An association between PPARα-L162V polymorphism and increased plasma LDL cholesterol levels after risperidone treatment

Peroxisome proliferator-activated receptor alpha (PPARα) and antipsychotic medications both influence polyunsaturated fatty acids (PUFA) homeostasis, and thus PPARα polymorphism may be linked to antipsychotic treatment response. Here we investigated whether the functional leucine 162 valine (L162V) polymorphism in PPARα influenced antipsychotic treatment in a group of psychosis patients (N = 186), as well as in a patient subgroup with risperidone, paliperidone, or combination treatment (N = 65). Antipsychotic-naïve first-episode patients and nonadherent chronic individuals were genotyped by polymerase chain reaction analysis. At baseline, and after 8 weeks of treatment with various antipsychotic medications, we assessed the patients' Positive and Negative Syndrome Scale (PANSS) scores; PANSS factors; and metabolic syndrome-related parameters, including fasting plasma lipid and glucose levels, and body mass index. In the total patient group, PPARα polymorphism did not affect PANSS psychopathology or metabolic parameters. However, in the subgroup of patients with risperidone, paliperidone, or combination treatment, PPARα polymorphism influenced changes in plasma LDL cholesterol. Specifically, compared to PPARα-L162L homozygous patients, PPARα-L162V heterozygous individuals exhibited significantly higher increases of LDL cholesterol levels after antipsychotic treatment. The PPARα polymorphism had a strong effect size, but a relatively weak contribution to LDL cholesterol level variations (∼12.8 %).

Association between PLA2 gene polymorphisms and treatment response to antipsychotic medications: A study of antipsychotic-naïve first-episode psychosis patients and nonadherent chronic psychosis patients

Here we investigated whether antipsychotic treatment was influenced by three polymorphisms: rs10798059 (BanI) in the phospholipase A2 (PLA2)G4A gene, rs4375 in PLA2G6, and rs1549637 in PLA2G4C. A total of 186 antipsychotic-naïve first-episode psychosis patients or nonadherent chronic psychosis individuals (99 males and 87 females) were genotyped by polymerase chain reaction analysis/restriction fragment length polymorphism. At baseline, and after 8 weeks of treatment with various antipsychotic medications, we assessed patients' Positive and Negative Syndrome Scale (PANSS) scores, PANSS factors, and metabolic syndrome-related parameters (fasting plasma lipid and glucose levels, and body mass index). We found that PLA2G4A polymorphism influenced changes in PANSS psychopathology, and PLA2G6 polymorphism influenced changes in PANSS psychopathology and metabolic parameters. PLA2G4C polymorphism did not show any impact on PANSS psychopathology or metabolic parameters. The polymorphisms' effect sizes were estimated as moderate to strong, with contributions ranging from around 6.2-15.7%. Furthermore, the polymorphisms' effects manifested in a gender-specific manner.

Flavonols in Action: Targeting Oxidative Stress and Neuroinflammation in Major Depressive Disorder

Major depressive disorder is one of the most common mental illnesses that highly impairs quality of life. Pharmacological interventions are mainly focused on altered monoamine neurotransmission, which is considered the primary event underlying the disease's etiology. However, many other neuropathological mechanisms that contribute to the disease's progression and clinical symptoms have been identified. These include oxidative stress, neuroinflammation, hippocampal atrophy, reduced synaptic plasticity and neurogenesis, the depletion of neurotrophic factors, and the dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis. Current therapeutic options are often unsatisfactory and associated with adverse effects. This review highlights the most relevant findings concerning the role of flavonols, a ubiquitous class of flavonoids in the human diet, as potential antidepressant agents. In general, flavonols are considered to be both an effective and safe therapeutic option in the management of depression, which is largely based on their prominent antioxidative and anti-inflammatory effects. Moreover, preclinical studies have provided evidence that they are capable of restoring the neuroendocrine control of the HPA axis, promoting neurogenesis, and alleviating depressive-like behavior. Although these findings are promising, they are still far from being implemented in clinical practice. Hence, further studies are needed to more comprehensively evaluate the potential of flavonols with respect to the improvement of clinical signs of depression.

Clozapine in Treatment-Resistant Schizophrenia and Its Augmentation with Electroconvulsive Therapy in Ultra-Treatment-Resistant Schizophrenia

Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses (two or more, with at least one being atypical). However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40–70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies.

Acute Mescaline Intoxication Followed by Catatonia

The paper deals with a case report of a 41-year-old man who in search of the meaning of life in a so-called “shamanic ritual” drank tea made from the San Pedro cactus as well as paste made of the same plant. The hallucinations were post poned and started after 9.5 hours caracterised by a psychotic reaction with symptoms of catatonia. He was admitted to our Department of Psychiatry where he was administered a second generation antipsychotic. The clinical presentation disappeared about 60 hours after the ingestion of mescaline mainly because of the antagonistic effect the antipsychotic has on the serotoninergic 5-HT2A receptors.

Psychiatric Illness or Immune Dysfunction-Brain Perfusion Imaging Providing the Answer in a Case of Anti-NMDAR Encephalitis

BACKGROUND

We investigated the potential use of SPECT quantification in addition to qualitative brain perfusion analysis for the detection of anti-NMDAR encephalitis. The question is how to normalize brain activity to be able to quantitatively detect perfusion patterns. Usually, brain activity is normalized to a structure considered unaffected by the disease.

METHODS

Brain [99mTc]-HMPAO SPECT was performed as a method to detect brain perfusion patterns. The patterns of abnormal brain perfusion cannot always be reliably and qualitatively assessed when dealing with rare diseases. Recent advances in SPECT quantification using commercial software have enabled more objective and detailed analysis of brain perfusion. The cerebellum and whole brain were used as the normalization structures and were compared with visual analysis.

RESULTS

The quantification analysis performed with whole brain normalization confirmed right parietal lobe hypoperfusion while also detecting statistically significant left-to-right perfusion differences between the temporal lobe and thalamus. Whole brain normalization further described bilateral frontal lobe hyperperfusion, predominantly of the left lobe, and was in accordance with visual analysis.

CONCLUSION

SPECT quantitative brain perfusion analysis, using the whole brain as the normalization structure rather than the cerebellum, in this case, improved confidence in the visual detection of anti-NMDAR encephalitis and provided unexpected solutions to atypical psychiatric dilemmas.

Quetiapine Add-On Therapy May Improve Persistent Sleep Disturbances in Patients with PTSD on Stabile Combined SSRI and Benzodiazepine Combination: A One-Group Pretest-Posttest Study

BACKGROUND

To assess potential benefits of quetiapine for persistent sleep disturbances in patients with posttraumatic stress disorder (PTSD) on stable combined SSRI and benzodiazepine therapy, who previously failed to respond to various benzodiazepine and non-benzodiazepine hypnotic adjuvant treatment as well as to first-generation antipsychotic add-on treatment.

SUBJECTS AND METHODS

Fifty-two male PTSD outpatients on stable combination treatment with SSRI and benzodiazepines, with persistent sleep disturbances not responding to prescription of zolpidem, flurazepam, nitrazepam, promazine, and levopromazine, were assessed for sleep disturbances improvements after prescription of quetiapine in the evening. Each patient met both ICD-10 and DSM-IV criteria for PTSD. Psychiatric comorbidity and premorbidity were excluded using the Mini-International Neuropsychiatric Interview (MINI). Improvement on the CAPS recurrent distressing dream item, reduction in the amount of time needed to fall asleep, prolongation of sleep duration, and reduction in average number of arousals per night in the last 7 days before the assessment period were used as efficacy measures.

RESULTS

All sleep-related parameters improved significantly at the end of a five-week follow-up: sleep duration increased by one hour (p<0.001), sleep latency decreased by 52.5 minutes (p<0.001), median number of arousals per night decreased from two to one (p<0.001), CAPS recurrent distressing dream item median decreased from five to four (p<0.001), and the number of patients dissatisfied with their sleep quality and quantity decreased from 45 to two (p<0.001).

CONCLUSION

Quetiapine prescribed in the evening may be successful therapy for persistent sleep disturbances in patients with PTSD and generally good response to an SSRI and benzodiazepine combination, who previously failed to respond to some of the usual hypnotic medication or addition of first-generation antipsychotics: zolpidem, flurazepam, nitrazepam, promazine, and levopromazine.

The Impact of Long-acting Paliperidone in Reducing Hospitalizations and Clinical Severity in Recent Onset Schizophrenia: A Mirror-image Study in Real-world Clinical Setting

Objective

Schizophrenia is a debilitating disease that disrupts the lives of many affected individuals and exerts a toll on the health system. Only few studies assessed once-monthly injectable formulation of paliperidone palmitate (PP-1M) and other long-acting antipsychotics in recent onset schizophrenia (ROS). To evaluate whether PP-1M is efficacious in reducing frequency and length of hospitalizations and psychosis symptom severity in patients with ROS.

Methods

This mirror-image study included 112 patients, suffering from ROS admitted in a psychiatric ward and successively treated with PP-1M for 1-year. Other psychotic disorders were excluded. We collected socio-demographic data of all subjects included, number and days of hospitalization, as well as Clinical Global Impression-Severity scale (CGI-S) and Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) scores at the initiation and after 1-year of PP treatment.

Results

After 1-year PP-1M treatment, mean scores of both CGI and CRDPSS significantly decreased (p < 0.001), as well as the mean number of hospitalizations (p = 0.002) and total hospitalization days (p < 0.001) in comparison with those of the previous year.

Conclusion

Our results suggest that PP-1M can be considered as an important therapeutic option in patients with ROS. Its use led to a meaningful reduction in the patient’s use of hospital services, as well as a significant clinical improvement of psychotic symptoms in our sample.

Dysregulated inflammation may predispose patients with serious mental illnesses to severe COVID‑19 (Review)

Genetic and nongenetic factors associated with an increased inflammatory response may mediate a link between severe coronavirus disease 2019 (COVID‑19) and serious mental illness (SMI). However, systematic assessment of inflammatory response‑related factors associated with SMI that could influence COVID‑19 outcomes is lacking. In the present review, dietary patterns, smoking and the use of psychotropic medications are discussed as potential extrinsic risk factors and angiotensin‑converting enzyme (ACE) insertion/deletion (I/D) gene polymorphisms are considered as potential intrinsic risk factors. A genetics‑based prediction model for SMI using ACE‑I/D genotyping is also proposed for use in patients experiencing severe COVID‑19. Furthermore, the literature suggests that ACE inhibitors may have protective effects against SMI or severe COVID‑19, which is often linked to hypertension and other cardiovascular comorbidities. For this reason, we hypothesize that using these medications to treat patients with severe COVID‑19 might yield improved outcomes, including in the context of SMI associated with COVID‑19.

Cytological Analysis of CSF in Patients with Acute Schizophrenia

Cerebrospinal fluid (CSF) analysis is one of the most important tests in the diagnosis of central nervous system (CNS) diseases. Although CSF analysis is most commonly used in neurological pathological conditions, it also has its place in psychiatry. Studies to date have described several valuable specific cytomorphological phenomena in the cerebrospinal fluid of patients with acute schizophrenia, which indicate inflammatory or immune-mediated etiopathogenesis of the disease. Additional and long-term research is needed to confirm and standardize the importance of cytological analysis of cerebrospinal fluid in the diagnosis and etiopathogenesis of acute schizophrenia.

Electroconvulsive Therapy During the COVID-19 Pandemic

In March 2020, three months after the first cases surfaced in the Chinese city of Wuhan, WHO declared a global pandemic of the novel coronavirus, which by than had already spread through a great number of countries all over the world. In order to protect the health of healthcare workers and patients, activities and measures of disease prevention have been taken; in such circumstances, psychiatry found itself faced with various challenges, one of them being the preservation of the continuity of electroconvulsive therapy (ECT) in patients with severe or refractory psychiatric disorders. Such patients are a priority and demand immediate treatment in hospital settings adapted to epidemiological circumstances. Having studied the instructions and recommendations of the competent authorities, as well as reviewing available literature, this paper presents the most important measures for the smooth performance of ECT in conditions associated with the COVID-19 disease.

COGNITIVE AND PSYCHOTIC SYMPTOMS IN A PATIENT WITH INFRATENTORIAL ARACHNOID CYST: CASE REPORT

We present a case of a patient with treatment resistant hallucinatory experiences with incidental finding of an arachnoid cyst localized in the posterior infratentorial cranial fossa dorsally to the cerebellum. Psychological testing revealed significant deficit of cognitive functions to the level of mild intellectual disability in a person that had previously finished high school with good grades. A combination of clozapine and lamotrigine led to significant improvement in mood and reduction of hallucinations, but without improvement in cognitive functions. We also performed a literature review of previously published case reports or case series of co-occurring posterior fossa arachnoid cyst and schizophrenia or psychosis or psychiatric symptoms using PubMed search and discuss some controversies considering their treatment outcome.

Long acting aripiprazole influences cognitive functions in recent onset schizophrenia

RATIONALE

Beneficial effects of aripiprazole on cognition in schizophrenia have been previously reported, but not in recent onset schizophrenia. Cognitive impairments have also been associated with catechol-O-methyltransferase (COMT), methylenetetrahydrofolate reductase (MTHFR), and serotonin transporter (SERT) gene polymorphisms which were earlier implicated in the pathophysiology of schizophrenia.

OBJECTIVES

This study examined the short-term influence of aripiprazole long-acting injectable (LAI) as well as of COMT, MTHFR, and SERT gene polymorphisms and their interactions on clinical features and cognitive functions in inpatients with recent onset schizophrenia.

METHODS

This study included 98 inpatients suffering from recent onset schizophrenia diagnosed according to DSM-5 criteria. Three months after initiating aripiprazole LAI, the severity of symptoms was assessed by the Positive and Negative Syndrome Scale (PANSS), while cognitive functions were measured by 5-KOG test for cognition. Genotypes of SERT, MTHFR, and COMT gene were determined by different polymerase chain reaction (PCR) methods.

RESULTS

Three-month aripiprazole LAI treatment was associated with a statistically significant change of PANSS total (p<0.001) and subscale scores as well as cognitive parameters of delayed recall (p<0.03), attention (p<0.01), and executive functions in the form of less perseverations (p<0.03), without influencing other examined cognitive functions. However, it significantly influenced composite cognitive score (p<0.02). In regard to the investigated genetic polymorphisms, we established a positive association between the COMT polymorphism (M/M allele carriers) and attention (p<0.01). Additionally, we also established a positive association between the COMT - MTHFR interaction and attention (p<0.02), as well as perseveration item belonging to executive functions (p<0.01). Two other investigated polymorphisms (MTHFR and SERT) were not significantly associated with cognitive indices. Investigated genetic polymorphisms and their interactions were not associated with PANSS scores.

CONCLUSIONS

Our findings suggest that aripiprazole LAI improves individual cognitive functions in recent onset schizophrenia. Investigated COMT polymorphism (Met/Met genotype), as well as the COMT-MTHFR interaction, were positively associated with attention and executive functioning (perseveration), potentially implying COMT's biomarker potential in terms of cognition in schizophrenia.

Changes in platelet serotonin concentration after four weeks of alcohol abstinence depending on the genotype of the serotonin transporter

BACKGROUND

Alcohol use disorder (AUD) is a psychiatric disorder characterized by excessive and uncontrolled drinking that causes distress and has damaging consequences for men and women of all ages. It is one of the four most disabling diseases and it affects approximately 14.6 million persons in Europe.

OBJECTIVES

Objective of this study is to investigate changes in platelet serotonin concentration after four weeks of alcohol abstinence in regards to the genotype of the serotonin transporter.

METHODS

A total of 154 patients with AUD were included in the study. Platelet serotonin concentrations were assessed by enzyme-linked immunosorbent assay. Genotype of serotonin transporter promoter polymorphism was determined by the polymerase chain reaction-based method.

RESULTS

We did not establish a statistically significant main effect of serotonin transporter polymorphism on platelet serotonin concentration after four weeks of abstinence.

CONCLUSION

Aforementioned finding is in line with previous research suggesting a complex relationship between serotonin transporter gene and platelet serotonin levels, and congruent with the well-established genotype interaction with numerous other factors, such as sex, ethnicity, education level, and stressful life events.

Clozapine-associated eosinophilia with multiple systemic involvement - case report and review of literature

Introduction

Due to its mood-stabilizing properties, clozapine is known for reducing symptom severity in manic episodes of treatment-resistant bipolar disorder as well as in treatment-resistant schizophrenia. However, its use may be hindered by potential adverse effects, including hematologic ones, such as non-dose-dependent eosinophilia. The mechanism of the underlying process probably involves a type-I hypersensitivity reaction, which can manifest as either transient asymptomatic eosinophilia or as eosinophilia with multiorgan dysfunction.

Objectives

We present the case of a patient diagnosed with manic episode of schizoaffective disorder who developed eosinophilia, with severe systemic manifestations, in response to clozapine therapy. A review of literature will be conducted in order to provide further insight into the phenomenon.

Methods

Case report and literature review.

Results

The incidence of eosinophilia reported in literature ranges between 0.2% and 62%, with its appearance about three weeks after clozapine initiation. Although clozapine is an antipsychotic that normally requires frequent monitoring due to the potential side effect of agranulocytosis, we would like to place emphasis on the possible risk of eosinophilia, in connection with potential fatal complications. As described in this report, eosinophilia could long remain unrecognized due to subsequent multiorgan involvement, including lymphadenopathy, leukocytosis, lymphopenia, anemia, liver enzyme elevations, as well as pleural effusion, all of which were described in our patient.

Conclusions

Clozapine-associated eosinophilia may be used as an early marker of possible clozapine-induced systemic complications and it may warrant prompt discontinuation of the causing drug, as suggested by the literature.

Effects of aripiprazole long-acting injectable antipsychotic on hospitalization in recent-onset schizophrenia

OBJECTIVE

Recent-onset schizophrenia (ROS) represents a critical period that can greatly influence the clinical course of schizophrenia. The use of long-acting injectable antipsychotics (LAIs) in this period is increasingly being considered as a first-line treatment option. Aripiprazole LAI (ALAI) is the newest of all LAI's available on the market, with limited data on its effects on hospitalization rates after first episode of schizophrenia. It was our goal to evaluate whether ALAI has an effect on hospitalization rates, number of bed days and clinical improvement in patients with ROS.

METHODS

This mirror-image study included 138 inpatients suffering from schizophrenia. We collected sociodemographic data on all individuals, number of hospitalization days, hospitalization rates as well as Clinical Global Impression Scale-severity of illness (CGI-S) and Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) scores at the initiation of ALAI and at the end of a 1 year follow up.

RESULTS

Mean number of hospitalizations and hospitalization days in the year after starting ALAI significantly decreased compared to the year before (p = 0.005 and p < 0.001). Mean scores on both CGI and CRDPSS also significantly decreased after initiating ALAI (p < 0.001).

CONCLUSION

Results suggest that ALAI is an important therapeutic option in patients with ROS. It leads to reduced usage of hospital services, potentially reducing the socio-economic healthcare burden.

Vitamin D and Neurotrophin Levels and Their Impact on the Symptoms of Schizophrenia

INTRODUCTION

Vitamin D is involved in brain development and functioning, as well as in regulation of neurotrophic factors. Changes in the expression of those factors are possibly responsible for morphologic abnormalities and symptoms in patients suffering from schizophrenia.

OBJECTIVE

The main goal of this research was to investigate the interrelationship between vitamin D, nerve growth factors (NGF, brain-derived neurotrophic factor [BDNF], and neuregulin-1 [NRG1]), and schizophrenia symptom domains.

METHODS

This research included 97 inpatients diagnosed with schizophrenia. Schizophrenia symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS). Blood samples were taken in order to analyze concentrations of vitamin D, BDNF, NRG1, and NGF growth factors. The obtained results were used in a multiple regression analysis.

RESULTS

The vitamin D concentration positively affected the concentration of NRG1 (F = 8.583, p = 0.005) but not the concentration of other investigated growth factors (BDNF and NGF). The clinical characteristics and symptom domains of schizophrenia seemed to be unaffected by the concentrations of vitamin D, BDNF, and NGF, while the NRG1 concentration significantly affected positive symptom domains of schizophrenia (F = 4.927, p = 0.030).

CONCLUSION

The vitamin D concentration positively affected NRG1 levels but not schizophrenia symptomatology as measured by PANSS. The as-sociation between the two could be intermediated via NRG1.

Schyzotipy: from Personality Organization to Transition to Schizophrenia

The traditional medical model of schizophrenia assumes a categorical view of the syndrome. On the contrary, the dimensional approach to schizophrenia infers that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. Schizotypy comprise a set of inherited traits reflected in personality organization, which presents as qualitatively similar to schizophrenia. Schizotipy is in line with continuum hypothesis of schizophrenia where different combinations of genes and environmental risk factors result in a range of different phenotypic expressions lying on a continuum from normal through to clinical psychosis. We discuss evidences for the continuity of psychotic symptoms to normal experiences and theoretical and future research implications of such a continuum.

THE ENIGMA OF LEWY BODY DEMENTIA: A CASE REPORT

Lewy body dementia is a progressive neurodegenerative disease and is considered to be the second most common cause of dementia in the elderly. Because of the complexity of clinical presentation, it is often misdiagnosed and mistaken for other dementias, which may result in administering inappropriate therapy, and thus worsening of the patient condition. We reviewed a case of a 71-year-old patient whose clinical presentation gradually occurred with complex visual hallucinations, atypical extrapyramidal motor symptoms, fluctuating cognitive impairments with delirious episodes, and oscillating syncope. Depressive mood, impaired daily functioning and sensitivity to antipsychotics were also noted. Extensive diagnostic workup was performed with neuropsychological testing and use of single-photon emission computerized tomography. Considering the clinical presentation and diagnostic procedures performed, the diagnosis of Lewy body dementia was set and pharmacotherapy was revised. We discuss the importance of taking overall clinical presentation and diagnostic treatment in consideration and applying appropriate therapy to slow down the progression of the disease and exacerbation of the patient's psychological functions.

THE USE OF ELECTRORETINOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY IN PATIENTS WITH SCHIZOPHRENIA

The use of electroretinography (ERG) and optical coherence tomography (OCT) has currently expanded beyond ophthalmology alone. The aim of this review is to present the results and knowledge acquired by these two methods in patients suffering from schizophrenia. Reviewing the studies applying ERG and OCT methods in the field of psychiatry, one can conclude that results of the research imply morphological and functional changes of retina in patients with schizophrenia that are not consistent. However, in most studies there was reduction of the amplitude and changes in the implicit time related parameters on ERG and thinning of the retinal nerve fiber layer on OCT. Neurons in the eye use the same neurotransmitters as neurons in the basal brain structures that are most affected in schizophrenia, according to the dopamine hypothesis of schizophrenia. Unlike neurons in the basal brain structures, the neurons in the eye are in vivo available to ERG. Using the aforementioned tests together with clinical diagnostic criteria of schizophrenia, the subgroups with different prognostic and therapeutic specificities within schizophrenia as a group of diseases might be identified more precisely.

The association between alexithymia and two dimensions of major depressive disorder: cognitive and somatic-affective

Aim: To explore the association between alexithymia and two dimensions of major depressive disorder (MDD): cognitive and somatic-affective. Patients and methods. Unicentric, cross-sectional study included consecutive sample of 63 patients at the Department of Psychiatry (DoP), Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia. Target population included outpatients with diagnosed MDD (F32 and F33, according to ICD-10). Inclusion criteria were: confirmed MDD diagnosis, age between 18 and 65 years, both genders, outpatient treatment at the DoP. The main outcome was the association between alexithymia, measured by total score on 20-item Toronto-Alexithymia scale (TAS-20), with two dimensions of MDD, cognitive and somatic-affective, measured by Beck Depression Inventory-II (BDI-II). Results: Both dimensions of BDI-II and the total severity of MDD symptoms were statistically significantly, although low, associated with alexithymia, and the differences between these two correlations were not (statistically) significant. However, in the multivariable model, the cognitive dimension (b = 0.64; β = 0.48; p = 0.002; statistically significant at the false discovery rate of 0.05) was primarily associated with alexithymia, and the somatic-affective was not, after all cognitive aspects were controlled for (b = -0.19; β = 0-0.14; p = 0.491; not statistically significant, with the false discovery rate of 0.05). Conclusion: Alexithymia is primarily associated with a pure cognitive dimension of MDD after somatic-affective elements are excluded. Somatic-affective dimension of MDD is not associated with alexithymia after the cognitive elements were controlled for. Both dimensions, as well as the overall severity of MDD, are associated with alexithymia, but this association is relatively low.

EIGHTY YEARS OF ELECTROCONVULSIVE THERAPY IN CROATIA AND IN SESTRE MILOSRDNICE UNIVERSITY HOSPITAL CENTRE

In 1937, Ugo Cerletti and Lucio Bini performed electroconvulsive treatment (ECT) in Rome for the first time. That was the time when different types of 'shock therapy' were performed; beside ECT, insulin therapies, cardiazol shock therapy, etc. were also performed. In 1938, Cerletti and Bini reported the results of ECT. Since then, this method has spread rapidly to a large number of countries. As early as 1940, just two years after the results of the ECT had been published, it was also introduced in Croatia, at Sestre milosrdnice Hospital, for the first time in our hospital and in the then state of Yugoslavia. Since 1960, again the first in Croatia and the state, we performed ECT in general anesthesia and continued it down to the present, with a single time brake.

Platelet Serotonin Concentration Is Associated with Illness Duration in Schizophrenia and Chronological Age in Depression

OBJECTIVE

Impaired serotonergic neurotransmission has been implicated in the pathogenesis of depression and schizophrenia. Blood platelets have been used for years as a peripheral model of neuronal serotonin dynamics. The objective was to investigate platelet count and serotonin concentration in patients with depression and schizophrenia, in an attempt to ascertain their clinical usefulness.

METHODS

953 participants were included in the study, 329 patients with depression, 339 patients with schizophrenia and 285 healthy controls. ELISA was used to assess platelet serotonin concentrations.

RESULTS

There were no statistically significant differences among groups regarding age, total platelet count and serotonin concentration. Linear regression analyses revealed inverse correlations between platelet serotonin concentration and age of patients with depression and healthy individuals, as well as between platelet serotonin concentration and illness duration in patients with schizophrenia. In other words, longer illness duration in patients with schizophrenia, and higher age in patients with depression and healthy individuals was associated with lower platelet serotonin concentrations.

CONCLUSION

Platelet count and serotonin concentration did not prove to be of diagnostic value in differentiating patients and healthy individuals. However, illness duration in patients with schizophrenia may be associated with reduced concentrations of platelet serotonin.

Video-Assisted Anal Fistula Treatment for Treatment of Complex Cryptoglandular Anal Fistulas with 2 Years Follow-Up Period: Our Experience

Aim: The aim of this prospective, nonrandomized, observational study was to present our results in operative treatment of complex anal fistulas using video-assisted anal fistula treatment (VAAFT) procedure with a curative intent in 2 years follow-up period. Materials and Methods: Between March 2016 and March 2018, 73 patients underwent the VAAFT procedure. Postoperative follow-up was 2 years, up to March 2020. Only patients with complex cryptoglandular anal fistulas were included. All patients were referred for magnetic resonance imaging of the pelvis. Fecal incontinence severity index score was used to assess any continence disturbance prior operation and postoperatively. Result: Primary healing occurred in 52 cases (71.23%) after first operation. From 21 patients who had recurrence or who had persisting disease, 16 patients accepted reoperation with second VAAFT procedure and additionally 10 patients achieved healing. From a total number of 73 patients who were included in study healing ultimately occurred in 62 cases (84.93%). In the first operation internal opening was identified in 47 cases (64.38%) and was closed with mattress suture, rectal advancement flap or ligation of intersphincteric fistula tract technique depending on its extent and type of fistula. Median primary healing rate was 6 weeks. There were no serious intra- or postoperative complications. None of the patients reported any type of continence disturbance. Discussion: VAAFT has been shown to offer good rates of healing, low morbidities, possibilities of multiple attempts in case of first failure and this series adds to the literature.

Prediction of schizophrenia using MAOA-uVNTR polymorphism: A case-control study

CONTEXT

Schizophrenia has been associated with disorder of the dopamine system, which is downregulated by projections of the serotonin pathway. Dopamine and serotonin levels are regulated by a system of transporters and enzymes. In this research, dopamine transporter polymorphism (DAT-VNTR), serotonin transporter polymorphism (5-HTTLPR), monoamine oxidase A (MAOA-uVNTR), and catechol-o-methyl transferase (COMT Val158Met) polymorphisms have been investigated.

AIMS

The aim of this study was to asses frequencies of these polymorphisms in the healthy control group and patients and to asses association with schizophrenia.

SETTINGS AND DESIGN

Three hundred and fourteen healthy volunteers and 306 schizophrenia patients were included. Schizophrenia was diagnosed by Diagnostic and Statistical Manual-IV of the American Psychiatric Association, and mini international neuropsychiatric interview questionnaire was used for screening of healthy population.

MATERIALS AND METHODS

Genotyping was performed using polymerase chain reaction (PCR) reaction followed by gel electrophoresis and PCR-restriction fragment length polymorphism.

STATISTICAL ANALYSIS

Categorical data were analyzed using the Chi-square test, age between subgroups was compared using the Mann-Whitney test, and all polymorphisms were tested for Hardy-Weinberg equilibrium. Logistic regression analysis was used to set the prediction model of schizophrenia.

RESULTS

Difference in genotype distribution was observed for COMT Val158Met in female and DAT-VNTR polymorphism in overall sample P = 0.021 and P = 0.028, respectively. Statistically significant association of MAOA-uVNTR and schizophrenia was observed after adjustment for anamnestic predictors of disease. P = 0.010, 80.45% participants were correctly classified.

CONCLUSION

Our results suggest an association of MAOA-uVNTR polymorphism with schizophrenia. The difference in the distribution of COMT Val158Met and DAT-VNTR polymorphism support the involvement of dopamine system components in the pathogenesis of schizophrenia.

Association between PLA2G6 gene polymorphism for calcium-independent phospholipase A2 and nicotine dependence among males with schizophrenia

We investigated the relationship between the rs10798059 (BanI) and rs4375 polymorphisms in the phospholipase A2 (PLA2)G4A and PLA2G6 genes and the risk of nicotine dependence in 263 Croatian patients with schizophrenia. We also examined whether interactions between these polymorphisms and smoking contributed to schizophrenia onset and Positive and Negative Syndrome Scale (PANSS) psychopathology. We found no significant differences in the distribution of PLA2G4A genotypes and alleles according to smoking status, and no effect of the PLA2G4A genotype-smoking interaction on disease onset or PANSS. The PLA2G6-TT homozygous genotype was significantly overrepresented in male smokers compared to nonsmokers (34.7% vs. 17.1%, p < 0.05). These patients had ∼2.6-fold higher risk of becoming smokers than males with heterozygous PLA2G6-CT and homozygous PLA2G6-CC genotypes. In addition, male smokers without the PLA2G6-C allele (PLA2G6-TT homozygous) experienced earlier onset than nonsmoking homozygous PLA2G6-TT males. Thus, the PLA2G6 polymorphism affected the risk of nicotine dependence in male patients and the PLA2G6 genotype-smoking interaction was linked to the age of disease onset.

INFLUENCE OF THE SEROTONERGIC SYSTEM POLYMORPHISM ON THE EXPRESSION OF DENTAL ANXIETY

- The aim of the study was to test the correlation between 5-HTTLPR polymorphism and dental anxiety. Research hypothesis was that positive relation between the expression of dental anxiety and the S allele exists in the population of healthy Caucasians. We conducted a prospective study on 159 subjects, volunteers made up of medical and non-medical staff of the Sestre milosrdnice University Hospital Centre. Both genders were included, age range 19 to 59, mentally and physically healthy (according to DSM-5 classification of mental disorders). For the purpose of this research, we used a sociodemographic questionnaire containing the following information: age, gender, education level, work status, marital status and residence. Corah's Dental Anxiety Scale-Revised (DAS-R) was used to measure dental anxiety. Data distribution was tested by Kolmogorov-Smirnov test, difference between the groups by ?χ2-test and one-way analysis of variance, and correlation of variables by logistic regression. In the study population, we found positive correlation between S-allele and total result in DAS-R questionnaire. The presence of S allele suggests that the person will have a higher result in DAS-R questionnaire, i.e. higher expression of dental anxiety.

Depressive symptoms in schizophrenia and dopamine and serotonin gene polymorphisms

Although depressive symptoms seem to be frequent in schizophrenia they have received significantly less attention than other symptom domains. As impaired serotonergic and dopaminergic neurotransmission is implicated in the pathogenesis of depression and schizophrenia this study sought to investigate the putative association between several functional gene polymorphisms (SERT 5-HTTLPR, MAO-A VNTR, COMT Val158Met and DAT VNTR) and schizophrenia. Other objectives of this study were to closely examine schizophrenia symptom domains by performing factor analysis of the two most used instruments in this setting (Positive and negative syndrome scale - PANSS and Calgary depression rating scale - CDSS) and to examine the influence of investigated gene polymorphisms on the schizophrenia symptom domains, focusing on depressive scores. A total of 591 participants were included in the study (300 schizophrenic patients and 291 healthy volunteers). 192 (64%) of schizophrenic patients had significant depressive symptoms. Genotype distribution revealed no significant differences regarding all investigated polymorphisms except the separate gender analysis for MAO-A gene polymorphism which revealed significantly more allele 3 carriers in schizophrenic males. Factor analysis of the PANSS scale revealed the existence of five separate factors (symptom domains), while the CDSS scale revealed two distinct factors. Several investigated gene polymorphisms (mostly SERT and MAO-A, but also COMT) significantly influenced two factors from the PANSS (aggressive/impulsive and negative symptoms) and one from the CDSS scale (suicidality), respectively. Depressive symptoms in schizophrenic patients may be influenced by functional gene polymorphisms, especially those implicated in serotonergic neurotransmission.

Activity of the hypothalamic-pituitary-adrenal axis and inflammatory mediators in major depressive disorder with or without metabolic syndrome

BACKGROUND

The aim of the present study was to explore the differences in serum CRP, IL-6, TNF-α, ACTH and cortisol among patients with major depressive disorder with or without metabolic syndrome (MS) compared to a healthy control group.

SUBJECTS AND METHODS

The MDD study group consisted of 80 patients (mean age of 50.03±9.55 years). The control group was recruited from the hospital personnel and it consisted of 40 examinees (mean age of 47.20±7.99 years). All patients who participated in the study were diagnosed with depressive disorder using MINI questionnaire, and Hamilton rating scale for depression. Diagnosis of the metabolic syndrome was set by NCEP ATP III criteria.

RESULTS

Examinees with depression but without MS had significantly more cortisol concentration when compared to the control group. CRP was significantly higher in the MDD group when compared to the control group and in MDD+MS group when compared to the control group. IL6 serum levels were significantly higher in the MDD group when compared to the healthy control group, and in MDD+MS group when compared to the healthy control group. ACTH had significant independent predictive values for abdominal obesity. Levels of TNF-α were statistically significant independent predictors for hyperglycaemia. Statistically significant predictive values for MDD were found for cortisol, and IL-6.

CONCLUSION

Results shown here emphasise the importance of neuroendocrine and inflammatory factors in pathogenesis of depressive disorder and MS. Further prospective research is necessary to clarify possible causal relationship between depression and MS. It is necessary to investigate the possibility of a joint biological mechanism in pathogenesis of these two disorders with the special attention given to the disturbances in the immune system.

Platelet serotonin concentration and depressive symptoms in patients with schizophrenia

Depressive symptoms seem to be frequent in schizophrenia, but so far they have received less attention than other symptom domains. Impaired serotonergic neurotransmission has been implicated in the pathogenesis of depression and schizophrenia. The objectives of this study were to investigate platelet serotonin concentrations in schizophrenic patients with and without depressive symptoms, and to investigate the association between platelet serotonin concentrations and symptoms of schizophrenia, mostly depressive symptoms. A total of 364 patients were included in the study, 237 of which had significant depressive symptoms. Significant depressive symptoms were defined by the cut-off score of 7 or more on Calgary Depression Rating Scale (CDSS). Platelet serotonin concentrations were assessed by the enzyme-linked immunosorbent assay (ELISA). Prevalence of depression in patients with schizophrenia was 65.1%. Schizophrenic patients with depressive symptoms showed lower platelet serotonin concentrations (mean±SD; 490.6±401.2) compared to schizophrenic patients without depressive symptoms (mean±SD; 660.9±471.5). An inverse correlation was established between platelet serotonin concentration and depressive symptoms, with more severe symptoms being associated with lower platelet serotonin concentrations. Depressive symptoms in schizophrenic patients may be associated with reduced concentrations of platelet serotonin.

Increased calcium-independent lipoprotein phospholipase A2 but not protein S100 in patients with schizophrenia

BACKGROUND

The aim of this paper was to investigate serum concentrations of calcium-independent lipoprotein phospholipase A2 (PLA2) and protein S100 in schizophrenia patients in comparison to healthy controls and correlate them with the clinical severity, duration, and number of schizophrenia relapses.

SUBJECTS AND METHODS

This study included 65 schizophrenia patients and 70 controls. Schizophrenia was diagnosed according to DSM-IV-TR criteria. Clinical severity was determined by PANSS. PLA2 and protein S100 concentration were assessed by the enzyme-linked immunosorbent assay (ELISA).

RESULTS

PLA2 concentrations were higher in patients with schizophrenia, whereas protein S100 concentrations were not. Higher concentrations of PLA2 were positively correlated with the duration of illness and number of episodes, as determined by multivariate analysis.

CONCLUSION

PLA2 might be considered a possible biochemical trait marker for schizophrenia. Further research with larger and more homogeneous clinical samples is required.

VALIDATION STUDY OF THE TORONTO ALEXITHYMIA SCALE (TAS-26) IN CROATIAN POPULATION

The aim of this study was to validate the Croatian translation of the Toronto Alexithymia Scale (TAS-26). For this purpose, 194 volunteers from the general population, both genders, aged between 18 and 60, were tested on this scale after it had undergone a repeated back-translation procedure by an independent bilingual translator. The mean total score on TAS-26 (mean ± SD) was 72.9±8.4. Cronbach's α-coefficient for the entire scale was 0.71, indicating the scale to be sufficiently reliable. When analyzing the α-coefficient of reliability for the entire scale, it was found that upon removal of one of the factors, only 3 factors ('I have physical sensations that even doctors don't understand'; 'When I'm upset, I don't know if I'm sad, frightened, or angry'; and 'I have feelings that I can't quite identify') would determine the α-coefficient of the entire scale amounting to less than 0.67, which would indicate insufficient reliability of the scale. The aforementioned factors belong to the group of F1 facet factors, the facet around which most items are grouped (n=12) and therefore the scale would be reliable enough even without the three factors. The results of factor analysis in our study confirmed the four-factor structure wherein most items are saturated by the first factor (n=12), and it denotes the alexithymia facet F1 (difficulty identifying feelings). Five items are saturated by the second factor and it denotes the alexithymia facet F2 (difficulty describing feelings), and the third factor which denotes facet F3 (reduced daydreaming) also saturated five items, whereas the fourth factor which denotes facet F4 (externally oriented thinking) saturated four items. The four listed facets explain 47.2% of variance wherein the highest percentage (20.1%) is attributed to facet F1, with facet F2 accounting for 12.1%, facet F3 for 7.5%, and facet F4 for 6.6% of variance.

Metabolic syndrome, activity of the hypothalamic-pituitary-adrenal axis and inflammatory mediators in depressive disorder

Depression has been associated with various cardiovascular risk factors such as hypertension, obesity, atherogenic dyslipidemia and hyperglycemia. In depressive disorder, hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis and changes in the immune system have been observed. On the other hand, somatic diseases such as obesity, hyperlipidemia, hypertension and diabetes mellitus type 2 are now perceived as important comorbid conditions in patients with depression. The pathogenesis of the metabolic syndrome and depression is complex and poorly researched; however, it is considered that the interaction of chronic stress, psychotrauma, hypercotisolism and disturbed immune functions contribute to the development of these disorders. The aim of the study was to investigate the relationship between depression and metabolic syndrome regarding the HPA axis dysfunction and altered inflammatory processes. Literature search in Medline and other databases included articles written in English published between 1985 and 2012. Analysis of the literature was conducted using a systematic approach with the search terms such as depression, metabolic syndrome, inflammation, cytokines, glucocorticoids, cortisol, and HPA axis. In conclusion, the relationship between depression and metabolic syndrome is still a subject of controversy. Further prospective studies are required to clarify the possible causal relationship between depression and metabolic syndrome and its components. Furthermore, it is important to explore the possibility of a common biologic mechanism in the pathogenesis of these two disorders, in which special attention should be paid to the immune system function, especially the possible specific mechanisms by which cytokines can induce and maintain depressive symptoms and metabolic disorders. The data presented here emphasize the importance of recognition and treatment of depressive disorders with consequent reduction in the incidence of metabolic syndrome, but also the need of regular search for metabolic disorders and their treatment to avoid all of these adverse effects and maybe reduce the incidence of depressive disorders.

Prevalence of metabolic syndrome among patients with major depressive disorder--differences between newly diagnosed first episode and recurrent disease

The objective of the present study was to assess differences in prevalence of the metabolic syndrome among depressed patients in regard to the duration of the illness (first episode versus recurrent episodes). A total of 190 patients suffering from major depressive disorder were included in the study, diagnosed according to International classification of disorders, 10th revision. The same criteria were used to divide participants into two groups: first episode major depressive disorder and major depressive disorder with recurrent episodes. The metabolic syndrome was defined according to the criteria of the American National Cholesterol Education Program-Treatment Panel III. Results showed that metabolic syndrome is significantly more prevalent in patients with recurrent major depressive disorder (45.2%) compared to patients with first episode of major depressive disorder (27.3%), mainly due to differences in plasma glucose, triglycerides and HDL-cholesterol levels. These findings indicate the importance of the duration of depression and the number of recurring episodes as factors involved in etiopathogenesis of the associated metabolic syndrome.

Serotonin transporter gene (5-HTTLPR) polymorphism and efficacy of selective serotonin reuptake inhibitors--do we have sufficient evidence for clinical practice

Depression pharmacotherapy can be described with weak predictability of individual response. Antidepressants are prescribed based on trial and error, as it is not possible to determine which patients will respond to antidepressants. It would appear that pharmacogenetics is the most promising path towards achieving the goal of individualized therapy. Today, the most commonly prescribed antidepressants are those from the group of selective serotonin reuptake inhibitors (SSRI). The most investigated genetic variations in the prediction and individualization of antidepressant therapy is the serotonin transporter gene (5-HTTLPR). The objective of this paper is to provide an overview of the research to date on 5-HTTLPR polymorphism in response to SSRI. This paper gives an overview of 35 studies investigating the efficacy of SSRI antidepressants in dependence of 5-HTTLPR polymorphism. The results of three meta-analyses examining this issue are discussed. Briefly, the great majority of studies conducted have shown that L-allele carriers have a faster and better response to SSRI antidepressants, if they are Caucasians. Studies with negative results included ethnically mixed populations, and it is known that there are different allele frequencies among ethnic groups and the consequence of this are the varying results of pharmacogenetic studies. Pharmacogenetic analysis of 5-HTTLPR polymorphism has proven to be economically cost-effective considering the recurrent course of the disease. It would appear that the response to SSRI antidepressants and the development of adverse reactions are associated with 5-HTTLPR polymorphism in Caucasians and this pharmacogenetic analysis could be one of the first in future clinical practice.

Diagnostic accuracy of serum brain derived neurotrophic factor concentration in antidepressant naïve patients with first major depression episode

Diagnosing major depressive disorder (MDD) continues to be based on meeting phenomenological and descriptive criteria. As of yet, there is still no non-invasive, peripheral biomarker that would allow for a certain diagnosis of MDD. The objective of this paper is to use the receiver operating characteristic (ROC) analysis to test the diagnostic value of serum concentrations of brain derived neurotrophic factor (BDNF) in diagnosing the first episode of MDD. Among 1014 patients admitted for an initial psychiatric evaluation, antidepressant naïve patients diagnosed with first episode MDD were separated into the test group. Only patients signing an informed consent form were included in the study. Using DSM-IV-TR diagnostic criteria, those patients meeting the MDD criteria (N = 122) and patients not meeting MDD or other psychiatric disorder criteria (N = 142) were differentiated. Subjects with repeated episode MDD (N = 121) and other psychiatric comorbid illnesses (N = 138) in the MDD group were excluded from the study. In the group without MDD or other psychiatric illnesses, patients with physical comorbidities (N = 59) were excluded. The serum concentration of BDNF was determined in all patients using the ELISA assay. Subjects with first episode MDD showed differences in serum BDNF concentrations (ng/mL) in comparison to the control group of patients not meeting the criteria for first episode MDD (mean ± SD; 37.5 ± 13.3 vs. 56.8 ± 6.3; t = 1.372; df = 262; p < 0.01). The ROC analysis established a discriminant diagnostic value of serum BDNF in diagnosing MDD. The area under the curve (AUC) was 0.892 with a 95% confidence level (0.826-0.939), which was statistically significant at p < 0.01. The serum BDNF had a high diagnostic sensitivity of 83.9% and a specificity of 93%. Serum BDNF concentrations appear to be a promising tool in discriminating subjects with MDD from those without MDD.