Cortisol-binding globulin levels in bipolar disorder

Cortisol-binding globulin (CBG) is an alpha-1-glycoprotein with high affinity for cortiso that could be a potential biological marker of chronic stress, according to several previous studies. In order to examine CBG concentrations in bipolar disorder, we determined serum CBG levels by radioimmunoassay with monoclonal antibodies in a sample of 39 RDC bipolar I patients in remission and 21 healthy age-, sex- and weight-matched control subjects. Only lithium treatment was permitted. Plasma cortisol and serum lithium levels were also determined. Bipolar males showed statistically significant lower serum CBG levels than controls, whereas women showed very similar values. No correlation was found between CBG levels and cortisol or lithium concentrations. It is concluded that CBG levels are affected by chronic affective illness, even during remission periods, at least in bipolar males.

Clinical status after two-weeks of antidepressant treatment: A prognostic factor in unipolar major depression?

Although most unipolar depression clinical guidelines advise against evaluating the efficacy of antidepressant pharmacological treatment until it has been administered in therapeutic doses for a minimum of 4–6 weeks, there is an increasing tendency to make therapeutic decisions after only 2 weeks of treatment. We present a study which aim is to determine whether the clinical course, following 2 weeks of antidepressant treatment, allows therapeutic decisions to be made for patients affected by a moderate/severe depressive episode. The study has an 8-week, prospective, observational design in which all consecutive in- and outpatients with moderate/severe unipolar major depression aged over 17 years received antidepressant treatment based on a standardized treatment protocol. Clinical status was assessed at baseline and at 2-, 4-, and 8-weeks. The final sample consisted of a total of 114 subjects. In our sample, the rate of remitters versus non-remitters was similar between the 2-week improvers and the 2-week non-improvers. It should also be emphasized that it was not possible to explain, based on the epidemiological and clinical characteristics assessed, which 2-week non-improvers would tend towards remission and which would show a partial or full response. Based on these results, for patients affected by a moderate/severe unipolar depressive episode, it would not be appropriate to make new therapeutic decisions following 2 weeks of anti-depressive pharmacological treatment depending on whether the patient has shown clinical improvement or not.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Polymorphic variation in the epigenetic gene DNMT3B modulates the environmental impact on cognitive ability: a twin study

BACKGROUND

Though cognitive abilities in adulthood are largely influenced by individual genetic background, they have also been shown to be importantly influenced by environmental factors. Some of these influences are mediated by epigenetic mechanisms. Accordingly, polymorphic variants in the epigenetic gene DNMT3B have been linked to neurocognitive performance. Since monozygotic (MZ) twins may show larger or smaller intrapair phenotypic differences depending on whether their genetic background is more or less sensitive to environmental factors, a twin design was implemented to determine if particular polymorphisms in the DNMT3B gene may be linked to a better (worse) response to enriched (deprived) environmental factors.

METHODS

Applying the variability gene methodology in a sample of 54 healthy MZ twin pairs (108 individuals) with no lifetime history of psychopathology, two DNMT3B polymorphisms were analyzed in relation to their intrapair differences for either intellectual quotient (IQ) or working memory performance.

RESULTS

MZ twin pairs with the CC genotype for rs406193 SNP showed statistically significant larger intrapair differences in IQ than CT pairs.

CONCLUSIONS

Results suggest that DNMT3B polymorphisms may explain variability in the IQ response to either enriched or impoverished environmental conditions. Accordingly, the applied methodology is shown as a potentially valuable tool for determining genetic markers of cognitive plasticity. Further research is needed to confirm this specific result and to expand on other putative genetic markers of environmental sensitivity.

Psychosis-inducing effects of cannabis are related to both childhood abuse and COMT genotypes

OBJECTIVE

To test whether the association between childhood abuse, cannabis use and psychotic experiences (PEs) was moderated by the COMT (catechol-O-methyltransferase) gene.

METHOD

Psychotic experiences (PEs), childhood abuse, cannabis use and COMT Val158Met genotypes were assessed in 533 individuals from the general population. Data were analysed hierarchically by means of multiple linear regression models.

RESULTS

Childhood abuse showed a significant main effect on both positive (β = 0.09; SE = 0.04; P = 0.047) and negative PEs (β = 0.11; SE = 0.05; P = 0.038). A significant three-way interaction effect was found among childhood abuse, cannabis use and the COMT gene on positive PEs (β = -0.30; SE = 0.11; P = 0.006). This result suggests that COMT genotypes and cannabis use only influenced PE scores among individuals exposed to childhood abuse. Furthermore, exposure to childhood abuse and cannabis use increased PE scores in Val carriers. However, in individuals exposed to childhood abuse but who did not use cannabis, PEs increased as a function of the Met allele copies of the COMT gene.

CONCLUSION

Cannabis use after exposure to childhood abuse may have opposite effects on the risk of PEs, depending on the COMT genotypes providing evidence for a qualitative interaction. Val carriers exposed to childhood abuse are vulnerable to the psychosis-inducing effects of cannabis.

Childhood adversity and psychosis: Examining whether the association is due to genetic confounding using a monozygotic twin differences approach

Purpose

To test whether the association between childhood adversity and positive and negative psychotic experiences is due to genetic confounding.

Method

Childhood adversity and psychotic experiences were assessed in an ongoing sample of 226 twins from the general population. A monozygotic (MZ) twin differences approach was used to assess possible genetic confounding.

Results

In the whole sample, childhood adversity was significantly associated with positive (β = 45; SE = 0.16; P = 0.008) and negative psychotic experiences (β = 0.77; SE = 0.18; P < 0.01). Within-pair MZ twin differences in exposure to childhood adversity were significantly associated with differences in positive (β = 71; SE = 0.29; P = 0.016) and negative psychotic experiences (β = 98; SE = 0.38; P = 0.014) in a subsample of 85 MZ twin pairs.

Conclusions

Individuals exposed to childhood adversity are more likely to report psychotic experiences. Furthermore, our findings indicate that this association is not due to genetic confounding.

Mild cognitive impairment: a risk indicator of later dementia, or a preclinical phase of the disease?

OBJECTIVES

The proposals for classifying the transitional range between normal, ageing-associated cognitive dysfunctions and those suggestive of evolution towards dementia do not clarify whether the profiles are risk indicators of later cognitive impairment or represent preclinical phases of dementia.

METHODS

Retrospective study of the baseline neuropsychological performance of ten subjects with subjective complaints of memory loss which evolved to dementia within 2 years and who meet clinical and neurological diagnosis for Probable Alzheimer's Disease (Progression group). They were compared with 34 normal subjects (Normative group), 33 patients with subjective complaints of memory who in 2 year did not evolve towards dementia and presented a stable profile (Stable group), and 47 Alzheimer's patients (Alzheimer group). A broad neuropsychological battery was administered to assess a range of cognitive functions.

RESULTS

The Progression group presented a globally poor baseline neuropsychological performance, except in Working Memory, with clear deficits in Episodic Memory and Visual Memory. In the logistic regression analysis, Delayed Verbal Memory was significant as prognostic value for 80 . 5% of cases.

CONCLUSION

Deficit on Episodic and Visual Memory at least 1.5 SD below T = 50 are preclinical manifestations of dementia in subjects with complain of memory loss. The use of broad neuropsychological batteries and the quantitative assessment of deficits is essential to identify and predict the risk of dementia.

A 6-month prospective, observational, naturalistic, uncontrolled study to evaluate the effectiveness and tolerability of oral ziprasidone in patients with schizophrenia

This multicenter, uncontrolled, naturalistic study evaluated the effectiveness and tolerability of 6 months of treatment with ziprasidone in 1266 patients with a diagnosis of schizophrenia. The percentage of responders (at least 30% reduction in PANSS total score) in the primary analysis sample (n=1022) was 47.3% (95% CI 44.2-50.4) at the end of the study. Patients showed a significant and clinically relevant reduction in the PANSS total, positive, negative and general psychopathology subscales scores (effect size of 1.60, 1.83, 0.62 and 1.40 respectively). Overall, 453 (35.8%) patients withdrew from the study; 9.3% withdrew owing to adverse events. Ziprasidone doses greater than 120 mg/day were associated with a lower risk of discontinuation for any cause (OR 0.46, 95% CI 0.33-0.65) Ziprasidone was well tolerated. Most common side effects were: insomnia, somnolence and nervousness. The effectiveness and tolerability of ziprasidone in clinical practice are consistent to those previously shown in the more restricted and homogeneous populations of clinical trials.

Impaired response inhibition in obsessive compulsive disorder

Objective

The present study investigates different three inhibitory control functions in patients with obsessive-compulsive disorder (OCD). Selective motor response inhibition was tested in a GO/NO-GO paradigm, the inhibition of a triggered motor response in a STOP paradigm and the ability to inhibit cognitive interference in a motor STROOP paradigm.

Methods

27 patients who met DSM-IV criteria for OCD and 25 age, handedness and IQ-matched healthy control subjects were tested in the GO/NO-GO, STOP and motor STROOP tasks.

Results

OCD patients performed significantly worse than controls in the selective inhibition of their motor responses (GO/NO-GO) and in the inhibition of cognitive interference (STROOP), and also showed worse performance in suppressing previously triggered motor responses (STOP).

Conclusion

Patients with OCD are impaired in motor and cognitive inhibitory mechanisms. The findings are consistent with psychobiological and neuropsychological models of OCD suggesting impairment of frontostriatal circuitries that mediate functions of inhibitory control.

Subtyping obsessive-compulsive disorder: clinical and immunological findings in child and adult onset

It has been suggested that certain kinds of childhood OCD with specific clinical, biological and immunological characteristics may form a subgroup of OCD. We study the presence of these characteristics in child onset OCD and propose that the disorder be considered as a subtype of adult OCD. Forty adult patients with OCD were divided in two groups according to time of disease onset: 18 early onset and 21 late. Both sets were compared with a control group of 14 psychiatric patients. Child onset OCD was associated with higher mean ASLO titers, higher frequencies of history of tic disorders and tonsillitis in childhood and compulsive symptoms. No differences were found in D8/17 antibody titers or in other autoimmune parameters. The findings suggest that child onset OCD can be considered as a subgroup of adult OCD, although more specific biological markers are needed to identify it.

Patient-rated emotional and physical functioning among hematologic cancer patients during hospitalization for stem-cell transplantation

In this 3-year prospective inpatient study, 220 patients received stem-cell transplantation (SCT) for hematologic cancer at a single institution. The objective of the study is to provide data on patient-rated emotional (depression and anxiety) and physical (overall physical status, energy level, and systemic symptomatology) functioning during hospitalization for SCT and to compare whether these differ between autologous and allogeneic SCT. Patients were assessed at hospital admission (T1), day of SCT (T2), and 7 days (T3) and 14 days (T4) after SCT, yielding a total of 852 evaluations. For the overall sample, anxiety was highest at T1 and decreased afterwards; a marked worsening in physical health status variables corresponded with a sharp increase in depression from T1 to T3, and was followed by an improvement in physical health and a reduction of depression. Compared to allogeneic SCT, a better physical outcome for autologous SCT was demonstrated by the significant group effect for systemic symptomatology and by the significant group x time interaction for overall physical status and energy level; there were no significant differences in depression or anxiety between SCT groups. These findings have implications for treatment decision making, coping with the transplantation process, and improving prevention and treatment strategies.

No brain perfusion impairment at long-term follow-up in elderly patients treated with electroconvulsive therapy for major depression

No functional neuroimaging study has previously assessed the long-term effects of electroconvulsive therapy (ECT) on brain perfusion. In this study, long-term follow-up brain perfusion in elderly patients treated with ECT for severe unipolar major depression was assessed. In 14 elderly major depressed patients who were ECT remitters, 22 elderly major depressed patients who were pharmacological treatment remitters and 25 age- and sex-matched healthy controls, a medication-free brain 9mTc-HMPAO-SPECT was performed after a minimum period of 12 months of euthymia and, in the case of the ECT remitters, at least 12 months after the last ECT session. Brain perfusion ratios in major depressed patients administered ECT were similar to those in major depressed patients receiving pharmacological treatment and in control subjects. This result suggests that elderly patients given ECT for severe unipolar major depression do not suffer brain perfusion abnormalities at long-term follow-up. Our study adds new evidence in favor of the safety of the ECT, particularly in elderly subjects.

[The 5-HT1A receptors: from molecular biology to neuropsychiatric symptoms]

Among the multiple serotonin receptors identified to date, the 5-hydroxytryptamine (5-HT)1A subtype is among the best known because selective ligands have been available for more than 15 years. Radioactive derivatives of these ligands make it possible to demonstrate the presence of 5-HT1A binding sites mainly in the limbic areas and in the raphe nuclei in the brain, where they correspond to post-synaptic receptors and pre-synaptic autoreceptors respectively. On stimulation of 5-HT1A autoreceptors, they regulate serotonin release in the distal regions of the neuron by inhibitory firing activity. In this way, they help to maintain the serotonin in the terminal regions at physiological levels, which favors correct neuronal functioning. This review article summarizes key data on localization, study technique, molecular biology, signal transduction, differential functional properties of pre-synaptic versus post-synaptic 5-HT1A receptors, and behavioral effects and clinical correlates of their activation, especially cognitive and emotional responses. Mention is made about the role of these receptors in the neurogenesis process of certain brain areas and of the possible clinical and therapeutic implications of these processes.

Residual symptoms in elderly major depression remitters

OBJECTIVE

To assess residual symptoms in severe geriatric major depression in remission, and to determine baseline clinical and sociodemographic predictors of residual symptoms in remitters.

METHOD

A total of 108 elderly patients with unipolar major depression were evaluated and treated naturalistically for 9 months so as to record the predictors of residual symptoms in remitters. In order to reduce the likelihood of confusing residual symptoms with normal effects of age, 30 control subjects were also monitored.

RESULTS

Seventy-nine patients (73.1%) were considered remitters and 82.3% of remitters showed residual symptoms. Medical burden, chronic stress and subjective social support were the only variables which predicted the severity of residual symptoms in remitters.

CONCLUSION

Residual symptoms in elderly patients with major depression in remission should not only be attributed exclusively to intrinsic factors of the illness or the age of the individual patient, but also to external factors.

Residual cognitive impairment in late-life depression after a 12-month period follow-up

OBJECTIVES

This study investigated cognitive impairment in late-life depression in a follow-up design. The main objective was to assess the most important cognitive domains implicated in late-life depression, in patients who underwent pharmacological treatment, in the acute phase and twelve months after.

METHODS

Neuropsychological and clinical data were used from the baseline of patients and controls, to determine the cognitive impairment in the acute phase. Patients repeated the neuropsychological assessment at twelve months.

RESULTS

There were significant differences between patients and controls at baseline. But in the patients there was no change over twelve months. There were no differences between remitted and non-remitted patients on neuropsychological scores.

CONCLUSIONS

The cognitive impairment seen in the elderly depressed patients seems to be a trait characteristic of this mental disease, even when the depressive episode has remitted.

[Treatment of bipolar II disorder with lamotrigine]

INTRODUCTION

This study analyzes the effectiveness and safety of lamotrigine in the treatment of bipolar II disorder. Patients and methods. Seventeen patients with DSM-IV bipolar II disorder with a history of poor response to lithium or other mood-stabilizers gave their consent to be treated with lamotrigine. Th ey we re followed-up for 6 months and assessed with the Young Mania Scale (YMRS), Hamilton Depression Rating Scale (HDRS-17) and the modified version of the Global Clinic Impresion Scale for Bipolar Disorder ( CG I-BP-M).

RESULTS

Twelve patients completed the study. Three patients dropped out due to side effects (two because of mild rash, which vanished after treatment was discontinued and one because of vomiting) and two due to lack of efficacy. The mean dose of lamotrigine for patients completing the study was 202.1 64.4 mg/day. There was a significant improvement in HDRS-17 scores (p= 0.004) and the depressive (p=0.002) and overall (p= 0.002) subscales of the CGI-BP-M.

CONCLUSIONS

This study confirms previous findings concerning the antidepressant profile of lamotrigine and its potential effectiveness in bipolar II disorder.

Could the hypofrontality pattern in schizophrenia be modified through neuropsychological rehabilitation?

OBJECTIVE

The effects of neuropsychological treatment on cognitive hypofrontality were examined in schizophrenic patients through the score activation.

METHOD

Eight subjects (six men and two women) with persistent negative symptoms and cognitive impairments were evaluated with single photon emission computed tomography (SPECT) procedures and neuropsychological battery before and after a neuropsychological treatment group.

RESULTS

After treatment an enhancement in neuropsychological performance was found, especially in executive functions. The activation score showed an increase over baseline levels and no cognitive-dependent hypofrontality after treatment was found. Although the prefrontal blood flow changes were small and non-specific, they suggest a reduction of the cognitive hypofrontality after neuropsychological treatment.

CONCLUSION

Cognitive improvements after neuropsychological treatment would possibly be related with the diminution of the functional hypoactivity in the prefrontal areas.

Clinical correlates of psychiatric comorbidity in bipolar I patients

OBJECTIVES

To ascertain the clinical implications of psychiatric comorbidity in the course and outcome of bipolar I patients.

METHODS

One hundred and twenty-nine bipolar I outpatients in remission [Young Mania Rating Scale (Y-MRS) < 7, Hamilton Depression Rating Scale (HDRS) < 9] were assessed by means of the Structured Clinical Interview for DSM-III-R axis I and axis II (SCID-I and SCID-II) in order to detect all possible psychiatric comorbid diagnoses. The sample was split according to the presence of psychiatric comorbidity and the groups were compared.

RESULTS

Psychiatric comorbidity was detected in 31% of the sample. A higher number of mixed features, depressive episodes and suicide attempts and a predominance of depressive onset amongst comorbid bipolar patients were the most relevant differences between the two groups.

CONCLUSIONS

There is an association between depression, suicidality and comorbidity in bipolar I disorder. As comorbidity had a clear relevance in the course and outcome of bipolar illness, this issue should be specifically assessed in clinical practice.

Could the hypofrontality pattern in schizophrenia be modified through neuropsychological rehabilitation?

OBJECTIVE

The effects of neuropsychological treatment on cognitive hypofrontality were examined in schizophrenic patients through the score activation.

METHOD

Eight subjects (six men and two women) with persistent negative symptoms and cognitive impairments were evaluated with single photon emission computed tomography (SPECT) procedures and neuropsychological battery before and after a neuropsychological treatment group.

RESULTS

After treatment an enhancement in neuropsychological performance was found, especially in executive functions. The activation score showed an increase over baseline levels and no cognitive-dependent hypofrontality after treatment was found. Although the prefrontal blood flow changes were small and non-specific, they suggest a reduction of the cognitive hypofrontality after neuropsychological treatment.

CONCLUSION

Cognitive improvements after neuropsychological treatment would possibly be related with the diminution of the functional hypoactivity in the prefrontal areas.

Executive function in patients with remitted bipolar disorder and schizophrenia and its relationship with functional outcome

BACKGROUND

Recent studies have reported that differences in cognitive performance between schizophrenic and bipolar patients seem to be smaller than expected. Patients with schizophrenia have consistently shown frontal executive dysfunctions, but studies regarding executive abilities in bipolar patients are scarce and discrepant. As executive function has been associated with psychosocial functioning in schizophrenia, we wanted to investigate if such a relationship is also present in bipolar disorder and the differences between the two groups.

METHODS

Executive function was assessed in 49 euthymic (at least 6 months in remission, Hamilton Depression Rating Scale < or = 8 and Young Mania Rating Scale < or = 6) bipolar and in 49 schizophrenic, residual-type (with at least 1 year without acute exacerbation and predominant negative symptomatology) patients, by the Wisconsin Card Sorting Test (WCST), FAS Test (COWAT) and Trail Making Test. Baseline clinical and psychosocial variables were controlled and psychopathology evaluated by means of the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The two groups showed a similar pattern of cognitive deficits in tests of executive function, except for the number of categories achieved in the WCST, which was significantly lower in the schizophrenic group (F = 7.26; p = 0.009). Functional outcome was predicted by the negative syndrome (PANSSN) and perseverative errors (WCST) in schizophrenic patients, and general psychopathology (PANSSG) was the best predictor of functional outcome in the bipolar group.

CONCLUSION

Executive function was a good predictor of functional outcome in the schizophrenic group, whereas clinical variables were more predictive of the bipolar one. Patterns of cognitive disturbances in tasks of executive function are similar in both groups but quantitatively more marked in schizophrenia.

The 5-HT(2A) receptor gene 102T/C polymorphism is associated with suicidal behavior in depressed patients

Several lines of evidence suggest that genetic factors constitute an important determinant of suicidal behavior. A significant association between the 5-HT(2A)-C allele and suicidality has recently been reported. The aim of this study was to investigate whether the proposed association between 5-HT(2A)-102T/C polymorphism and suicidality could be replicated in a larger and independent sample of Spanish patients with major depression. The 102T/C polymorphism of the 5-HT(2A) receptor gene was analyzed in 159 patients with major depression (DSM-IV criteria) and 164 unrelated and healthy controls using a case control design. All individuals were subjects of Spanish origin. Significant differences in allele (chi-square = 4.13, df = 1, P = 0.04) and genotype (chi-square = 6.19, df = 2, P = 0.04) distributions were found between non-suicide attempters and suicide attempters. Moreover, those patients carrying 5-HT(2A)-C allele had more than five times the risk for attempting suicide than noncarriers (OR = 5.50, 95% CI = 1.18-35.20, P = 0.01). Our results replicate the proposed association between 5HT(2A)-C allele and suicidality in major depression. Moreover, no overall associations are detected when patients with major depression and controls are compared for 102T/C frequencies, suggesting that the increased risk for suicidality conferred by 5-HT(2A)-C allele is primarily associated with suicidal behavior and not with the diagnosis of major depression itself.

Role of risperidone in bipolar II: an open 6-month study

BACKGROUND

Since treatment approaches thought to be useful for mania are presumably suitable for hypomania as well, little systematic research has been done on the treatment of hypomanic episodes and their long-term outcome. As systematic trials have shown that the atypical antipsychotic risperidone may be effective and safe in the treatment of acute mania, we decided to conduct an open-label study of its effectiveness and tolerability in hypomania associated with bipolar II.

METHODS

Forty-four DSM-IV bipolar II patients with Young Mania Rating Scale (YMRS) scores above 7 were included and followed-up for 6 months. Efficacy was measured by means of the YMRS and the Clinical Global Impression for Bipolar Disorder (CGI-BD). Treatment-emergent depression was measured by the Hamilton Depression Rating Scale (HDRS-17), and the Udvalg for Kliniske Undersøgelser (UKU) subscale was used for neurological/extrapyramidal side-effects.

RESULTS

Thirty-four patients completed the trial. The mean dose of risperidone at endpoint was 2.8 mg/day. Last observation-carried-forward analysis showed significant reduction of YMRS scores from the first week of treatment, which continued until the endpoint (P<0.0001). At 6-month follow-up, 60% of patients were assymptomatic according to the CGI. The 32% who received risperidone in monotherapy seemed to respond equally well. Risperidone, as used in this study, appeared to be most protective against hypomanic than depressive recurrences. Nine patients (12%) had a depressive relapse during 6-month follow-up, one patient (2%) had an hypomanic relapse and another (2%) had both. No patients developed tardive dyskinesia during the duration of the study. Although most patients received risperidone in combination with standard mood-stabilizers, only three patients discontinued risperidone because of other side-effects.

LIMITATIONS

In the absence of a placebo arm, it is uncertain to what extent the foregoing results could be ascribed to spontaneous remission of bipolar II disorder.

CONCLUSIONS

Risperidone, either in combination with mood-stabilizers or alone was well-tolerated in bipolar II patients, who presented in a hypomanic state, and appeared efficacious. Further controlled research on the role of atypical antipsychotics in the treatment of less-than-manic forms of bipolar illness is warranted.

Olanzapine as long-term adjunctive therapy in treatment-resistant bipolar disorder

The aim of this study was to estimate the long-term effectiveness of olanzapine as adjunctive therapy in patients with bipolar disorder who exhibited an inadequate response to mood stabilizers. Twenty-three Research Diagnostic Criteria (RDC) patients with bipolar I and II were assessed by means of the Schedule for Affective Disorders and Schizophrenia and entered if they gave their consent to participate. All of them had experienced frequent relapses, residual subsyndromal symptoms, and inadequate responses to other drugs, such as lithium, valproate, or carbamazepine. While maintaining other drugs, they all received open-label, increasing doses of olanzapine, until achieving clinical response. Other drugs were maintained. The patients were assessed several consecutive times from baseline to the endpoint with the Clinical Global Impressions (CGI) scale for use in bipolar illness. Records of recurrences, hospitalizations, and side effects were also collected. The last-observation-carried-forward analysis showed that there was a significant reduction of CGI scores after the introduction of olanzapine, either in manic symptoms (p = 0.0015), depressive symptoms (p = 0.0063), or global symptoms (p = 0.0003). The most frequent adverse events were somnolence (17%) and weight gain (13%). The mean dose of olanzapine at the end of the 43-week follow-up was 8.1 mg/day. Olanzapine may be a useful medication for the long-term adjunctive treatment of patients with bipolar disorder who exhibit a poor response to mood stabilizers, such as lithium, valproate, or carbamazepine. These results suggest mood-stablizing properties of olanzapine.

Efficacy and safety of risperidone in the treatment of schizoaffective disorder: initial results from a large, multicenter surveillance study. Group for the Study of Risperidone in Affective Disorders (GSRAD)

BACKGROUND

An adequate therapy for psychotic disorders needs to be effective against mood as well as psychotic symptoms. Analyses of data from clinical trials of risperidone in schizophrenia and small open-label studies in mania suggest that risperidone may have this broad efficacy profile. We present data on a 6-week trial of risperidone for the treatment of schizoaffective disorder that was part of a larger, 6-month surveillance study of patients with affective disorders.

METHOD

One hundred two patients suffering from schizoaffective disorder (DSM-IV or ICD-10) entered the trial. Inclusion criteria consisted of a current DSM-IV diagnosis of schizoaffective disorder, bipolar type; DSM-IV manic or mixed psychotic episode; and a Young Mania Rating Scale (YMRS) score > 7 for a mixed episode (> 20 for a manic episode). Assessments included the YMRS, the Positive and Negative Syndrome Scale (PANSS), the Hamilton Rating Scale for Depression (HAM-D), the 4-item Clinical Global Impressions (CGI) scale, and the UKU Side Effect Rating Scale subscale for neurologic side effects. For patients entering the study, open-label risperidone therapy was added to their existing regimens of mood-stabilizing treatments. Other antipsychotic drugs were not allowed.

RESULTS

Ninety-five patients completed the 6-week trial. At week 6, the mean +/- SD dose of risperidone was 4.7+/-2.5 mg/day. The mean scores on the assessment scales at baseline and week 6 (unless otherwise stated) were as follows: YMRS, 22.7 and 4.7, an improvement of 18.0 points (p < .0001); PANSS (at baseline and week 4), 74.1 and 54.2, an improvement of 19.9 points (p < .0001); HAM-D, 14.0 and 7.4, an improvement of 6.6 points (p < .0001); CGI (at baseline and week 4), 2.6 and 1.7, an improvement of 0.9 points (p < .0001). At week 4, most patients had shown improvement in symptom severity, and 9.3% were completely symptom-free. There were no statistically significant differences between baseline and week 4 in the severity of extrapyramidal symptoms as measured by the UKU. Risperidone was well tolerated; side effects were few and generally mild.

CONCLUSION

The results to date with risperidone indicate that it may have both antipsychotic and mood-stabilizing properties. Despite the limitations of the open-label design, the results indicate that risperidone is a safe and effective therapy in combination with mood-stabilizers for the treatment of patients with manic, hypomanic, and depressive symptoms of mixed episodes in schizoaffective disorder, bipolar type.

Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences

The validity and nosologic status of schizoaffective disorder is still a controversial issue. This study was conducted to analyze the demographic, clinical and prognostic variables that determine the validity of the diagnosis of schizoaffective disorder bipolar type. We analyzed and compared 138 outpatients: 67 with type I bipolar disorder, 34 with schizoaffective disorder bipolar type and 37 with schizophrenia. They were all diagnosed following research diagnostic criteria and assessed according to the Schedule for Affective Disorders and Schizophrenia. Schizoaffective unipolar patients were excluded. The results reaffirmed that, from the standpoints of demographics, clinical features and prognosis, schizoaffective disorders bipolar type can be classified as a phenotypic form at an intermediate point between bipolar I disorder and schizophrenia. These results emphasize the importance of longitudinal follow-up in the diagnosis and assessment of psychotic syndromes. Although cross-sectional symptoms were closer to the schizophrenia spectrum, the course of the illness resembled more that of bipolar patients, resulting in an intermediate outcome.

Frontal cerebral perfusion dysfunction in elderly late-onset major depression assessed by 99MTC-HMPAO SPECT

Baseline regional cerebral blood flow of thirty unmedicated late-onset unipolar major depressed patients over the age of 60 years and 20 sex-, age-, and vascular risk factor-matched healthy controls was imaged with single photon emission computed tomography, using technetium-99m hexamethylpropylene amine oxime as a tracer. To avoid errors of diagnosis--in particular, confusion between major depression and organic cognitive impairment--only treatment responders were included in the final sample. Statistically significant differences were observed in both left and right anterior frontal regions, with reduced uptake in depressed patients; these differences were more pronounced in the left hemisphere. Among patients, there was no correlation between regional cerebral blood flow and the severity of baseline symptoms. Our results support the hypothesis that certain neuroanatomic regions of the central nervous system may be functionally involved in elderly unipolar major depression, particularly in the late-onset subgroup.

Citalopram versus nortriptyline in late-life depression: a 12-week randomized single-blind study

OBJECTIVE

The aim of this single-blind study was to examine the efficacy and tolerability of citalopram compared to nortriptyline in moderate to severe major depressive patients aged 60 years or over.

METHOD

In- and out-patients (N=58) with unipolar major depression were randomized to 12-week flexible dose treatment with nortriptyline or citalopram.

RESULTS

No significant differences between the number of drop-outs in either group were observed, but the autonomic side-effects were significantly higher for nortriptyline than for citalopram. A significantly higher remission rate to nortriptyline than to citalopram was demonstrated, particularly if severe patients (endogenous or psychotic patients) were assessed.

CONCLUSION

The remission rate to a therapeutic plasma level of nortriptyline appears to be higher than the remission rate to a standard dose of citalopram in a group of elderly major depressed patients, especially those with endogenous or psychotic features. On the other hand, citalopram appears to be better tolerated.

Genetic variation in the 5-HT5A receptor gene in patients with bipolar disorder and major depression

In the present study, genetic variation of the 5-HT5A receptor was analyzed in patients affected by affective disorders and healthy controls. The sample consisted of 181 patients with major depression, 88 patients with bipolar affective disorder (BP) and 157 unrelated controls (C), all of Spanish origin. Two polymorphisms (-19G/C and 12A/T) in the 5-HT5A receptor gene were analyzed by polymerase chain reaction amplification and subsequent enzyme digestion. No genotype, allele or haplotype differences were found when we compared patients and controls. When clinical variables were considered as possible tools for detecting genetic heterogeneity, no differences were found. Our results suggest that the polymorphisms analyzed in the 5-HT5A receptor gene do not play a major role in the pathogenesis of affective disorders.

[Serotonin receptor changes in depression: evidences and limitations]

Serotonin and serotonin receptors might be involved in the pathophysiology of depression. In the following, research data supporting the general hypothesis of adaptatives changes in density and functioning of serotonergic receptors in depression are review. Binding assays, platelet and neuroendocrine studies supports this theory. The density of 5-HT2A binding sites in postmortem brain tissue of depressed patients and suicide victims, as well as in platelets of drug-free depressed patients has been found to be increased by several authors. The reduce hormonal response to fenfluramine challenge test in depression appears to indicate a sub-normal functioning of 5-HT2A receptors, however studies evaluating physiologic platelet 5-HT2A receptor-mediated responses have produced conflicting results. On the other hand, neuroendocrine challenges tests with 5-HT1A agonists suggest that presynaptic and postsynaptic 5-HT1A receptors may be also desensitized in depression. To date, postmorten receptor 5-HT1A studies in suicide victims have not yielded consistent. Taken together, these findings provide support for hypotheses of amine receptor abnormalities in depression, and indicate the need for expanded studies of amine receptor density and function in depression. Nevertheless, the role of these changes in the pathophysiology of depression has not been proved.

Variability in the 5-HT(2A) receptor gene is associated with seasonal pattern in major depression

The 102-T/C polymorphism of the 5-HT(2A) receptor gene was analysed in 159 patients with major depression and 164 unrelated and healthy controls using a case-control design. Allele and genotype frequencies did not differ between cases and controls. No differences according to sex, age of onset, melancholia, suicidal behaviour or family history of psychiatric illness were found. However, genotype distributions significantly differed between patients with seasonal pattern in their episodes (MDS) and patients with no seasonal pattern (N-MDS) (chi(2) = 10.63; P = 0.004). A seasonal pattern was 7.57 times more frequent in 102C-allele carriers than in 102T homozygous (95.1% of patients MDS carried 102C-allele vs 72% of patients N-MDS (chi(2) = 9.45, df=1, P = 0.002; OR = 7.57 (95% CI: 1.65--48.08)). These results suggest that variation in the 5-HT2A receptor gene may play a role in the development of major depression with seasonal pattern and support the existence of a genetic and etiological heterogeneity underlying the diagnosis of major depression.

Deficit in schizophrenia: the relationship between negative symptoms and neurocognition

The aim of the study was to analyze the role of clinical and neuropsychological variables in the psychosocial functioning and evolution of negative schizophrenia. We examined a sample of 49 negative schizophrenic outpatients who were pharmacologically stabilized. The subjects were evaluated clinically with the Positive and Negative Syndrome Scale (PANSS) and the Schedule for Affective Disorders and Schizophrenia (SADS), and neuropsychologically with a broad neuropsychological test battery. The correlations between all of the variables were studied and their predictive capacity assessed by linear regression methods. When the neuropsychological impairment criterion was established, we were able to distinguish two groups of patients with similar psychopathologies, but different neuropsychological and prognostic characteristics. Schizophrenic patients with neuropsychological impairment showed worse prognosis, worse evolution, and worse psychosocial adaptation than nonneuropsychologically impaired schizophrenics. Cognitive variables are statistically good predictors of evolution, prognosis, and adaptation. In conclusion, the negative syndrome of schizophrenia is neuropsychologically heterogeneous. Although negative patients present a similar clinical profile, their neuropsychological and prognostic characteristics may differ.

Adjunctive gabapentin treatment of bipolar disorder

INTRODUCTION

The aim of this study was to analyze the effectiveness of gabapentin administration to bipolar patients who had an incomplete response to other mood stabilizers.

SUBJECTS AND METHODS

Twenty-two RDC bipolar 1 and II patients were assessed by means of the SADS and entered if they gave their consent to participate. All them had suffered from frequent relapses, subsyndromal features (mostly depressive) and incomplete response to other drugs. They all received open-label increasing doses of gabapentin until clinical response. The patients were assessed through the CGI-BP and a specific questionnaire at baseline and at 12 weeks of follow-up.

RESULTS

Six out of the 22 patients dropped out for various reasons (four because of relapse, one because of side effects and one more because of poor compliance). Eight of the 16 patients that completed the 12-week follow-up showed at least two stages of improvement in the CGI. Using the last observation-carried forward analysis, the improvement was statistically significant for the depression subscale, and apparently related to social functioning, irritability and anxiety. Only one patient dropped out because of intolerance (mild rash). The mean dose of gabapentin was 1,310 mg/day.

CONCLUSION

Gabapentin may be a useful drug for the add-on treatment of bipolar patients with poor response to other mood stabilizers. Gabapentin may improve depressive residual symptoms such as irritability, social withdrawal or anxiety. These results should be confirmed in randomized clinical trials.

What is the role of psychotherapy in the treatment of bipolar disorder?

BACKGROUND

The authors review and criticize the different roles developed by psychotherapy in the treatment of bipolar disorder, from psychodynamic conceptions to a biopsychosocial model.

METHODS

The main computerized database (Medline, Current Contents, Psychological Abstracts) have been consulted, using the terms 'psychotherapy', 'psychosocial' and 'bipolar disorder' as key words.

RESULTS

Psychoanalysis, psychoeducation, family therapy, cognitive-behavioral therapy and interpersonal therapy have been used in the treatment of bipolar patients. To date, none have established efficacy in controlled clinical trials regarding aspects such as hospitalization, recurrences or suicidal behavior, as medication alone does. Research on this issue usually undergoes methodological pitfalls. Nonetheless, the psychoeducative approach combined with several cognitive-behavioral techniques, either in group or individually, seem to be the most promising, focusing on information, treatment compliance, and illness management skills.

CONCLUSIONS

There is a need for systematic clinical research on psychotherapy applied to bipolar disorder in order to show its true usefulness. Psychoeducation should prove its positive influence on the course and outcome of bipolar disorder.

Bipolar II disorder and comorbidity

The validity and reliability of the diagnosis of bipolar II disorder has been questioned by means of comorbidity with nonaffective disorders, including substance abuse, personality disorders, and anxiety disorders. This study examined the comorbid diagnosis of a sample of bipolar II patients, comparing patients with comorbidity and those with "pure" bipolar II disorder. Forty Research Diagnostic Criteria (RDC) bipolar II patients were assessed by means of the Schedule for Affective Disorders and Schizophrenia, Lifetime Version (SADS-L) and Structured Clinical Interview for DSM-III-R axis I (SCID-II) for personality disorders. Patients fulfilling RDC criteria for any psychiatric disorder (except personality disorders) or DSM-IV criteria for any personality disorder were compared with patients without comorbidity. For practical reasons, cyclothymia was not considered as a comorbid diagnosis. Half of the sample had lifetime comorbidity with other psychiatric disorders, mainly personality disorders (33%), substance abuse or dependence (21%), and anxiety disorders (8%). However, only the rates of suicidal ideation (74% v 24%, chi square [chi2] = 9.03, P = .003) and suicide attempts (45% v 5%, chi2 = 8.53, P = .003) were significantly different between patients with and without comorbidity. In summary, although the rates of comorbidity are relatively high in bipolar II disorder, most clinical and course variables are strikingly similar in patients with and without comorbidity except for suicidal behavior, suggesting that comorbidity does not reduce the validity of the diagnosis of bipolar II disorder.

Clinical factors associated with treatment noncompliance in euthymic bipolar patients

BACKGROUND

Noncompliance with medication is a very common feature among bipolar patients. Rates of poor compliance may reach 64% for bipolar disorders, and noncompliance is the most frequent cause of recurrence. Knowledge of the clinical factors associated with noncompliance would enhance clinical management and the design of strategies to achieve a better outcome for bipolar patients. Although most patients withdraw from medication during maintenance treatment, compliance studies in euthymic bipolar samples are scarce.

METHOD

Compliance treatment and its clinical correlates were assessed at the end of 2-year follow-up in 200 patients meeting Research Diagnostic Criteria for bipolar I or bipolar II disorder by means of compliance-focused interviews, measurements of plasma concentrations of mood stabilizers, and 2 structured interviews: the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM-III-R Axis II disorders. Well-compliant patients and poorly compliant patients were compared with respect to several clinical and treatment variables.

RESULTS

The rate of mildly and poorly compliant patients was close to 40%. Comorbidity with personality disorders was strongly associated with poor compliance. Poorly compliant patients had a higher number of previous hospitalizations, but reported fewer previous episodes. The type of treatment was not associated with compliance.

CONCLUSION

Clinical factors, especially comorbidity with personality disorders, are more relevant for treatment compliance than other issues such as the nature of pharmacologic treatment. Compliant patients may have a better outcome in terms of number of hospitalizations, but not necessarily with respect to the number of episodes. Bipolar patients, especially those with personality disorders, should be monitored for treatment compliance.

Alpha-1-acid glycoprotein in major depressive disorder. Relationships to severity, response to treatment and imipramine plasma levels

BACKGROUND

Increased plasma levels of alpha-1-acid glycoprotein (AGP) were reported in major depressive disorder. However, the relationship between AGP levels, severity of depression, treatment response and antidepressant levels are still unclear.

METHODS

Plasma AGP levels were measured in 36 subjects with major depressive disorder before and after a 6-week treatment with imipramine and in 30 controls. Free imipramine plasma levels of depressed patients were measured at 6 weeks. Comparative analysis between depressed patients and controls, between non-responders (N = 12) and responders (N = 24), and between severely depressed patients (N = 14) and moderately depressed patients (N = 22) were made.

RESULTS

Depressed patients had significantly higher mean values of AGP than control subjects. Imipramine non-responders and specially severely depressed patients had significantly greater increases of AGP levels during treatment than other depressed subgroups. There was no correlation between baseline AGP levels and severity of depression or free imipramine levels.

LIMITATIONS

The most significant limitations of this study are the small sample size and the fact that all the subjects were out-patients. Results should not be generalized to in-patient populations.

CONCLUSIONS

Depressed patients showed high baseline concentrations of AGP. AGP levels did not predict either free imipramine plasma levels or differential response after 6 weeks of treatment with imipramine. A greater increase of AGP during treatment was associated with severity of depression and treatment non-response.

CLINICAL IMPLICATIONS

The relationship between high plasma levels of AGP, severity of depression and lack of treatment response is clarified. The influence of imipramine levels is minimized.

[Functional neuroimaging of emotions and bipolar disorder]

In this review we comment the results of functional neuroimaging works of emotions on normal population and some parallelisms with the emotional changes of bipolar disorder correlated with their functional neuroimaging. Initially we refer the emotional ontogenetical development of human brain based on regional cerebral sanguineous flow evolution (FSC). Secondly we describe the differences of FSC between the externally generated emotions versus internally; between positive versus negative emotions and the correlation between FSC and some facial expressions. When FSC of bipolar disorder is compared with normal emotions on general population, we observe that temporal cortex, the prefrontal medial and insular anterior cortex, change their perfusion with the switch or the change of emotional expression. It is possible to determine if the findings obtained in samples of healthy subjects and bipolar patients converge in a dimensional model, or if on the contrary they support the categorical hypotheses, moving the emotional aspects to a second term on bipolar disorder.

Cognitive dysfunctions in bipolar disorder: evidence of neuropsychological disturbances

Although cognitive dysfunctions in psychosis have classically been associated with schizophrenia, there is clinical evidence that some bipolar patients show cognitive disturbances either during acute phases or in remission periods. The authors critically review the data on cognitive impairment in bipolar disorder. The main computerized databases (Medline, Psychological Abstracts, Current Contents) have been consulted crossing the terms 'cognitive deficits', 'neuropsychology', 'intellectual impairment', 'mania', 'depression' and 'bipolar disorder'. Changes in the fluency of thought and speech, learning and memory impairment, and disturbances in associational patterns and attentional processes are as fundamental to depression and mania as are changes in mood and behavior. Moreover, a significant number of bipolar patients show persistent cognitive deficits during remission from affective symptoms. However, there are several methodological pitfalls in most studies such as unclear remission criteria, diagnostic heterogeneity, small sample sizes, absence of longitudinal assessment, practice effect and poor control of the influence of pharmacological treatment. Most studies point at the presence of diffuse cognitive dysfunction during the acute phases of bipolar illness. Most of these deficits seem to remit during periods of euthymia, but some of them may persist in approximately one third of bipolar patients. Methodological limitations warrant further research in order to clear up the relationship between neuropsychological functioning and clinical, demographic and treatment variables in bipolar disorder.

Enhanced corticotropin response to corticotropin-releasing hormone as a predictor of mania in euthymic bipolar patients

BACKGROUND

Dysregulation of corticotropin (ACTH) and cortisol response after corticotropin-releasing hormone (CRH) stimulation has been reported in bipolar patients. Most findings involve the pathophysiology of the depressive phase of the illness and its prediction. However, the possible predictive value of the CRH challenge test with respect to manic episodes remains unknown.

METHODS

The ACTH and free cortisol response to the injection of 100 microg of synthetic human CRH and plasma cortisol-binding globulin levels were measured in 42 lithium-treated patients suffering from Research Diagnostic Criteria bipolar I disorder in remission, and 21 age- and sex-matched normal controls. A 1-year follow-up was conducted to assess any possible relationship between outcome and the hormonal response.

RESULTS

Bipolar patients showed higher baseline and peak ACTH concentrations than control subjects. A higher area under ACTH concentration curve after CRH stimulation predicted manic/hypomanic relapse within 6 months by multiple regression analysis.

CONCLUSION

Bipolar patients in remission show mild abnormalities in ACTH levels before and after CRH stimulation. CRH challenge may be a potentially good predictor of manic or hypomanic relapse in remitted bipolar patients.

Variability in the serotonin transporter gene and increased risk for major depression with melancholia

The serotonin transporter (SERT) gene is a particularly interesting candidate for genetic involvement in affective disorders owing to its role in both the regulation of serotonergic neurotransmission and the mechanism of action of many antidepressant drugs. In this study, variability in the SERT gene was analyzed for the first time in a sample of patients with major depression with melancholia (MDDM) in the context of a genetic association study. Two different polymorphisms of the SERT gene (17q11.1-17q12) were analyzed: a variable number of tandem repeats (VNTR) polymorphism in intron 2, and a deletion/insertion polymorphism (5-HTTLPR) in the promoter region of the gene, the short variant of which (allele 484) reduces the transcriptional efficiency of the SERT gene. Our sample consisted of 74 unrelated subjects who strictly met DSM-IV criteria for MDDM and 84 healthy controls, all of Spanish origin. The analysis of haplotype distribution for both polymorphisms showed significant differences between cases and controls (log-likelihood ratio chi2=11.15, df=4, P=0.025). Moreover, when the frequencies of the 484-STin2.10 haplotype were considered in comparison with any other haplotype combination, a significant increase in this haplotype was found in patients with MDDM [z=2.53 (95% CI, 1.21-5.34), P=0.007]. According to these results, variability in the SERT gene has a small effect on liability to MDDM. Our findings are compatible with an additive effect of both the 484 low-activity allele and a mutation elsewhere within the transporter gene or a susceptibility locus nearby in linkage disequilibrium with the VNTR marker.