Cortico-thalamic development and disease: From cells, to circuits, to schizophrenia

The human brain is the most complex structure generated during development. Unveiling the ontogenesis and the intrinsic organization of specific neural networks may represent a key to understanding the physio-pathological aspects of different brain areas. The cortico-thalamic and thalamo-cortical (CT-TC) circuits process and modulate essential tasks such as wakefulness, sleep and memory, and their alterations may result in neurodevelopmental and psychiatric disorders. These pathologies are reported to affect specific neural populations but may also broadly alter physiological connections and thus dysregulate brain network generation, communication, and function. More specifically, the CT-TC system is reported to be severely affected in disorders impacting superior brain functions, such as schizophrenia (SCZ), bipolar disorder, autism spectrum disorders or epilepsy. In this review, the focus will be on CT development, and the models exploited to uncover and comprehend its molecular and cellular mechanisms. In parallel to animal models, still fundamental to unveil human neural network establishment, advanced in vitro platforms, such as brain organoids derived from human pluripotent stem cells, will be discussed. Indeed, organoids and assembloids represent unique tools to study and accelerate fundamental research in CT development and its dysfunctions. We will then discuss recent cutting-edge contributions, including in silico approaches, concerning ontogenesis, specification, and function of the CT-TC circuitry that generates connectivity maps in physiological and pathological conditions.

Perinatal mental health and COVID-19: Navigating a way forward

The COVID-19 pandemic and its aftermath have increased pre-existing inequalities and risk factors for mental disorders in general, but perinatal mental disorders are of particular concern. They are already underdiagnosed and undertreated, and this has been magnified by the pandemic. Access to services (both psychiatric and obstetric) has been reduced, and in-person contact has been restricted because of the increased risks. Rates of perinatal anxiety and depressive symptoms have increased. In the face of these challenges, clear guidance in perinatal mental health is needed for patients and clinicians. However, a systematic search of the available resources showed only a small amount of guidance from a few countries, with a focus on the acute phase of the pandemic rather than the challenges of new variants and variable rates of infection. Telepsychiatry offers advantages during times of restricted social contact and also as an additional route for accessing a wide range of digital technologies. While there is a strong evidence base for general telepsychiatry, the particular issues in perinatal mental health need further examination. Clinicians will need expertise and training to navigate a hybrid model, flexibly combining in person and remote assessments according to risk, clinical need and individual patient preferences. There are also wider issues of care planning in the context of varying infection rates, restrictions and vaccination access in different countries. Clinicians will need to focus on prevention, treatment, risk assessment and symptom monitoring, but there will also need to be an urgent and coordinated focus on guidance and planning across all organisations involved in perinatal mental health care.

Off-label long acting injectable antipsychotics in real-world clinical practice: a cross-sectional analysis of prescriptive patterns from the STAR Network DEPOT study

INTRODUCTION

Information on the off-label use of Long-Acting Injectable (LAI) antipsychotics in the real world is lacking. In this study, we aimed to identify the sociodemographic and clinical features of patients treated with on- vs off-label LAIs and predictors of off-label First- or Second-Generation Antipsychotic (FGA vs. SGA) LAI choice in everyday clinical practice.

METHOD

In a naturalistic national cohort of 449 patients who initiated LAI treatment in the STAR Network Depot Study, two groups were identified based on off- or on-label prescriptions. A multivariate logistic regression analysis was used to test several clinically relevant variables and identify those associated with the choice of FGA vs SGA prescription in the off-label group.

RESULTS

SGA LAIs were more commonly prescribed in everyday practice, without significant differences in their on- and off-label use. Approximately 1 in 4 patients received an off-label prescription. In the off-label group, the most frequent diagnoses were bipolar disorder (67.5%) or any personality disorder (23.7%). FGA vs SGA LAI choice was significantly associated with BPRS thought disorder (OR = 1.22, CI95% 1.04 to 1.43, p = 0.015) and hostility/suspiciousness (OR = 0.83, CI95% 0.71 to 0.97, p = 0.017) dimensions. The likelihood of receiving an SGA LAI grew steadily with the increase of the BPRS thought disturbance score. Conversely, a preference towards prescribing an FGA was observed with higher scores at the BPRS hostility/suspiciousness subscale.

CONCLUSION

Our study is the first to identify predictors of FGA vs SGA choice in patients treated with off-label LAI antipsychotics. Demographic characteristics, i.e. age, sex, and substance/alcohol use co-morbidities did not appear to influence the choice towards FGAs or SGAs. Despite a lack of evidence, clinicians tend to favour FGA over SGA LAIs in bipolar or personality disorder patients with relevant hostility. Further research is needed to evaluate treatment adherence and clinical effectiveness of these prescriptive patterns.

Pattern of predictive features of continued cannabis use in patients with recent-onset psychosis and clinical high-risk for psychosis

Continued cannabis use (CCu) is an important predictor for poor long-term outcomes in psychosis and clinically high-risk patients, but no generalizable model has hitherto been tested for its ability to predict CCu in these vulnerable patient groups. In the current study, we investigated how structured clinical and cognitive assessments and structural magnetic resonance imaging (sMRI) contributed to the prediction of CCu in a group of 109 patients with recent-onset psychosis (ROP). We tested the generalizability of our predictors in 73 patients at clinical high-risk for psychosis (CHR). Here, CCu was defined as any cannabis consumption between baseline and 9-month follow-up, as assessed in structured interviews. All patients reported lifetime cannabis use at baseline. Data from clinical assessment alone correctly classified 73% (p < 0.001) of ROP and 59 % of CHR patients. The classifications of CCu based on sMRI and cognition were non-significant (ps > 0.093), and their addition to the interview-based predictor via stacking did not improve prediction significantly, either in the ROP or CHR groups (ps > 0.065). Lower functioning, specific substance use patterns, urbanicity and a lack of other coping strategies contributed reliably to the prediction of CCu and might thus represent important factors for guiding preventative efforts. Our results suggest that it may be possible to identify by clinical measures those psychosis-spectrum patients at high risk for CCu, potentially allowing to improve clinical care through targeted interventions. However, our model needs further testing in larger samples including more diverse clinical populations before being transferred into clinical practice.

Reduced TMS-evoked fast oscillations in the motor cortex predict the severity of positive symptoms in first-episode psychosis

Accumulating evidence points to neurophysiological abnormalities of the motor cortex in Schizophrenia (SCZ). However, whether these abnormalities represent a core biological feature of psychosis rather than a superimposed neurodegenerative process is yet to be defined, as it is their putative relationship with clinical symptoms. in this study, we used Transcranial Magnetic Stimulation coupled with electroencephalography (TMS-EEG) to probe the intrinsic oscillatory properties of motor (Brodmann Area 4, BA4) and non-motor (posterior parietal, BA7) cortical areas in twenty-three first-episode psychosis (FEP) patients and thirteen age and gender-matched healthy comparison (HC) subjects. Patients underwent clinical evaluation at baseline and six-months after the TMS-EEG session. We found that FEP patients had reduced EEG activity evoked by TMS of the motor cortex in the beta-2 (25-34 Hz) frequency band in a cluster of electrodes overlying BA4, relative to HC participants. Beta-2 deficits in the TMS-evoked EEG response correlated with worse positive psychotic symptoms at baseline and also predicted positive symptoms severity at six-month follow-up assessments. Altogether, these findings indicate that reduced TMS-evoked fast oscillatory activity in the motor cortex is an early neural abnormality that: 1) is present at illness onset; 2) may represent a state marker of psychosis; and 3) could play a role in the development of new tools of outcome prediction in psychotic patients.

Classification of Psychoses Based on Immunological Features: A Machine Learning Study in a Large Cohort of First-Episode and Chronic Patients

For several years, the role of immune system in the pathophysiology of psychosis has been well-recognized, showing differences from the onset to chronic phases. Our study aims to implement a biomarker-based classification model suitable for the clinical management of psychotic patients. A machine learning algorithm was used to classify a cohort of 362 subjects, including 160 first-episode psychosis patients (FEP), 70 patients affected by chronic psychiatric disorders (schizophrenia, bipolar disorder, and major depressive disorder) with psychosis (CRO) and 132 health controls (HC), based on mRNA transcript levels of 56 immune genes. Models distinguished between FEP, CRO, and HC and between the subgroup of drug-free FEP and HC with a mean accuracy of 80.8% and 90.4%, respectively. Interestingly, by using the feature importance method, we identified some immune gene transcripts that contribute most to the classification accuracy, possibly giving new insights on the immunopathogenesis of psychosis. Therefore, our results suggest that our classification model has a high translational potential, which may pave the way for a personalized management of psychosis.

Telework during COVID-19 outbreak: Impact on mental health among Italian workers

Introduction

Since February 2020, the outbreak of COVID-19 has spread to several countries worldwide, including Italy, leading to an uptake of telework.

Objectives

We aim to evaluate the psychopathological impact of teleworking during the COVID-19 pandemic in Italy, identifying mental health determinants among home-based workers.

Methods

804 participants completed an online survey, including the psychometric scales “Depression, Anxiety and Stress Scale – 21 items” (DASS-21) and the “Insomnia Severity Index” (ISI). Teleworkers were also asked to provide information about their current work routine, home environment and clinical history.

Results

At the DASS-21, 30% of the participants presented pathological levels of depression, 20.8% of anxiety and 30.7% of stress. At the ISI, 5% appeared to suffer from insomnia. Respondents with psychological and physical frailties, greater social isolation or inadequate working spaces manifested higher levels of psychiatric symptoms. Moreover, we also find a correlation of these symptoms with occupations in education. Telework was broadly appreciated and 87% of respondents expressed a willingness to maintain access to this arrangement.

Conclusions

Our results document that about a third of our sample manifested psychopathological symptoms while teleworking during the COVID-19 outbreak in Italy. However, telework itself does not seem to be directly associated with increased psychiatric symptoms, which were instead exacerbated by COVID-19-related stressful circumstances, as well as by constitutional and social determinants of health. Going forward, authorities should promote adequate measures in order to guarantee a healthy approach to teleworking.

Disclosure

No significant relationships.

The Impact of Lithium on Brain Function in Bipolar Disorder: An Updated Review of Functional Magnetic Resonance Imaging Studies

Lithium remains a gold standard treatment for bipolar disorder (BD), and functional magnetic resonance imaging (fMRI) studies have contributed to clarifying its impact on neural circuitries in affected individuals. However, the specific neurobiological mechanisms through which lithium exerts its effects on brain function are not fully understood. In this review, we aimed to summarize the results of recent fMRI studies evaluating the impact of lithium on brain functional activity and connectivity in patients diagnosed with BD. We performed a literature search of available sources found in the PubMed database reported in English since 2016, when the last available review on this topic was published. Five fMRI studies in resting-state condition and six studies performed during the execution of emotional tasks met the inclusion criteria. Overall, the available evidence supports normalizing effects of lithium on brain activity and connectivity. Most of these studies reported a normalization in prefrontal regions and interconnected areas involved in emotion regulation and processing, regardless of the task employed. Importantly, lithium treatment showed distinct patterns of activity/connectivity changes compared with other treatments. Finally, lithium modulation of neural circuitries was found to be associated with clinical improvement in BD. These results are consistent with the hypothesis that selective abnormalities in neural circuitries supporting emotion processing and regulation improve during lithium treatment in BD. However, the heterogeneity of the examined studies regarding study design, sample selection, and analysis methods might limit the generalizability of the findings and lead to difficulties in comparing the results. Therefore, in future studies, larger cohorts and homogeneous experimental tasks are needed to further corroborate these findings.

M6. REDUCED READINESS POTENTIAL AS A NEUROPHYSIOLOGICAL CORRELATE OF SELF-DISTURBANCES IN EARLY–COURSE PSYCHOSIS: PRELIMINARY FINDINGS FROM A HIGH–DENSITY EEG STUDY

Background

Self-disturbances reflect a core dimension of Schizophrenia that can be identified before disease onset and might underlie the development of typical psychotic symptoms. The Sense of Agency (SoA) can be conceptualized as the pre-reflective sensation of being the one who is causing or generating an action or thought. Passivity phenomena, such as the reported feeling and belief that one’s thoughts or actions are generated and/or controlled by an external agent, are exquisite examples of SoA disturbances observed in Schizophrenia. Despite intensive research, the neurobiological pathogenetic mechanisms underlying such disturbances remain unclear.

Among several putative neurophysiological brain abnormalities, a reduction of the Bereitschaftspotential, also called pre-motor or Readiness Potential (RP), was described in chronic, medicated patients with Schizophrenia. Given its anticipation of voluntary movement by 1 – 2 seconds over the motor cortex and supplementary motor area contralateral to the effector, RP has previously been proposed to be a neural signature of volition to initiate movement. Interestingly, higher RPs among healthy subjects have been recently associated with stronger intentional binding, suggesting increased SoA in subjects exhibiting stronger premovement activity. The objective of our work was to study RP abnormalities in patients with a psychotic illness of recent onset and to relate them to self disturbances, in order to clarify the relationship between known neurophysiological and psychopathological abnormalities.

Methods

We employed high-density electroencephalography (64-channel BrainAmp, Brain Products GmbH, Gilching, Germany) to record scalp potentials during a self-paced movement task in a group of seven early–course psychosis patients (mean age = 24,5, range 20–33) and an equal group of age– and gender– matched (mean age =25,3, range 19 – 36) healthy control subjects. Patients were recruited during an acute stage of their disorder requiring hospitalization and were treated with low–dose atypical antipsychotics. Exclusion criteria included major medical or neurological illness affecting the CNS and any intellectual developmental disorder. Several parameters related to the elicited RP were recorded, including maximum amplitude and slope. The Examination of Anomalous Self Experience (EASE) scale was chosen to assess Self disturbances in the patient group by an experienced clinician who was blind to the neurophysiological outcome.

Results

RP was found to be reduced in patients, compared to healthy control subjects, in both its amplitude and slope (p < 0,005) despite comparable EMG activity. EASE scores of items ‘EASE-10’ (a comprehensive item that reflect most prototypically the disorders of self-experience) and ‘EASE-2’ (“Self-Awareness”) appeared to increase monotonically with the decrease of RP slope (p < 0,05).

Discussion

Our preliminary data show that disturbances of RP are present since the early course of psychotic disorders. They also suggest that such abnormalities may reflect the severity of self-disturbances in these patients. If confirmed in a larger, medication-naïve samples, our findings might clarify the underlying neural mechanisms of such abnormalities and provide a solid basis for further investigation of RP disturbances as an early biological marker for Schizophrenia spectrum disorders.

Emotion Dysregulation: A Review of the Concept and Implications for Clinical Practice

Introduction

Over the past decade, emotion dysregulation has become a very popular term in the psychiatric and clinical psychology literature and it has been described as a key component in a range of mental disorders. For this reason, it has been recently called the “hallmark of psychopathology” (Beauchaine et al., 2007). However, many issues make this concept controversial.

Objectives

To explore emotion dysregulation, focusing on problems related to its definition, meanings and role in many psychiatric disorders.

Aims

To clarify the psychopathological core of emotion dysregulation and to discuss potential implications for clinical practice.

Methods

A literature review was carried out by examining articles published in English between January 2003 and June 2015. A search of the databases PubMed, PsycINFO, Science Direct, Medline, EMBASE and Google Scholar was performed to identify the relevant papers.

Results

Although, there is no agreement about the definition of emotion dysregulation, the following five overlapping, not mutually exclusive dimensions were identified: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity and cognitive reappraisal difficulty. These dimensions characterise a number of psychiatric disorders in different proportions, with borderline personality disorder and eating disorders seemingly more affected than other conditions.

Conclusions

This review highlights a discrepancy between the widespread clinical use of emotion dysregulation and inadequate conceptual status of this construct. Better understanding of the various dimensions of emotion dysregulation has implications for treatment. Future research needs to address emotion dysregulation in all its multifaceted complexity.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Factors associated with first- versus second-generation long-acting antipsychotics prescribed under ordinary clinical practice in Italy

Background

For many years, long-acting intramuscular (LAI) antipsychotics have been prescribed predominantly to chronic and severe patients, as a last resort when other treatments failed. Recently, a broader and earlier use of LAIs, particularly second-generation LAIs, has been emphasized. To date, few studies attempted to frame how this change in prescribing took place in real-world practice. Therefore, this study aimed to describe the clinical features of patients prescribed with LAIs, and to explore possible prescribing differences between first- and second-generations LAIs under ordinary clinical practice in Italy.

Methods

The STAR Network “Depot” Study is an observational, longitudinal, multicenter study involving 35 centers in Italy. In the cross-sectional phase, patients prescribed with LAIs were consecutively recruited and assessed over a period of 12 months. Descriptive statistics and multivariable logistic regression analyses were employed.

Results

Of the 451 recruited patients, 61% were males. The level of social and working functioning was heterogeneous, as was the severity of disease. Seventy-two per cent of the patients had a diagnosis of the schizophrenia spectrum. Seventy per cent were prescribed with second-generation antipsychotic (SGA) LAIs (mostly paliperidone, aripiprazole and risperidone). Compared to first-generation antipsychotic (FGA) LAIs, patients prescribed with SGA LAIs were more often younger; employed; with a diagnosis of the schizophrenia spectrum or bipolar disorder; with higher levels of affective symptoms; with fewer LAI prescriptions in the past.

Discussion

LAIs’ prescribing practices appear to be more flexible as compared to the past, although this change is mostly restricted to SGA LAIs.

Human induced pluripotent stem cells (hiPSCs) in schizophrenia: Modelling the disease and the treatment response

Response to drug treatment is under the sophisticated control of complex signalling pathways and gene regulatory networks. Indeed, drug-induced modulation of dysregulated gene expression and altered synaptic plasticity are critical steps for the successful treatment of neuropsychiatric disorders. Among the antipsychotic drugs, clozapine (CLZ) is widely considered to be the most effective medication for the treatment of schizophrenia. However, due to its high risk for severe side effects, CLZ use is currently restricted to patients who do not respond to other antipsychotics. Nonetheless, up to 20% of patients are considered nonresponders to CLZ treatment. The mechanism of action underlying CLZ's exceptional clinical efficacy in SCZ is not fully understood. In this context, in vitro molecular and functional assessment of patient-derived glutamatergic and GABAergic neurons’ properties are mandatory to reveal the mechanisms underlying CLZ responsiveness and might mirror the clinical response. Here, we will describe the generation of hiPSCs from SCZ patients, classified based on their response to conventional treatments, to CLZ or total resistance to every treatment. These patient-specific hiPSCs have been converted into enriched cortical glutamatergic neurons and parvalbumin-positive GABAergic interneurons populations that are under inspection to reveal phenotypic and molecular/pharmacological aspects correlating with patient-specific responsivity pattern to CLZ treatment. These results might help to unveil the molecular basis of treatment response profiles that can be exploited to predict response to antipsychotic drugs and that might help to develop personalized treatments, more individually tailored and less hazardous.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Chronobiology, sleep-related risk factors and light therapy in perinatal depression: the "Life-ON" project

BACKGROUND

Perinatal depression (PND) has an overall estimated prevalence of roughly 12 %. Untreated PND has significant negative consequences not only on the health of the mothers, but also on the physical, emotional and cognitive development of their children. No certain risk factors are known to predict PND and no completely safe drug treatments are available during pregnancy and breastfeeding. Sleep and depression are strongly related to each other because of a solid reciprocal causal relationship. Bright light therapy (BLT) is a well-tested and safe treatment, effective in both depression and circadian/sleep disorders.

METHODS

In a 3-year longitudinal, observational, multicentre study, about 500 women will be recruited and followed-up from early pregnancy (10-15 gestational week) until 12 months after delivery. The primary aim of the present study is to systematically explore and characterize risk factors for PND by prospective sleep assessment (using wrist actigraphy, polysomnography and various sleep questionnaires) and bloodbased analysis of potential markers during the perinatal period (Life-ON study). Secondary aims are to explore the relationship between specific genetic polymorphisms and PND (substudy Life-ON1), to investigate the effectiveness of BLT in treating PND (substudy Life-ON2) and to test whether a short term trial of BLT during pregnancy can prevent PND (substudy Life-ON3).

DISCUSSION

The characterization of specific predictive and risk factors for PND may substantially contribute to improve preventive medical and social strategies for the affected women. The study results are expected to promote a better understanding of the relationship between sleep disorders and the development of PND and to confirm, in a large sample of women, the safety and efficacy of BLT both in prevention and treatment of PND.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02664467 . Registered 13 January 2016.

Effectiveness of long-acting injectables and clozapine in a real-world setting during the early-stages of psychotic illness

Introduction

Intervention in the early-stages of psychosis may be able to shape the clinical course; critical period (CP) is best represented by the first 5 years from first admission (FA).

Objectives

To investigate the effectiveness of pharmacological intervention within and beyond the CP.

Aims

(1) To compare hospitalization rates of patients stabilized on treatment with LAIs and CLZ. (2) To determine whether treatment with LAIs and CLZ within CP can influence hospitalization rates.

Methods

Data were retrospectively collected from patients diagnosed with non-affective psychoses with FA between 2000 and 2014; 200 patients were then divided into three groups, according to stabilized treatment regimen during the final year of observation: treatment as usual (TAU), CLZ, LAIs. hospitalization duration (HSPD) and frequency (HSP) were calculated for each group.

Results

Despite a major severity before assignment to either CLZ or LAIs treatment, HSPD and HSP in both groups shifted below those observed for the TAU arm. Patients who began treatment with LAIs within the CP showed a highly significant decrease of both HSPD and HSP (respectively 17.4 ± 18 vs. 2.6 ± 8.2; Z = −2.856; P < 0.005 and 1.1 ± 0.8 vs. 0.2 ± 0.5; Z = −3.115; P < 0.005). No significant changes in hospitalization rates were observed for subjects who began treatment with LAIs after the CP.

Conclusions

Our study confirms that treatment with either CLZ or LAIs significantly impacts the course of psychotic disorders. The data seem to suggest that LAIs and CLZ should be considered more effective than conventional oral antipsychotics in the early-stages of psychotic illness. The difference among treatments tends to wane beyond the CP, especially for LAIs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Association of weekly gemcitabine to conformal radiotherapy as organ-sparing strategy in locally advanced or relapsed bladder cancer

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Background: Radical surgery is considered the only curative option for locally advanced or relapsed bladder cancer. However, the uncertain prognosis of disease and the poor quality of life due to lack of bladder reservoir require further investigation on possible therapeutic approaches. Methods: This trial has been designed for testing safety and activity of dose-escalating gemcitabine associated to concomitant conformal radiotherapy for locally advanced or relapsed bladder cancer. Patients received radiotherapy at 2 Gy per day to reach a total dose of 60 Gy over 6 weeks. Gemcitabine was administered once-a-week as one-hour IV infusion before starting the radiation treatment. The first explored dose of drug was 300 mg/m2 and the escalation was planned through a Fibonacci modified method by subsequent increases of 100 mg/m2 until definition of the dose-limiting toxicity (DLT). The recommended dose for future phase II study was one level inferior to the reached maximum tolerated dose (MTD). Results: Eighteen patients with median age of 72 years entered the study, half of whom affected by locally advanced tumours, the remainders by recurrence after conservative surgery. The majority of the latter initially had pT2 (UICC staging) muscle invasive transitional cell carcinoma. Twelve patients were treated with weekly gemcitabine at 300 mg/m2 without appearance of any DLT. Among the first 3 patients receiving the dose level of 400 mg/m2, one patient had grade 4 neutropenia. Further 3 patients were enrolled for testing the above dose level, but one of them experienced bowel perforation, therefore the established MTD was 400 mg/m2. The recommended dose of weekly gemcitabine was 300 mg/m2. Effectively, we could observe 11 (61%) pathological complete responses (pCR) confirmed by bladder mapping two months after treatment completion. Nine pCR (82%) occurred in the patients with locally advanced therapy-naïve bladder cancer. Patients with conserved bladders had excellent function, without hematuria, urgency or incontinence. Conclusions: The association of weekly gemcitabine to conformal radiotherapy provides a new alternative to radical surgery approach and strongly supports the organ-sparing strategy for locally advanced bladder cancer.

No significant financial relationships to disclose.