus ameliorating outcome of BD-P and reducing the biological changes associated with a long duration of illness. Further studies with bigger samples are needed to detect more specific biological markers of the psychotic dimension of bipolar affective disorder.

T helper 17 cells may drive neuroprogression in major depressive disorder: Proposal of an integrative model

The exact pathophysiology of major depressive disorder (MDD) remains elusive. The monoamine theory, which hypothesizes that MDD emerges as a result of dysfunctional serotonergic, dopaminergic and noradrenergic pathways, has guided the therapy of this illness for several decades. More recently, the involvement of activated immune, oxidative and nitrosative stress pathways and of decreased levels of neurotrophic factors has provided emerging insights regarding the pathophysiology of MDD, leading to integrated theories emphasizing the complex interplay of these mechanisms that could lead to neuroprogression. In this review, we propose an integrative model suggesting that T helper 17 (Th17) cells play a pivotal role in the pathophysiology of MDD through (i) microglial activation, (ii) interactions with oxidative and nitrosative stress, (iii) increases of autoantibody production and the propensity for autoimmunity, (iv) disruption of the blood-brain barrier, and (v) dysregulation of the gut mucosa and microbiota. The clinical and research implications of this model are discussed.

Is duration of illness really influencing outcome in major psychoses?

BACKGROUND

An increasing number of studies identifies the duration of illness (DI) as an important predictor of outcome in patients affected by major psychoses (MP). The aim of the present paper was to revise medical literature about DI and its effects on MP, focusing in particular on the relationship between DI and outcome with particular reference to treatment response, suicidal risk, cognitive impairment and social functioning.

METHODS

A search in the main database sources has been performed to obtain a comprehensive overview. Studies with different methodologies (open and double-blinded) have been included, while papers considering other variables such as duration of untreated episode/illness were excluded. MP included the diagnoses of schizophrenia, bipolar disorder and major depressive disorder.

RESULTS

Available data show that DI influences treatment response, suicidal risk and loss of social functioning in schizophrenic patients, while results are more controversial with regard to cognitive impairment. In bipolar disorder, a long DI has been associated with less treatment response, more suicidal risk and cognitive impairment, but more data are needed to draw definitive conclusions. Finally, studies, regarding DI of illness and its predictive value of outcome in major depressive disorder show contradictory results.

CONCLUSIONS

DI appears a negative outcome factor particularly for schizophrenia, while with regard to mood disorders, more data are needed to draw definitive sound conclusions.

Are antidepressants equally effective in the long-term treatment of major depressive disorder?

OBJECTIVE

Few studies have compared simultaneously different antidepressants in long-term treatment of major depressive disorder (MDD). Long-term prevention of recurrences should be the main goal of MDD treatment. The purpose of this study was to compare antidepressants of different pharmacological classes in terms of retention in treatment (no discontinuation for recurrences, hospitalizations, side effects).

METHODS

One hundred and fifty outpatients with an MDD diagnosis, treated with antidepressants in mono-therapy, were included. Follow-up period was set at 24 months, and information have been obtained from charts, interviews with patients and their relatives, and from the Lombardy regional register. A survival analysis (Kaplan-Meier) was performed, considering recurrences, hospitalizations, or discontinuation due to side effects as 'death' events.

RESULTS

In our sample, 48.7% of the patients presented a recurrence within the first 2 years of treatment. Bupropion appears less effective in long-term treatment of MDD than the other compared antidepressants, with exception of fluoxetine (p = 0.09), amitriptyline (p = 0.13), fluvoxamine (p = 0.83), venlafaxine (p = 0.5), and trazodone (p = 0.58). Fluvoxamine appears to be less effective than citalopram (p = 0.036), paroxetine (p = 0.037), clomipramine (p = 0.05), sertraline (p = 0.011), and duloxetine (p = 0.024).

CONCLUSIONS

Bupropion and fluvoxamine appear less effective in long-term treatment of MDD. These results should be confirmed by randomized placebo-controlled prospective studies with larger samples.

Role of immunological factors in the pathophysiology and diagnosis of bipolar disorder: comparison with schizophrenia

Several lines of evidence point to the key role of neurobiological mechanisms and shared genetic background in schizophrenia and bipolar disorder. For both disorders, neurodevelopmental and neurodegenerative processes have been postulated to be relevant for the pathogenesis as well as dysregulation of immuno-inflammatory pathways. Inflammation is a complex biological response to harmful stimuli and it is mediated by cytokines cascades, cellular immune responses, oxidative factors and hormone regulation. Cytokines, in particular, are supposed to play a critical role in infectious and inflammatory processes, mediating the cross-talk between the brain and the immune system; they also possibly contribute to the development of the central nervous system. From this perspective, even though mixed results have been reported, it seems that both schizophrenia and bipolar disorder are associated with an imbalance in inflammatory cytokines; in fact, some of these could represent biological markers of illness and could be possible targets for pharmacological treatments. In light of these considerations, the purpose of the present paper was to provide a comprehensive and critical review of the existing literature about immunological abnormalities in bipolar disorder with particular attention to the similarities and differences with schizophrenia.

Duration of untreated illness (DUI) and schizophrenia sub-types: a collaborative study between the universities of Milan and Moscow

BACKGROUND

Several studies show an association between a long duration of untreated illness (DUI) and poor outcome in schizophrenic patients. DUI, in turn, may be influenced by different variables including specific illness-related factors as well as access to local psychiatric services.

AIMS

The purposes of the present study were to detect differences in terms of DUI among schizophrenics coming from different geographic areas and to evaluate differences in DUI across diagnostic sub-types.

METHOD

One hundred and twenty-five (125) schizophrenic patients of the Psychiatric Clinic of Milan (n = 51) and Moscow (n = 74) were enrolled. SCID-I was administered to all patients and information about DUI was obtained by consulting clinical charts and health system databases, and by means of clinical interviews with patients and their relatives. DUI was defined as the time between the onset of illness and the administration of the first antipsychotic drug. One-way analyses of variance (ANOVAs) were performed to find eventual differences in terms of DUI across diagnostic sub-types.

RESULTS

Italian patients showed a longer DUI (M = 4.14 years, SD = 4.95) than Russians (M = 1.16 years, SD = 1.43) (F = 24.03, p < .001). DUI was found to be longer in paranoid schizophrenics (M = 3.47 years, SD = 4.19) compared to catatonic patients (M = 0.96 years, SD = 0.94) (F = 3.56, p = .016).

CONCLUSIONS

The results of the present study suggest that the different schizophrenic sub-types may differ in terms of DUI, likely due to different clinical severity and social functioning. Studies with larger samples are needed to confirm the data of the present study.

Prominent clinical dimension, duration of illness and treatment response in schizophrenia: a naturalistic study

OBJECTIVE

Preliminary data indicate that predominant positive symptoms are predictive of subsequent treatment response, while negative and cognitive symptoms are associated with poor outcome. Purpose of the present study was to investigate the relation between the predominant clinical dimension, duration of illness and acute antipsychotic response in a sample of schizophrenic inpatients.

METHODS

Fifty-one schizophrenic inpatients, receiving an antipsychotic mono-therapy, were dimensionally assessed at the admission in the Acute Psychiatric Unit of the University of Milan. Treatment response was selected as parameter of outcome and defined as a reduction >50% of baseline total The Positive and Negative Syndrome Scale (PANSS) score. Demographic and clinical variables between responders and non-responders were compared using one-way analysis of variance for continuous variables and χ(2) test for dichotomous ones. Binary logistic regression was performed to find if dimensional scores and duration of illness were associated with acute antipsychotic response.

RESULTS

A longer duration of illness was found in non-responders respect to responders (15.61 years vs. 8.28 years)(F=4.98, p=0.03). Higher scores on PANSS positive sub-scale (OR=1.3, p=0.03), lower scores on cognitive PANSS scores (OR=0.75, p=0.05) and shorter duration of illness (OR=0.93, p=0.04) were found to be predictive of acute antipsychotic response.

CONCLUSION

These preliminary results show that a long duration of illness as well as a more severe cognitive impairment is predictive of treatment non-response, indicating a worse outcome for chronic patients with predominant cognitive symptoms.