Genetic risk scores associated with temperament clusters in Finnish depression patients

OBJECTIVE

Cloninger's temperament dimensions have been studied widely in relation to genetics. In this study, we examined Cloninger's temperament dimensions grouped with cluster analyses and their association with single nucleotide polymorphisms (SNPs). This study included 212 genotyped Finnish patients from the Ostrobothnia Depression Study.

METHODS

The temperament clusters were analysed at baseline and at six weeks from the beginning of the depression intervention study. We selected depression-related catecholamine and serotonin genes based on a literature search, and 59 SNPs from ten different genes were analysed. The associations of single SNPs with temperament clusters were studied. Using the selected genes, genetic risk score (GRS) analyses were conducted considering appropriate confounding factors.

RESULTS

No single SNP had a significant association with the temperament clusters. Associations between GRSs and temperament clusters were observed in multivariate models that were significant after permutation analyses. Two SNPs from the DRD3 gene, two SNPs from the SLC6A2 gene, one SNP from the SLC6A4 gene, and one SNP from the HTR2A gene associated with the HHA/LRD/LP (high harm avoidance, low reward dependence, low persistence) cluster at baseline. Two SNPs from the HTR2A gene were associated with the HHA/LRD/LP cluster at six weeks. Two SNPs from the HTR2A gene and two SNPs from the COMT gene were associated with the HP (high persistence) cluster at six weeks.

CONCLUSION

GRSs seem to associate with an individual's temperament profile, which can be observed in the clusters used. Further research needs to be conducted on these types of clusters and their clinical applicability.

Predictors of short-term response and the role of heavy alcohol use in treatment of depression

BACKGROUND

Depression and alcohol use disorders frequently co-occur. However, research on psychosocial interventions for treating this dual pathology is limited. The Ostrobothnian Depression Study (ODS) aimed to increase the systematic use of evidence-based methods, particularly among patients with comorbid depression and substance use in a naturalistic setting. This is a secondary analysis of the ODS study. The aim of the present study was to explore the predictors of a response to treatment during the first six months of the ODS intervention with a specific focus on the role of comorbid heavy alcohol use.

METHODS

The study sample (n = 242) comprised psychiatric specialist care patients with depression (Beck Depression Inventory score ≥ 17) at baseline. Patients with a baseline Alcohol Use Disorders Identification Test (AUDIT) score > 10 (n = 99) were assigned to the AUD (Alcohol Use Disorder) group in this study. The ODS intervention comprised behavioral activation (BA) for all and additional motivational interviewing (MI) for those in AUD group. The predictors of response to treatment (minimum of 50% reduction in depressive symptoms) during the first six months were analyzed with logistic regression models.

RESULTS

In the total sample at six months (n = 150), predictors of response to treatment were more severe depression (OR 1.10, CI 1.02-1.18), larger amounts of alcohol consumed (OR = 1.16, CI 1.03-1.31) and antipsychotic medication "not in use" (OR = 0.17, CI 0.07-0.44). In the non-AUD group (n = 100), more severe depression (OR 1.12, CI 1.01-1.25) and antipsychotics "not in use" (OR 0.20, CI 0.06-0.67) also predicted a positive response. Among AUD group patients (n = 50), larger amounts of alcohol consumed (OR 1.54, CI 1.04-2.27) and antipsychotic medication "not in use" (OR 0.12, CI 0.02-0.60) predicted a response to the treatment intervention.

CONCLUSIONS

The severity of symptoms and comorbid disorders were found to predict better treatment response, suggesting that the intervention was more effective in patients with severe symptoms. Patients with depression should be treated effectively regardless of having concomitant AUD. The results of this study suggest that BA combined with MI should be one of the treatment options for this dual pathology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02520271 (11/08/2015).

Co-medication with disulfiram markedly increased serum clozapine levels: Two case reports

BACKGROUND

Alcohol use disorder (AUD) is a significant co-morbidity in patients with schizophrenia. Clozapine offers some benefits in treating patients with refractory schizophrenia and AUD, but co-medicating with disulfiram is also common.

PROCEDURES

We report two cases where co-medicating with disulfiram led to a significant increase in clozapine serum levels.

FINDINGS

Clozapine serum levels decreased to one-third in Patient 1 when disulfiram was discontinued and started to increase again when disulfiram was reintroduced. Patient 2 developed toxic serum levels of clozapine during disulfiram treatment combined with heavy coffee drinking and symptoms reminiscent of neuroleptic malignant syndrome.

CONCLUSIONS

Clozapine and disulfiram are both metabolized by cytochrome P450 CYP1A2 and clinically relevant interaction through this shared pathway is possible.

The role of alcohol use and adiposity in serum levels of IL-1RA in depressed patients

BACKGROUND

The role of Interleukin-1 Receptor antagonist (IL-1Ra), an innate antagonist to pro-inflammatory cytokine IL-1, has attracted increasing attention due to its potential pathogenic and therapeutic implications in depression. However, the role of alcohol and adiposity in modulating IL-1Ra cytokine pathway in depressed patients has remainned unknown. The aim of this study was to follow the changes in IL-1Ra serum levels in depressed patients with or without simultaneous alcohol use disorder (AUD) and different degrees of adiposity during 6 months of follow-up.

MATERIALS AND METHODS

A total of 242 patients with depression were followed for 6 months. At baseline 99 patients had simultaneous AUD. Levels of serum IL-1Ra and common mediators of inflammation (IL-6, hs-CRP) were measured. Clinical assessments included Body Mass Index (BMI), Montgomery-Asberg Depression Rating Scale (MADRS) and Alcohol Use Disorders Identification Test (AUDIT) scores.

RESULTS

Significant reductions in clinical symptoms and IL-1Ra were observed during 6-month follow-up. In hierarchical linear regression analysis, the effect of MADRS score, age, gender, and smoking had a combined effect of 2.4% in the model. The effect of AUDIT score increased the effect to 4.2% of variance (p = 0.08), whereas adding BMI increased the effect to 18.5% (p <  0.001).

CONCLUSION

Adiposity may influence the IL-1Ra anti-inflammatory response in depressed patients, whereas the effect of alcohol consumption in these patients seems insignificant. These findings should be considered in studies on the role of IL-1Ra in depression.

TRIAL REGISTRATION

Ostrobothnia Depression Study in ClinicalTrials.gov , Identifier NCT02520271 .

Electroconvulsive therapy increases temporarily plasma vascular endothelial growth factor in patients with major depressive disorder

OBJECTIVES

Vascular endothelial growth factor (VEGF) has been related to the etiology of major depressive disorder (MDD). The findings involving the effects of electroconvulsive therapy (ECT) on the VEGF levels have been conflicting. The aim was to examine the possible changes in the VEGF levels and their associations with clinical outcome in patients with MDD during ECT.

METHODS

The study comprised 30 patients suffering from MDD. Their plasma VEGF levels were measured at baseline and 2 and 4 hr after the first, fifth, and last ECT session. The severity of depression was quantified by the Montgomery-Asberg Depression Rating Scale (MADRS).

RESULTS

The VEGF levels increased between the 2-hr and 4-hr measurements during the first (p = .003) and the fifth (p = .017) sessions. The baseline VEGF levels between individual ECT sessions remained unchanged during the ECT series. No correlations were found between the increased VEGF levels and the clinical outcome.

CONCLUSIONS

Electroconvulsive therapy increased the VEGF levels repeatedly at the same time point in two different ECT sessions. These increases had no association with the response to ECT. Consequently, VEGF may act as a mediator in the mechanism of action of ECT.

A Survey of Electroconvulsive Therapy in Finland

OBJECTIVES

The purpose of this study was to explore the use of electroconvulsive therapy (ECT) in Finland in 2013. This included the rate of use, patient ages, sex, number of treatments, patient diagnoses, regional distribution, and availability of ECT.

METHODS

A structured electronic questionnaire was used to collect data regarding the use of ECT from 21 Finnish hospital districts' 29 psychiatric ECT units. Data for comparison were collected from scientific publications concerning the use of ECT in Sweden, Norway, Denmark, and Estonia.

RESULTS

Of 29 psychiatric ECT units, 25 (86%) responded. Electroconvulsive therapy was available in all except 1 hospital district, which used the services of another hospital district. Electroconvulsive therapy was administered to 1023 patients in total. The mean number of treatments per patient was 9.7. Twenty-three persons per 100,000 inhabitants received ECT. The ECT rate between hospital districts varied from 7.5 to 53.0 per 100,000 inhabitants. The mean number and median were 24.9 and 21.7 per 100,000 inhabitants, respectively. Maintenance therapy was administered to 27.1% of patients. Most (75%) of the ECT units indicated the capability to administer ECT to all patients who required it. The most common indications for ECT were major depression (38.4%), psychotic depression (30.9%), and bipolar disorder with depressive episodes (14.2%).

CONCLUSIONS

Electroconvulsive therapy was available in every hospital district in Finland. In Finland, ECT was administered at approximately the same level as in Norway, Denmark, and Estonia (24, 32, and 28 per 100,000 inhabitants, respectively), but less than in Sweden (41 per 100,000 inhabitants).

Impact of Comorbid Alcohol Use Disorder on Health-Related Quality of Life Among Patients With Depressive Symptoms

Background and Aim: In psychiatric clinical practice, comorbidity of depression and alcohol use disorder (AUD) is common. Both disorders have a negative impact on health-related quality of life (HRQoL) in general population. However, research on the impact of comorbid AUD on HRQoL among clinically depressed patients is limited. The purpose of this study was to explore the impact of a psychosocial treatment intervention on HRQoL for depressive patients in specialized psychiatric care with a special focus on the impact of AUD on HRQoL. Material and Methods: Subjects were 242 patients of the Ostrobothnia Depression Study (ClinicalTrials.gov Identifier NCT02520271). Patients referred to specialized psychiatric care who scored at least 17 points on the Beck Depression Inventory at baseline and who had no psychotic disorders were included in the ODS. The treatment intervention in ODS comprised behavioral activation for all but began with motivational interviewing for those with AUD. HRQoL was assessed regularly during 24-month follow-up by the 15D instrument. In the present study, HRQoL of ODS patients with or without AUD was compared and the factors explaining 15D score analyzed with a linear mixed model. In order to specify the impact of clinical depression on HRQoL during the early phase of treatment intervention, a general population sample of the Finnish Health 2011 Survey was used as an additional reference group. Results: HRQoL improved among all ODS study sample patients regardless of comorbid AUD during the first year of follow-up. During 12-24 months of follow-up the difference between groups was seen as HRQoL continued to improve only among the non-AUD patients. A combination of male gender, anxiety disorder, and AUD was associated with the poorest HRQoL in this sample. In combined sample analyses with the reference group, clinical depression had an impact on HRQoL in short-term follow-up regardless of the treatment intervention. Conclusions: This study suggests that, in terms of improvement in HRQoL, the heterogenous group of depressive patients in specialized psychiatric care can be successfully treated with behavioral activation in combination with motivational interviewing for those with AUD. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02520271. Ostrobothnia Depression Study (ODS). A Naturalistic Follow-up Study on Depression and Related Substance Use Disorders. (2015). Available online at: https://clinicaltrials.gov/ct2/show/NCT02520271.

Status of inflammation and alcohol use in a 6-month follow-up study of patients with major depressive disorder

INTRODUCTION

The studies on the relationship between alcohol consumption, the status of inflammation, and depression have produced conflicting results. In this study, we followed patients with major depressive disorders by monitoring biomarkers of inflammation together with biomarkers of heavy alcohol use.

METHOD

The levels of IL-6 (interleukin-6), IL-8 (interleukin-8), hs-CRP (high sensitivity C-reactive protein), YKL-40 (also known as Chitinase-3-like protein 1 or CHI3L1), and biomarkers of alcohol consumption and liver status (GT, CDT, ALT, alkaline phosphatase) were measured at baseline and after 6 months of psychiatric treatment from 242 patients suffering from current major depressive disorder (MDD) with (n = 99) or without (n = 143) alcohol use disorder (AUD).

RESULTS

At baseline, the patients with MDD + AUD showed higher levels of inflammatory biomarkers IL-6 (p < 0.001), hs-CRP (p < 0.01), YKL-40 (p < 0.05), and biomarkers of alcohol consumption, than the corresponding group of non-AUD patients. These differences disappeared during follow-up and recovery from depression. The level of IL-8 decreased significantly in both AUD (p < 0.05) and non-AUD (p < 0.05) patients. During follow-up, the biomarkers of alcohol consumption, GT and CDT, in AUD patients were found to decrease in parallel with serum YKL-40 levels.

CONCLUSIONS

Alcohol consumption appears to modulate the status of inflammation in depressive patients. A more systematic use of biomarkers of inflammation together with biomarkers of alcohol consumption and liver status may prove to be of value in a more comprehensive assessment and treatment of patients with depression.

Implementing physical exercise and music interventions for patients suffering from dementia on an acute psychogeriatric inpatient ward

Background: Increasing attention is focusing on psychosocial interventions for treating patients with dementia. Aims: This observational intervention study investigated the impact of physical exercise and music interventions among patients with dementia on an acute psychogeriatric ward. Materials and methods: The data were collected during February 2009-December 2010 (n = 89; treatment as usual) and during April 2011-March 2013 (n = 86; treatment as usual with physical exercise, e.g. balance, flexibility, strength training, and music interventions, e.g. singing, listening to music and playing instruments). The primary outcome measure was the Neuropsychiatric Inventory and the secondary outcome measures were the Alzheimer's Disease Cooperative Study-Activities of Daily Living, the Barthel Index, and the Mini-Mental State Examination. Results: In both groups, neuropsychiatric symptoms (NPS) decreased (p < .001) but daily functioning deteriorated (p < .001). No significant between-group differences for either outcome variable were found. Based on linear mixed models, fewer exercise sessions associated with more severe symptoms (p = .030), and the time variable (admission/discharge) with a decline in the level of NPS (p < .001). Moreover, female gender (p = .026) and more exercise sessions (p = .039) associated with an increased level of functioning (p = .031) and the time variable (admission/discharge) with a drop in the level of functioning during hospitalization (p < .001). Conclusion: Although no differences were found between the study groups, analysis within the intervention group suggest that physical exercise may have some positive effects for both NPS and the level of functioning in some patients with dementia while no positive effects regarding music interventions were found.

Assessment of alcohol consumption in depression follow-up using self-reports and blood measures including inflammatory biomarkers

AIMS

Alcohol consumption has been suggested a major role in the pathogenesis and prognosis of depression. However, reliable identification of hazardous drinking continues to be problematic. We compared the accuracy of different biomarkers and self-reports of alcohol consumption in the follow-up study of depression.

METHODS

Data from 202 patients with major depressive disorder were obtained through self-reports, AUDIT and AUDIT-C questionnaires and biomarker analyses. The clinical assessments and measurements of biomarkers (GT, CDT, GT-CDT-combination, MCV, ALT, AST, hs-CRP, IL-6) were performed at baseline and after six months of treatment. Based on self-reported alcohol intake at baseline the patients were classified to three subgroups.

RESULTS

About 27.2% of patients were categorized to high-risk drinkers, 26.3% low-risk drinkers and 46.5% abstainers. High-risk drinkers showed significantly higher mean values of GT, CDT, GT-CDT-combination and IL-6 than abstainers, diagnostic accuracy being highest with the combined marker of GT-CDT. The accuracy of AUDIT and AUDIT-C to detect high-risk drinking was also significant. During follow-up, the differences observed in the biomarkers at baseline disappeared together with recovery from depression.

CONCLUSIONS

Our data suggest the combined use of GT-CDT and AUDIT questionnaires to improve the identification of drinking of patients with depression. This approach could be useful for improving treatment adherence and outcome in depressed patients.

The association of obesity and coronary artery disease genes with response to SSRIs treatment in major depression

Selective serotonin reuptake inhibitors (SSRIs) are first-line antidepressants for the treatment of major depressive disorder (MDD). However, treatment response during an initial therapeutic trial is often poor and is difficult to predict. Heterogeneity of response to SSRIs in depressed patients is partly driven by co-occurring somatic disorders such as coronary artery disease (CAD) and obesity. CAD and obesity may also be associated with metabolic side effects of SSRIs. In this study, we assessed the association of CAD and obesity with treatment response to SSRIs in patients with MDD using a polygenic score (PGS) approach. Additionally, we performed cross-trait meta-analyses to pinpoint genetic variants underpinnings the relationship of CAD and obesity with SSRIs treatment response. First, PGSs were calculated at different p value thresholds (P_T) for obesity and CAD. Next, binary logistic regression was applied to evaluate the association of the PGSs to SSRIs treatment response in a discovery sample (ISPC, N = 865), and in a replication cohort (STAR*D, N = 1,878). Finally, a cross-trait GWAS meta-analysis was performed by combining summary statistics. We show that the PGSs for CAD and obesity were inversely associated with SSRIs treatment response. At the most significant thresholds, the PGS for CAD and body mass index accounted 1.3%, and 0.8% of the observed variability in treatment response to SSRIs, respectively. In the cross-trait meta-analyses, we identified (1) 14 genetic loci (including NEGR1, CADM2, PMAIP1, PARK2) that are associated with both obesity and SSRIs treatment response; (2) five genetic loci (LINC01412, PHACTR1, CDKN2B, ATXN2, KCNE2) with effects on CAD and SSRIs treatment response. Our findings implicate that the genetic variants of CAD and obesity are linked to SSRIs treatment response in MDD. A better SSRIs treatment response might be achieved through a stratified allocation of treatment for MDD patients with a genetic risk for obesity or CAD.

Reversible psychiatric adverse effects related to deep brain stimulation of the anterior thalamus in patients with refractory epilepsy

OBJECTIVE

Anterior nucleus of thalamus (ANT) deep brain stimulation (DBS) is becoming a more common treatment for drug-resistant epilepsy. Epilepsy and depression display a bidirectional association. Anterior nucleus of thalamus has connections to anterior cingulate cortex and orbitomedial prefrontal cortex, hence, a possible role in emotional and executive functions, and thus, ANT DBS might exert psychiatric adverse effects. Our aim was to evaluate previous and current psychiatric symptoms in patients with epilepsy undergoing ANT DBS surgery and assess the predictability of psychiatric adverse effects. Programming-related psychiatric adverse effects are also reported.

METHOD

Twenty-two patients with ANT DBS for retractable epilepsy were examined, and a psychiatric evaluation of depressive and other psychiatric symptoms was performed with Montgomery and Åsberg Depression Rating Scale (MADRS), Beck Depression Inventory (BDI), and Symptom Checklist prior to surgery, concentrating on former and current psychiatric symptoms and medications. The follow-up visit was one year after surgery.

RESULTS

At the group level, no changes on mood were observed during ANT DBS treatment. Two patients with former histories of depression experienced sudden depressive symptoms related to DBS programming settings; these were quickly alleviated after changing the stimulation parameters. In addition, two patients with no previous histories of psychosis gradually developed clear paranoid and anxiety symptoms that also relieved slowly after changing the programming settings.

CONCLUSION

The majority of our ANT DBS patients did not experience psychiatric adverse effects. Certain DBS parameters might predispose to sudden depressive or slowly manifesting paranoid symptoms that are reversible via programming changes.

Effect of electroconvulsive therapy on brain-derived neurotrophic factor levels in patients with major depressive disorder

OBJECTIVES

Brain-derived neurotrophic factor (BDNF) has been associated with depression and its treatment response. The aim of the present study was to explore the effect of electroconvulsive therapy (ECT) on serum and plasma BDNF levels and change of Montgomery-Asberg Depression Rating Scale (MADRS) and their associations in patients with major depressive disorder (MDD).

METHODS

The study included thirty patients suffering from MDD. Their serum and plasma BDNF levels were examined before ECT (baseline) and after the first, fifth, and last ECT session. The severity of the depression and the response to ECT were measured with MADRS.

RESULTS

Electroconvulsive therapy caused no significant changes in serum BDNF levels. Plasma BDNF levels decreased during the fifth ECT session between the baseline and the 2-hr samples (p = 0.019). No associations were found between serum or plasma BDNF levels and remission. The correlations between plasma and serum BDNF levels in each measurement varied between 0.187 and 0.636.

CONCLUSIONS

Neither serum nor plasma BDNF levels were systematically associated with the clinical remission. However, the plasma BDNF levels somewhat varied during the ECT series. Therefore, the predictive value of BDNF for effects of ECT appears to be at least modest.

Outcome of neuropsychiatric symptoms and daily functioning of patients with dementia treated on an acute psychogeriatric ward

BACKGROUND

Dementia is associated with progressive deterioration in multiple cognitive domains, functional impairment and neuropsychiatric symptoms (NPS).

AIMS

The aim of this study was to explore the factors associated with the outcome of NPS and daily functioning in patients with dementia during acute psychogeriatric hospitalization.

MATERIALS AND METHOD

The data (n = 175) were collected between 2009 and 2013 in naturalistic settings on one acute psychogeriatric ward at one university hospital in Finland. Behavioural symptoms were assessed using the Neuropsychiatric Inventory (NPI) and activities of daily living using the Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL).

RESULTS

During the hospital stay (45 days ±30.4) NPI total score decreased from 33.9 to 18.2 (p < .001). Daily functioning score decreased from 31.7 to 20.9 (p < .001). The number of patients taking antipsychotics (96-130, p = .004) and anxiolytics (54-102, p < .001) increased from admission to discharge. Overall mean dosage (mg/day) of antipsychotics (from 40.2 to 72.0 in chlorpromazine equivalents, p < .00) and anxiolytics (from 3.43 to 7.47 in diazepam equivalents, p < .001) also increased. Higher antipsychotic dosage at discharge was a significant predictor for large NPI score change (p = .002) indicating better symptom reduction. Neither higher antipsychotic dosage or anxiolytic dosage at discharge were significant predictors for ADL score change.

CONCLUSIONS

Neuropsychiatric symptoms improved while deterioration was found in daily functioning from admission to discharge. Higher antipsychotic dosage at discharge was a predictor for larger NPI score change indicating better symptom reduction. Preventing threatening ADL decline during hospital stay is especially important.

Behavioral activation versus treatment as usual in naturalistic sample of psychiatric patients with depressive symptoms: a benchmark controlled trial

BACKGROUND

More systematic use of evidence-based brief therapies is needed in the treatment of depression within psychiatric care. The aim of this study was to explore the impact of behavioral activation therapy (BA) for patients with depressive symptoms in a routine clinical setting of secondary psychiatric care.

METHODS

The BA-treated intervention group (n = 242) comprised patients with depressive symptoms (Beck Depression Inventory (BDI) score ≥ 17 at baseline). The control group (n = 205) patients received treatment as usual in the same catchment area. The groups were matched at baseline using BDI and Alcohol Use Disorders Identification Test scores and inpatient/outpatient status. The groups were compared at 6-, 12- and 24-month follow-up points on functional outcome (Global Assessment of Functioning scale), service use, dropout and deaths. The Montgomery-Åsberg Depression Rating Scale was used to assess depressive symptoms in the intervention group.

RESULTS

The estimated difference in GAF score between intervention and control group patients was significant at 12- and 24-months follow-up points in favor of intervention group (GAF score difference 4.85 points, p = 0.006 and 5.71 points, p = 0.005, respectively; estimate for patient group 2.26, p = 0.036). The rates of dropout, mortality and service use were similar between the groups. Among the intervention group patients, the estimated improvement in MADRS score compared to baseline was statistically significant throughout the follow-up (p < 0.001 at all follow-up points).

CONCLUSIONS

The systematic use of BA among secondary psychiatric care depressive patients provides encouraging results despite the patients had various comorbid non-psychotic disorders.

TRIAL REGISTRATION

ClinicalTrials.gov , Identifier NCT02520271, Release Date: 06/27/2015, retrospectively registered.

The effects of adiposity and alcohol use disorder on adipokines and biomarkers of inflammation in depressed patients

Patients with depression and alcohol use disorder frequently present with elevated markers of inflammation. Adipose tissue may function as a source for inflammation, yet the interplay between adiposity, alcohol use and depression has remained unknown. We examined 242 patients, referred to treatment for depressive symptoms, and followed for a period of 6 months. The assessments included screening for alcohol use and measurements of body mass index, serum adiponectin, leptin, resistin, progranulin, hs-CRP, IL-6 and MCP-1 at baseline and after 6 months of treatment. During follow-up, mean MADRS and AUDIT scores decreased significantly, whereas BMI increased. The changes in the levels of cytokines and adipokines were influenced by alcohol consumption and adiposity in a gender-dependent manner. The presence of AUD seemed to particularly influence the levels of cytokines. The levels of IL-6, hs-CRP, progranulin, and leptin differed between AUD and non-AUD groups at baseline, but no longer at 6 months. Baseline levels of leptin and resistin were higher in women and changes occurring in leptin, progranulin, and adiponectin were more notable in women. The data indicates significant gender-dependent interactions between depression, alcohol and mediators of inflammation, which should be considered in studies on the pathogenesis of depression and its comorbidities.

Low tumor necrosis factor-α levels predict symptom reduction during electroconvulsive therapy in major depressive disorder

OBJECTIVE

Changes in the tumor necrosis factor-α (TNFα) have been associated with major depressive disorder (MDD). Findings concerning the effects of electroconvulsive therapy (ECT) on the TNFα level have been contradictory. The aim was to examine the immediate and long-term changes in the TNFα level and their associations with symptom reduction in patients with MDD during ECT.

METHOD

The study included 30 patients with MDD. Their TNFα levels were measured at baseline and 2 and 4 hr after the first, fifth and last ECT session. Depressive symptoms were assessed with the Montgomery-Asberg Depression Rating Scale (MADRS).

RESULTS

The TNFα level decreased from baseline to the 2- and 4-hr measurements. There was a correlation between the first ECT session TNFα levels and the relative symptom reduction according to the MADRS score after the ECT series. Both the first (baseline) ECT and 4-hr TNFα levels were lower in responders than in nonresponders.

CONCLUSION

ECT consistently induced a decrease in the TNFα level after each studied session. A low TNFα level at the first ECT appeared to predict a symptom reduction. These findings suggest that TNFα might have a role in the pathogenesis in MDD and in the mechanism of action of ECT.

Association of the Polygenic Scores for Personality Traits and Response to Selective Serotonin Reuptake Inhibitors in Patients with Major Depressive Disorder

Studies reported a strong genetic correlation between the Big Five personality traits and major depressive disorder (MDD). Moreover, personality traits are thought to be associated with response to antidepressants treatment that might partly be mediated by genetic factors. In this study, we examined whether polygenic scores (PGSs) derived from the Big Five personality traits predict treatment response and remission in patients with MDD who were prescribed selective serotonin reuptake inhibitors (SSRIs). In addition, we performed meta-analyses of genome-wide association studies (GWASs) on these traits to identify genetic variants underpinning the cross-trait polygenic association. The PGS analysis was performed using data from two cohorts: the Pharmacogenomics Research Network Antidepressant Medication Pharmacogenomic Study (PGRN-AMPS, n = 529) and the International SSRI Pharmacogenomics Consortium (ISPC, n = 865). The cross-trait GWAS meta-analyses were conducted by combining GWAS summary statistics on SSRIs treatment outcome and on the personality traits. The results showed that the PGS for openness and neuroticism were associated with SSRIs treatment outcomes at p < 0.05 across P_T thresholds in both cohorts. A significant association was also found between the PGS for conscientiousness and SSRIs treatment response in the PGRN-AMPS sample. In the cross-trait GWAS meta-analyses, we identified eight loci associated with (a) SSRIs response and conscientiousness near YEATS4 gene and (b) SSRI remission and neuroticism eight loci near PRAG1, MSRA, XKR6, ELAVL2, PLXNC1, PLEKHM1, and BRUNOL4 genes. An assessment of a polygenic load for personality traits may assist in conjunction with clinical data to predict whether MDD patients might respond favorably to SSRIs.

The State of Opioid Agonist Therapy in Canada 20 Years after Federal Oversight

Opioid agonist therapy was introduced in Canada in 1959 with the use of methadone for the treatment of opioid dependence. The regulation of methadone was the responsibility of Health Canada until 1995, when oversight was transferred to the provincial health systems. During the more than 20 years since the federal health authority transferred oversight of methadone to the provincial level, methadone programming has evolved differently in every province. The landscape of opioid dependence treatment is varied across the country, with generally increasing treatment capacity in all provinces and dramatic increases in some. Each province has an independent methadone program with differing policies, contingency management strategies, laboratory monitoring policies, and delivery methods. Treatment options have increased, with buprenorphine- and heroin-assisted treatment becoming available to limited degrees. Despite this, access remains a challenge in many parts of the country (particularly rural and remote areas) because the demand for treatment has increased even more rapidly than the capacity. Although treatment access remains a priority in many jurisdictions, there is also a need to attend to treatment quality as treatment access expands, including integration with addiction counselling, primary care, and mental health care. As well, coordinated monitoring and reporting of treatment need, quality, and delivery are required; implementing a national policy to promote planning would have tremendous value.

Histaminergic gene polymorphisms associated with sedation in clozapine-treated patients

Sedation is a common adverse effect of clozapine treatment, which may be partly related to clozapine binding to histamine receptors in the central nervous system. The objective of this study was to investigate whether single nucleotide polymorphisms (SNPs) in the histaminergic system are associated with sedation in clozapine-treated patients. The study population comprised 237 clozapine-treated, Finnish, Caucasian patients that were diagnosed with schizophrenia and 176 were genotyped using Illumina HumanCoreExome-12 BeadChip. Sedation levels were assessed using self-rating questions from the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS). The relationships between 55 different SNPs in the histaminergic system and adverse sedation effects were examined. SNPs were analyzed separately, and in groups, to formulate a genetic risk score (GRS). A permutation test was performed to avoid type I errors. Eight linked SNPs (r² = 1) in the HNMT gene were also associated with sedation according to the GLM, adjusted for age, gender and BMI (false-discovery-rate-adjusted p = 0.013). An association on a trend level between a GRS of four different SNPs (recessive histamine N-methyltransferase HNMT rs2737385, additive histamine receptor H₁ rs1552498, dominant HRH1 rs17034063 and recessive amine oxidase, copper containing 1 AOC1 rs6977381) and sedation was found (permuted p-value = 0.066) in a generalized linear model (GLM) incorporating age, gender and body mass index (BMI; adjusted R² = 0.22). Polymorphisms in genes encoding histamine receptors or enzymes related to histamine metabolism may explain individual variation in sedative effects experienced during clozapine treatment.

Anxiety Disorders and Temperament-an Update Review

PURPOSE OF REVIEW

The review focused on associations between temperament dimensions and clinical features in different anxiety disorders, likewise in obsessive-compulsive disorder in clinical samples of adults. A literature search was conducted in the Medline and PsycINFO databases covering the years 2010-2016. A systematic review and grading of the level of evidence for an association between temperament dimension scores and clinical features in each disorder were performed.

RECENT FINDINGS

Twenty papers reporting 18 different studies were included. Five of the papers focused on panic disorder (PD), five on social anxiety disorder (SAD), three on post-traumatic stress disorder (PTSD), one on generalized anxiety disorder (GAD), three on obsessive-compulsive disorder (OCD), and an additional three papers on several anxiety disorders. The review consolidates the finding that trait anxiety, especially as assessed by Cloninger's model or the five-factor model, is a phenomenon common to all anxiety disorders and OCD. More follow-up studies including large samples are needed to differentiate the dimensional profiles of trait anxiety in specific disorders.

Resistin as an inflammatory marker in patients with schizophrenia treated with clozapine

BACKGROUND

Schizophrenia is associated with excess cardiovascular comorbidity and mortality related to lifestyle factors, such as lack of physical activity, poor diet, and smoking. The prevalence of metabolic syndrome is increased among patients with schizophrenia, with the highest rates among patients on clozapine treatment. Smoking, obesity, physical inactivity, airway inflammation and obstruction, and adipose tissue and inflammatory marker activation are related in systemic inflammation. Low-grade inflammation is also associated with schizophrenia. Adipokine resistin is a biomarker involving several acute and chronic inflammatory states. However, the inflammatory role of resistin is so far inconclusive and studies in schizophrenia are scanty.

AIMS

The aim of the present study was to explore the role of serum resistin as an inflammatory marker in patients with schizophrenia on clozapine treatment.

METHODS

Associations between serum levels of resistin and some other selected cytokines/adipokines (adiponectin, leptin, adipsin, IL-6, IL-1Ra, TNF-α, hs-CRP) and metabolic markers in 190 patients with schizophrenia on clozapine treatment were studied using a cross-sectional study design.

RESULTS

Among male patients especially, smokers had higher levels of resistin than non-smokers, and among smokers resistin levels were associated with IL-1Ra and hs-CRP levels. In the whole patient group levels of resistin associated with levels of IL-1Ra, and among male patients with low HDL-cholesterol.

CONCLUSIONS

Resistin is a biomarker of systemic inflammation associated with smoking among patients with schizophrenia on clozapine treatment. Resistin might have a role as a marker of cardiovascular comorbidity.

Changes in interleukin-6 levels during electroconvulsive therapy may reflect the therapeutic response in major depression

OBJECTIVE

Interleukin-6 (IL-6) has been reported to be elevated in major depressive disorder (MDD) but decreased by antidepressive medication. IL-6 levels are markedly elevated both after epileptic seizures and single electroconvulsive therapy (ECT) session, but long-term changes in IL-6 levels after ECT have not been studied. The correlation between immediate and long-term changes in proinflammatory cytokines and outcome after ECT was investigated.

METHOD

Thirty patients suffering from MDD participated in the study. IL-6, interleukin-1β (IL-1β) and interleukin-1 receptor antagonist (IL-1RA) levels were examined at baseline and at 2 and 4 h after the first, fifth and the last ECT sessions. The response to ECT was measured with Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

ECT repeatedly caused an increase in IL-6 levels at the 4-h time point. However, the baseline IL-6 levels decreased among remitters, but not among non-remitters, towards the end of ECT. IL-1β levels were mostly below detectable level, and IL-1Ra levels did not change during and after ECT.

CONCLUSION

ECT has distinct acute and long-term effects on IL-6 levels. Interestingly, the long-term effect of ECT on IL-6 seems to correlate with outcome, providing further evidence of the mechanism of action of ECT and supporting the inflammation theory in MDD.

INSIG2 polymorphism and weight gain, dyslipidemia and serum adiponectin in Finnish patients with schizophrenia treated with clozapine

Aim: To investigate INSIG2's association with obesity, weight change and serum lipid profile during clozapine treatment. Materials & methods: Subjects with schizophrenia (n = 190) were genotyped, identifying seven SNPs. Genetic risk scores (GRSs) were calculated to adiponectin, high-density lipoprotein cholesterol, triglycerides and weight gain. Results: In the model for weight gain, SNPs rs12151787, rs17047733 and rs10490626 were selected. Explanatory variables were BMI (p = 5.05 × 10-5), age (p = 0.003) and GRS (p = 2.81 × 10-5, p = 0.0002 after permutation). No GRS resulted for adiponectin or high-density lipoprotein cholesterol. Rs2161829 and rs10490620 were selected for triglycerides; this GRS was insignificant after permutation. Conclusion: INSIG2 plays a role in weight gain and obesity during clozapine treatment.

Temperament and character profiles associated with depression and treatment response in patients with or without comorbid substance abuse

There is limited knowledge on the relationship between temperament and character profiles and substance abuse comorbidity in depressed patients. We recruited 127 depressed patients without alcohol use problems (non-AUP) and 89 depressed patients with alcohol use problems (AUP). We assessed all patients using the Temperament and Character Inventory (TCI-R) at baseline and after 6 weeks of treatment. Using univariate general linear models (GLMs), we analyzed differences in TCI-R between AUP and non-AUP. GLMs were also used in analyzing the associations between TCI-R changes and antidepressive treatment responses measured with changes in Montgomery Åsberg Depression Rating Scale score (ΔMADRS). Alcohol use explained independently significant proportions of the variation in Novelty Seeking, Self-Directedness, and Persistence. Reward Dependence score change explained 14.1% of the ΔMADRS in AUP, but was non-significant in non-AUP. Character score changes in Self-Directedness and Self-Transcendence explained together 14.1% of ΔMADRS in non-AUP, whereas they were all non-significant in AUP. AUP compared with non-AUP patients had lower Self-Directedness and Persistence and higher Novelty Seeking scores. Detected changes in Reward Dependence and lower Self-Directedness in AUP patients could be reflective of different biological mechanisms associated with depressive symptomatology in alcohol abuse. Changes in character are associated with acute treatment response in non-AUP.

Association Study of Arcuate Nucleus Neuropeptide Y Neuron Receptor Gene Variation And Serum Npy Levels in Clozapine Treated Patients With Schizophrenia

Background

Antipsychotic-induced weight gain (AIWG) leads to metabolic consequences and comorbidity, social stigmatization and nonadherence in patients with schizophrenia. Neuropeptide Y (NPY) has an important role in appetite and body weight regulation. Associations between AIWG and serum NPY levels, and genetic polymorphisms (SNPs) associated with its serum levels have been little studied in these patients.

Subjects and methods

Associations between serum NPY concentration and other metabolic and inflammatory markers, and 215 SNPs in 21 genes (NPY gene, NPY receptor genes and genes encoding arcuate nucleus NPY neuron receptors) were studied in 180 patients with schizophrenia on clozapine treatment.

Results

The serum levels of NPY correlated with levels of resistin (r = 0.31, P < 0.001) and age (r = 0.22, P = 0.003). In the general linear univariate model the best-fitting model with explanatory factors age, serum resistin level, serum insulin level, BMI and gender explained 18.0% (P < 0.001) of the variance of serum NPY. Genetic risk score (GRSNPY) analysis found twelve significant (P < 0.05) serum NPY concentration related SNPs among α7 nicotinic acetylcholine receptor gene CHRNA7, insulin receptor gene INSR, leptin receptor gene LEPR, glucocorticoid receptor (GR) gene NR3C1, and NPY gene. However, after permutation test of gene score the predictive value of GRSNPY remained non-significant (P = 0.078).

Conclusions

Serum NPY level does not seem to be a feasible biomarker of AIWG. Serum NPY level alterations are not significantly associated with the candidate gene polymorphisms studied.

Acute Psychogeriatric Inpatient Treatment Improves Neuropsychiatric Symptoms but Impairs the Level of Functioning in Patients with Dementia

AIMS

To explore the impact of hospitalization on neuropsychiatric symptoms (NPS) and the level of functioning in patients with dementia. Our aim was also to study the influence of psychotropic medications.

METHODS

Behavioral disturbances, cognition and functional status of 89 patients were assessed using the Neuropsychiatric Inventory (NPI), Mini-Mental State Examination, Barthel Index, and Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCSADL).

RESULTS

The total NPI score decreased from 34.6 to 19.5 (p < 0.001), and ADL decreased from 32.2 to 21.7 (p < 0.001) during the hospital stay (mean of 44 days). For a change in ADL, only the effect of anxiolytics was significant (p = 0.045). For a change in NPI with antipsychotic and anxiolytic doses and Mini-Mental State Examination as covariates, no significant relationship was found.

CONCLUSION

NPS improved significantly during hospitalization, but neither antipsychotic nor anxiolytic medication use explained this improvement. In patients using anxiolytics, the functional decline was substantial. These results do not support anxiolytic use in demented patients with NPS.

Psychiatric hospital admission and long-term care in patients with very-late-onset schizophrenia-like psychosis

OBJECTIVE

In this register-based study the rates and durations of psychiatric hospitalizations were compared between patients with very-late-onset schizophrenia-like psychosis (VLOSLP, n = 918) and elderly patients with illness onset before 60 years (n = 6142). The proportion of patients ending up in long-term care (LTC) or long-lasting psychiatric hospital care (LLP) was also studied.

METHODS

A sample of patients with schizophrenia aged 65 or over was collected from the Finnish Hospital Discharge Register. Psychiatric hospitalizations were calculated per year, and logistic regression was used to compare onset groups and factors associated with ending up in LTC/LLP.

RESULTS

Between 1999 and 2003, 27% of patients with VLOSLP and 23% of patients with earlier onset had at least one psychiatric hospitalization (p = 0.020). When the rates of patients' stays in psychiatric hospital per year were compared, the only difference was that in the first year 14% (141/918) and 11% (679/6142) had at least one day in psychiatric hospital (p < 0.001) respectively. In logistic regression onset group of schizophrenia was not associated with LTC/LLP, except weakly the VLOSLP group in women (p = 0.042, OR 1.23). Patients having any cardiovascular disease (p < 0.001, OR 0.63) or a respiratory disease (p = 0.008, OR 0.73) were less likely to end up in LTC/LLP.

CONCLUSION

The patients with VLOSLP needed more psychiatric hospital care than those with earlier illness onset. Ending up in LTC/LLP was equally common in both onset groups, but some physical diseases, such as cardiovascular and respiratory, diminished the likelihood of this.

[The latest antipsychotics--novelties or reiteration of the old?]

Both conventional and more recent antipsychotics are effective in the treatment of hallucinatory and delusional symptoms in psychotic patients. With the exception of clozapine, no major differences in the efficacy of different antipsychotics have been found in clinical drug trials. There are, however, significant differences between drugs in their adverse effects, and the new antipsychotics or dosage forms introduced over the past ten years actually provide novel alternatives for the treatment of patients having body weight issues or cardiometabolic risk factors. Long-acting injections in turn reduce the need for psychiatric hospital care.

Patients with very-late-onset schizoprhenia-like psychosis have higher mortality rates than elderly patients with earlier onset schizophrenia

OBJECTIVE

In this register-based study of schizophrenia patients aged 65 years or above, mortality and causes of death diagnosed at age of 60+ (very-late-onset schizophrenia-like psychosis, VLOSLP) were studied in comparison with sex- and age-matched general Finnish population. Standardized Mortality Ratios (SMRs) of VLOSLP patients were also compared with those of earlier onset (below 60 years) schizophrenia patients, and hazard of death was calculated between these patient groups.

METHODS

The data was obtained from Finnish nationwide registers and consisted of 918 VLOSLP patients and 6142 earlier onset patients who were at least 65 years on 1 January 1999. The register-based follow-up for mortality covered 10 years between 1999 and 2008.

RESULTS

Overall SMR was 5.02 (4.61-5.46) in the group of VLOSLP patients and 2.93 (2.83-3.03) in the group of earlier onset patients. In men, SMRs were 8.31 (7.14-9.62; n = 179) and 2.91 (2.75-3.07, n = 1316) and in women 4.21 (3.78-4.66; n = 364) and 2.94 (2.82-3.07, n = 2055). In the VLOSLP group, SMRs were higher in most causes-of-death categories such as accidents, respiratory diseases, dementias, neoplasms and circulatory diseases. However, in direct comparison adjusted for several variables, the difference between these groups was minimal (Hazard Ratio, HR, 1.16 95%CI 1.05-1.27, p = 0.003).

CONCLUSION

Patients with VLOSLP, especially men, are at even higher risk of death than schizophrenia patients with earlier onset. Physical comorbidities and accidents in the VLOSLP group mostly explained this result. Targeted clinical interventions with effective collaboration between psychiatry and primary and specialist-level somatic care are crucial to reduce their excess mortality

The International SSRI Pharmacogenomics Consortium (ISPC): a genome-wide association study of antidepressant treatment response

Response to treatment with selective serotonin reuptake inhibitors (SSRIs) varies considerably between patients. The International SSRI Pharmacogenomics Consortium (ISPC) was formed with the primary goal of identifying genetic variation that may contribute to response to SSRI treatment of major depressive disorder. A genome-wide association study of 4-week treatment outcomes, measured using the 17-item Hamilton Rating Scale for Depression (HRSD-17), was performed using data from 865 subjects from seven sites. The primary outcomes were percent change in HRSD-17 score and response, defined as at least 50% reduction in HRSD-17. Data from two prior studies, the Pharmacogenomics Research Network Antidepressant Medication Pharmacogenomics Study (PGRN-AMPS) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, were used for replication, and a meta-analysis of the three studies was performed (N=2394). Although many top association signals in the ISPC analysis map to interesting candidate genes, none were significant at the genome-wide level and the associations were not replicated using PGRN-AMPS and STAR*D data. The top association result in the meta-analysis of response represents SNPs 5′ upstream of the neuregulin-1 gene, NRG1 (P = 1.20E - 06). NRG1 is involved in many aspects of brain development, including neuronal maturation and variations in this gene have been shown to be associated with increased risk for mental disorders, particularly schizophrenia. Replication and functional studies of these findings are warranted.

Factors associated with subjective side-effects during clozapine treatment

OBJECTIVE

Clozapine is associated with subjectively unpleasant or clinically serious side-effects, which may affect treatment adherence. The aims of the study were to explore the association of clozapine+ norclozapine serum concentration and other factors with subjective side-effects in schizophrenia patients.

METHODS

In this cross-sectional study, 237 patients with a diagnosis of schizophrenia, schizo-affective or other non-organic psychoses completed the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS), a self-report scale measuring side-effects of antipsychotics and a clinical questionnaire. Clozapine+ norclozapine serum concentration of 190 patients was measured. Of the patients 80 (33.7%) were on antipsychotic combination therapy.

RESULTS

Higher clozapine+ norclozapine concentrations were associated with the depression-anxiety factor of LUNSERS and antipsychotic combination treatments were associated with sympatichotonia-tension factor. Younger patients reported sedation more often than older patients.

CONCLUSION

According to the present results, high clozapine concentrations were associated with depression-anxiety symptoms, but the causality remains unknown.

Meta-analysis of anxiety disorders and temperament

BACKGROUND

The aims of the present study were to explore whether symptoms in different anxiety disorders are associated with Cloninger's model temperament dimensions novelty seeking (NS), harm avoidance (HA), reward dependence and persistence compared with control subjects in clinical samples of adults or late adolescents.

METHOD

Literature search in the following databases: Cochrane Library, PubMed (Medline), Web of Science, Psycinfo and PsycArticles. Systematic review, grading the level of evidence and meta-analysis for each disorder by comparing the temperament dimension scores between patient and control samples in single studies.

RESULTS

A total of 40 papers fulfilled the inclusion criteria. Meta-analyses were conducted on a total of 24 studies focusing on panic disorder (PD), social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD). The primary finding was a constant and clinically marked positive association between the HA temperament dimension and symptoms of PD, SAD and OCD, with a most marked effect in SAD, and a moderate effect in OCD and PD. Second, less marked and clinically marginal associations between NS score and SAD and OCD (negative associations), but no associations with PD were observed. The meta-analyses revealed heterogeneity between the results of individual studies, especially in the analyses including SAD and OCD.

CONCLUSIONS

PD, SAD and OCD share a marked and state-dependent avoidant behavioral pattern, which is common for all anxiety disorders. However, PD showed a different pattern of arousal to novel stimuli from that of SAD and OCD. The findings are state dependent and based on cross-sectional studies.

Serotonin transporter (5-HTTLPR) and norepinephrine transporter (NET) gene polymorphisms: susceptibility and treatment response of electroconvulsive therapy in treatment resistant depression

Serotonin transporter (5-HTTLPR) and norepinephrine transporter (NET182C) polymorphisms are associated with susceptibility and treatment response in major depressive disorder (MDD). Thus, we examined association between these polymorphisms and susceptibility to treatment resistant depression, and treatment response in severe MDD patients treated with electroconvulsive therapy (ECT). In total, 119 Finnish patients with treatment resistant depression and 395 healthy volunteer blood donors were genotyped. Depression severity was assessed using the Montgomery-Åsberg Depression Scale (MADRS), with MADRS score change during ECT the treatment response indicator. Underrepresentation of the 5-HTTLPR l/l genotype in the NET TT subgroup was observed in patients compared with controls. There were no genotype or allele frequency differences between patients and control groups separately. Patients with combined 5-HTTLPR l/l and NET TT genotypes also had poorer treatment responses than other patients. No differences in ECT response were observed when the polymorphisms were examined separately. Our results suggest that a NET 182C and 5-HTTLPR polymorphism interaction is associated with susceptibility to treatment resistant depression and ECT treatment response in antidepressant resistant depression patients.

SERT and NET polymorphisms, temperament and antidepressant response

BACKGROUND

The genetic variations in norepinephrine transporter (NET) and serotonin transporter (SERT) genes have been associated with personality traits, several psychiatric disorders and the efficacy of antidepressant treatment.

AIMS

We investigated the separate effects and possible interactions between NET T-182C (rs2242446) and SERT 5-HTTLPR (rs4795541) polymorphisms on selective serotonin reuptake inhibitors (SSRI) treatment response and temperamental traits assessed by the Temperament and Character Inventory (TCI) in a clinical sample of subjects with major depressive disorder (MDD).

METHODS

Our sample of 97 patients with major depression completed the 107-item TCI temperament questionnaire (version IX) at the initial assessment of the study and after 6 weeks of follow-up. All subjects received selective SSRI medications. Temperament dimension scores at baseline ( 1 ) and endpoint ( 2 ) during antidepressant treatment were analyzed between NET and SERT genotypes.

RESULTS

SS-genotype of 5-HTTLPR was associated with higher baseline Persistence scores than SL- or LL-genotype. A corresponding but weaker association was found at endpoint. No differences were found between 5-HTTLPR genotypes and other temperament dimensions and 5-HTTLPR genotypes had no effect on treatment response.

CONCLUSIONS

Our results suggest that the SS-genotype of 5-HTTLPR is associated with Persistence scores in patients with MDD. Higher Persistence could be viewed as a negative trait when recovering from stress and its association with short and "weaker" S-allele may be related to less efficient serotonin neurotransmission, possibly resulting in less effective coping strategies on a behavioral level.

[Diagnosis and drug therapy of anxiety disorders in primary health care]

Generalized anxiety disorder, panic disorder and social phobia are common in primary health care patients. They may, however, be difficult to identify, since the patients seek medical attention primarily because of somatic symptoms. Anxiety disorders cause suffering, impair functional capability and are frequently accompanied by excessive use of healthcare services. These disorders are often accompanied by comorbid depression, which must be taken into consideration in the therapy. They are treated with psychotherapy, drug treatment or combination thereof. SSRI and SNRI drugs are the first-line choice of medication.

Smoking and weight among patients using clozapine

BACKGROUND

Both obesity and smoking are common in schizophrenia patients taking clozapine, causing cardiovascular disease and premature deaths.

METHODS

Two hundred and thirty-seven patients with schizophrenia or related psychoses treated with clozapine completed the Liverpool University Neuroleptic Assessment Scale (LUNSERS) and a questionnaire including current height, weight, changes therein and smoking status.

AIMS

The aim of this study was to analyze weight and weight change in smoking and non-smoking patients taking clozapine. A possible interaction between obesity and smoking was explored.

RESULTS

No association was found between weight change and smoking status during clozapine treatment. There was no significant difference in body mass index (BMI) between non-smokers and smokers. In the analysis of covariance (ANCOVA) with BMI as the dependent variable, the best fitting model comprised age, sex, intensity of sedation, and reported amount of smoking as explanatory variables (ηp(2)= 0.116; P = 0.029; power = 0.750). None of the explanatory proportions of any single factor was significant.

CONCLUSIONS

Estimated according to reported weight gain and BMI, no difference was found between smoking and non-smoking clozapine-treated patients. Number of cigarettes smoked explained BMI if age and sex were taken into account. This result is in line with the findings of some general population studies, where heavy smoking has been associated with a greater risk of obesity.

Association study of the HTR2C, leptin and adiponectin genes and serum marker analyses in clozapine treated long-term patients with schizophrenia

Clozapine treatment is associated with weight gain and cardio-metabolic consequences among patients with schizophrenia. Polymorphisms of leptin, serotonin receptor HTR2C and adiponectin genes have been associated with antipsychotic-induced weight gain and metabolic comorbidity. However, the results of the studies so far are inconclusive. The aim of the present study was first to test for a possible role of serum leptin and adiponectin levels as a marker of weight gain in association with inflammatory cytokines/adipokines (IL-6, IL-1Ra, hs-CRP and adipsin), and second to study associations between SNPs LEP rs7799039 (-2548 A/G), ADIPOQ rs1501299 and HTR2C rs1414334 and weight gain and levels of leptin and adiponectin, in 190 patients with schizophrenia on clozapine treatment, with retrospectively assessed weight change and cross-sectionally measured cytokine levels. A strong association was found between serum levels of leptin and weight gain and cytokines/adipokines related to metabolic comorbidity, especially among female patients (in women leptin vs. weight gain, IL-6 and IL-1Ra, P<0.001; in men leptin vs. weight gain, P=0.026, leptin vs. IL-1Ra, P<0.001). In male patients low adiponectin level was a more specific marker of clozapine-induced weight gain (P=0.037). The results of the present study do not support a major role of SNPs LEP rs7799039, ADIPOQ rs1501299 and HTR2C rs1414334 in the regulation of weight gain or association of serum levels of leptin and adiponectin and corresponding studied SNPs in patients with schizophrenia on clozapine treatment.

Cytokine and adipokine alterations in patients with schizophrenia treated with clozapine

Metabolic syndrome is associated with both schizophrenia and antipsychotic medication, especially clozapine, with alterations in inflammatory cytokines and adipokines. However, the data in this field is heterogeneous and the sample sizes of the patients are limited. In this study we assessed the serum levels of cytokines/adipokines IL-6, IL-1Ra, hs-CRP and adiponectin, and components of metabolic syndrome in 190 patients with treatment resistant schizophrenia treated with clozapine. Substantial metabolic comorbidity was found in this patient group; overweight/obesity, smoking, hypertriglyceridemia, low HDL-cholesterol, high HOMA-IR, low adiponectin levels, elevated hs-CRP levels and elevated IL-1Ra levels. Elevated IL-1Ra levels are associated with insulin resistance, obesity and hypertriglyceridemia. Low adiponectin levels were associated with hypertriglyceridemia, low HDL cholesterol and high glucose, and in male patients also with obesity and high IL-1Ra levels. After controlling for confounding factors age and smoking, levels of IL-1Ra and hs-CRP associated with obesity, and the levels of IL-6 associated with obesity in female patients. We conclude that there are partly gender dependent cytokine and adipokine alterations in patients with schizophrenia on clozapine treatment associated with metabolic comorbidity. The genetic background of these cytokine alterations needs to be further investigated.

Polymorphism in alpha 2A adrenergic receptor gene is associated with sialorrhea in schizophrenia patients on clozapine treatment

OBJECTIVE

Clozapine-induced sialorrhea (CIS) is a common, inconvenient and socially stigmatizing adverse effect. The pathophysiology of CIS may be related to the effect of clozapine on the muscarinic and adrenergic receptors as well as the disruption of the circadian rhythms. The aim of this study was to find out if polymorphisms in muscarinic M1 and M3 receptor genes (CHRM1 and CHRM3), adrenoceptor alpha 2A gene (ADRA2A) or clock circadian regulator gene (CLOCK) are associated with CIS.

METHODS

Two hundred and thirty-seven clozapine-treated Finnish schizophrenia patients were genotyped for CHRM1, CHRM3, CLOCK and ADRA2A polymorphisms, and their salivary dysfunction was assessed with two questions. Twenty-six of these patients had previously been on medication to treat CIS. Comparisons of the genotypes between patients with excessive versus non-excessive salivation were analysed. Genotype distributions between patients and control group and haplotypes were also studied.

RESULTS

CHRM1, CHRM3 and CLOCK polymorphisms and haplotypes were not associated with CIS. ADRA2A (rs1800544) genotype was associated with CIS (p = 0.029). In patients with CIS, CC genotype (n = 103) was more common than in G-allele carriers (n = 79) (p = 0.013, OR 2.13, 95% CI: 1.17-3.88). No differences were found in the distributions of genotypes between patients and controls.

CONCLUSIONS

ADRA2A genotype was associated with CIS.

CYP1A2 polymorphism -1545C > T (rs2470890) is associated with increased side effects to clozapine

BACKGROUND

Cytochrome P450 1A2 gene (CYP1A2) polymorphisms have been suggested to be associated with increased side effects to antipsychotics. However, studies on this are scarce and have been conducted with either various antipsychotics or only in small samples of patients receiving clozapine. The aim of the present study was to test for an association between the CYP1A2 -1545C > T (rs2470890) polymorphism and side effects in a larger sample of patients during long-term clozapine treatment.

METHODS

A total of 237 patients receiving clozapine treatment completed the Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) assessing clozapine-induced side effects. Of these patients, 180 completed the questionnaire satisfactorily, agreed to provide a blood sample, and were successfully genotyped for the polymorphism.

RESULTS

The TT genotype of CYP1A2 polymorphism -1545C > T (rs2470890) was associated with significantly more severe side effects during clozapine treatment (p = 0.011). In a subanalysis, all seven types of side effects (sympathicotonia-tension; depression-anxiety; sedation; orthostatic hypotension; dermal side effects; urinary side effects; and sexual side effects) appeared numerically (but insignificantly) more severely among TT carriers. In addition, use of mood stabilizers was more common among patients with the TT genotype (OR = 2.63, p = 0.004).

CONCLUSIONS

This study has identified an association between the CYP1A2 polymorphism -1545C > T (rs2470890) and the occurrence of more severe clozapine side effects. However, these results should be regarded as tentative and more studies of larger sample sizes will be required to confirm the result.

A cluster model of temperament as an indicator of antidepressant response and symptom severity in major depression

OBJECTIVE

Not enough is known about which patients suffering from major depressive disorder benefit from antidepressant drug treatment. Individual temperament is relatively stable over a person's lifespan and is thought to be largely biologically predefined. We assessed how temperament profiles are related to depression and predict the efficacy of antidepressant treatment.

METHODS

We recruited one hundred Finnish outpatients (aged 19 to 72) suffering from major depressive disorder, of whom 86 completed the 6-week study. We assessed their temperament features with the Temperament and Character Inventory and used cluster analysis to determine the patient's temperament profile. We also categorized the patients according to the vegetative symptoms of major depressive disorder.

RESULTS

There was an association between skewed temperament profile and severity of major depressive disorder, but the temperament profiles alone did not predict antidepressant treatment response. Those with higher baseline vegetative symptoms score had modest treatment response. Our model with baseline Montgomery Åsberg Depression Rating Scale (MADRS) vegetative symptoms, age and temperament clusters as explanatory variables explained 20% of the variance in the endpoint MADRS scores.

CONCLUSION

The temperament clusters were associated both with severity of depression and antidepressive treatment response of depression. The effect of the temperament profile alone was modest but, combined with vegetative symptoms of depression, their explanatory power was more marked suggesting that there could be an association of these two in the biological basis of MDD.

Change in antipsychotic usage pattern and risk of relapse in older patients with schizophrenia

OBJECTIVE

The aim of this study was to explore the use of first (FGAs) and second generation antipsychotics (SGAs) in older outpatients with schizophrenia and schizoaffective disorder. Factors associated with schizophrenic relapses were also studied.

METHODS

The study sample consisting of 8792 patients aged 64 years or more was collected from Finnish nationwide registers. The register data on the use of FGAs and SGAs were followed up between 1998 and 2003. Factors associated with psychiatric hospitalization in 1999 indicating relapse were studied using logistic regression analysis.

RESULTS

The use of SGAs increased from 2.8% to 12.4%, and the use of FGAs decreased from 57.5% to 39.4%. The use of a combination of SGAs and FGAs increased from 4.0% to 8.5%. The proportion of those who did not buy any antipsychotics varied between 35.8% and 39.7%. The number of patients hospitalized on psychiatric wards within a year (1999; relapsed) was 8.8%. Factors independently associated with relapse were use of combined FGAs and SGAs [odds ratio (OR) 1.70, p = 0.001] and use of antidepressants (OR 1.27, p = 0.019). Diagnosis of cardiovascular disease was negatively associated with risk of schizophrenic relapse (OR 0.84, p = 0.040).

CONCLUSION

The use of SGAs increased while the use of FGAs decreased in older outpatients with schizophrenia. Almost 40% of the study sample did not use any antipsychotic medication. The 1-year relapse rate was 8.8%. Several factors, such as combined use of FGAs and SGAs, or antidepressants, were associated with schizophrenic relapse, whereas cardiovascular disease showed a negative association with the relapse.

[Pharmacological therapy in emergency psychiatry]

Pharmacological therapy is often inevitable in psychiatric emergency situations, but does not suffice alone. The onset or exacerbation of a psychiatric illness and acute life crisis may require immediate initiation of psychotropic medication. Evidence-based knowledge of the application of psychotropic medication in emergency call situations is very scarce, because randomization, blinding and placebo control of drug treatments in these situations are ethically very problematic. This is why psychiatric emergency call units have established treatment practices that are based on long-term clinical experience and well-tried routines.

Mortality and causes of death in older patients with schizophrenia

OBJECTIVE

The aim of this study was to evaluate mortality and causes of death in older patients with schizophrenia in comparison with the general population. The mortality of patients experiencing relapse was also compared with those in remission.

METHODS

The study sample consists of patients (n = 9461) over 65 years by the first of January 1999, with schizophrenia or schizoaffective disorder (ICD-8, ICD-9: 295, ICD-10: F20, F25) as the main register diagnosis during the period 1969-1998. The sample was collected from nationwide registers in Finland and followed up between 1999 and 2008.

RESULTS

Overall Standard Mortality Ratio (SMR) of the older schizophrenia patients was 2.69 [95% confidence interval, 2.62-2.76]. For natural causes of death, overall SMR was 2.58 (2.51-2.65; n = 5301), and for unnatural causes of death, it was 11.04 (9.75-12.47; n = 262). The most common causes of death matched those in the general population. Of patients who died during follow-up, 31% (1709/5596) had at least one psychiatric hospitalization within 5 years before follow-up. The SMR for this group was higher (3.92; 3.73-4.11) than in those patients (2.37; 2.29-2.44) with no such treatment during that time.

CONCLUSION

All-cause mortality of older patients with schizophrenia was almost threefold that of general population. They died for similar reasons to the general population; however, deaths for unnatural causes were especially common (accidents and suicides). Those patients still experiencing relapses in older age have an increased risk of death compared with those with schizophrenia in remission.

Differential use of extended and immediate release quetiapine: a retrospective registry study of Finnish inpatients with schizophrenia spectrum and bipolar disorders

OBJECTIVE

Extended release (XR) and immediate release (IR) quetiapine have differing dosing, titration and plasma concentration profiles. The authors assessed whether the use of quetiapine XR and IR in schizophrenia spectrum disorders (SCZ) and bipolar disorder (BD) differ.

DESIGN

Retrospective non-interventional registry study.

SETTING

Secondary healthcare.

PARTICIPANTS

All SCZ and BD (ICD-10 codes F20-F29, F30-F31) patients discharged between June 2008 and June 2010 from a Finnish psychiatric hospital with any use of quetiapine during their inpatient stay.

PRIMARY AND SECONDARY OUTCOME MEASURES

Differences in patient characteristics between quetiapine XR and IR users were tested. To assess the profile of XR versus IR patients, logistic regressions were performed.

RESULTS

43 patients used quetiapine XR, 58 used quetiapine IR and 55 used both formulations (n=156). 102 patients were diagnosed with SCZ and 54 with BD, with no significant differences between the quetiapine formulations. The mean daily dose of quetiapine XR was significantly higher than that of quetiapine IR (542 mg vs 328 mg; p<0.001). This was also true for the SCZ subgroup (XR: 593 mg vs IR: 338 mg; p<0.001) and the BD subgroup (XR: 466 mg vs IR: 308 mg; p=0.009). 48% of all quetiapine IR patients used a mean dose of ≤200 mg compared with 2% of XR patients. Injectable antipsychotics were combined with quetiapine IR but not with quetiapine XR (12% vs 0%; p=0.019). At discharge, quetiapine XR was used as monotherapy to a greater extent than IR (79% vs 44%; p=0.003). The odds for quetiapine XR use in hospital were lower with advancing age, substance abuse diagnosis and prior IR use.

CONCLUSIONS

Among SCZ and BD inpatients, quetiapine XR was more often used as monotherapy and in significantly higher doses than quetiapine IR. Differential use of the quetiapine formulations appears to depend, at least in part, on patient characteristics.