Gender-related distribution of personality disorders in a sample of patients with panic disorder

Objective

We examined gender differences in the frequency of DSM-IV personality disorder diagnoses in a sample of patients with a diagnosis of panic disorder (PD).

Method

One hundred and eighty-four outpatients with a principal diagnosis of PD (DSM-IV) were enrolled. All patients were evaluated with a semi-structured interview to collect demographic and clinical data and to generate Axis I and Axis II diagnoses in accordance with DSM-IV criteria.

Results

Males were significantly more likely than females to meet diagnoses for schizoid and borderline personality disorder. Compared to males, females predominated in histrionic and cluster C diagnoses, particularly dependent personality disorder diagnoses. A significant interaction was found between female sex and agoraphobia on personality disorder (PD) distribution.

Conclusions

Male PD patients seem to be characterized by more severe personality disorders, while female PD patients, particularly with co-morbid agoraphobia, have higher co-morbidity rates with personality disorders belonging to the ‘anxious-fearful cluster’.

A cluster-analytical approach toward real-world outcome in outpatients with stable schizophrenia

BACKGROUND

This study aims to empirically identify profiles of functioning, and the correlates of those profiles in a sample of patients with stable schizophrenia in a real-world setting. The second aim was to assess factors associated with best profile membership.

METHODS

Three hundred and twenty-three outpatients were enrolled in a cross-sectional study. A two-step cluster analysis was used to define groups of patients by using baseline values for the Heinrichs-Carpenter Quality of Life Scale (QLS) total score. Logistic regression was used to construct models of class membership.

RESULTS

Our study identified three distinct clusters: 50.4% of patients were classified in the "moderate" cluster, 27.9% in the "poor" cluster, 21.7% in the "good" cluster. Membership in the "good" cluster versus the "poor" cluster was characterized by less severe negative (OR=.832) and depressive symptoms (OR=.848), being employed (OR=2.414), having a long-term relationship (OR=.256), and treatment with second-generation antipsychotics (SGAs) (OR=3.831). Nagelkerke R(2) for this model was .777.

CONCLUSIONS

Understanding which factors are associated with better outcomes may direct specific and additional therapeutic interventions, such as treatment with SGAs and supported employment, in order to enhance benefits for patients, as well as to improve the delivery of care in the community.

[Treatment of obsessive-compulsive disorder: drugs, psychotherapy or combined treatments?]

Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, little is known concerning whether combining both treatments ab initio is more effective than either monotherapy alone. A review of the available literature, which is poor, shows that combining ab initio CBT and SRI has not been found to be clearly superior of either therapy alone, except for patients with severe depression (who could be treated effectively with pharmacotherapy alone) and for children and adolescents. Another promising area of research is combined sequential treatment, that is the addition of CBT in subjects not responding to SRIs alone. More research is clearly needed in order to achieve a personalized treatment plan for every OCD patient.

[Lithium treatment and potential long-term side effects: a systematic review of the literature]

INTRODUCTION AND AIM

Lithium is recommended by all treatment guidelines for bipolar disorder (BD) as a first-line maintenance treatment. However, the potential side effects and risks associated with long-term lithium use may at times make the implementation of these recommendations in daily practice challenging. The aim of the study is to review available literature on potential long-term side effects of lithium.

MATERIALS AND METHODS

A PubMed/Medline search was performed on papers dealing with long-term treatment with lithium and side effects. Articles published from January 1980 to February 2013 were selected.

RESULTS

Long-term lithium treatment is associated with a reduced urinary concentrating ability, with subsequent polyuria and polidypsia and nephrogenic diabetes insipidus (in 10-40% of patients). Lithium also reduces glomerular filtration rate, and increases risk of renal failure, although the absolute risk is small (0.5% of patients). Lithium treatment is associated with significant higher TSH levels, with a 6-fold greater risk of hypothyroidism in lithium-treated than in control subjects. Less known is the increase of PTH and calcium levels induced by lithium. An exacerbation of psoriasis is also frequently associated with lithium treatment.

CONCLUSIONS

Lithium remains a fundamental tool for the treatment of BD. Clinicians should know potential side effects (renal, endocrine and dermatological) associated with long-term treatment with lithium, for a correct management of the patient. A specialist referral is often necessary; the question is how to deal with long-term side effects more than whether or not withdrawing lithium. This decision should remain a psychiatrist's competence.

Vagus nerve stimulation for treatment-resistant mood disorders: a long-term naturalistic study

BACKGROUND

Limited therapeutic options are available for patients with treatment-refractory major depression who do not respond to routinely available therapies. Vagus nerve stimulation showed adjunctive antidepressant effect in chronic treatment resistant depression, even though available studies rarely exceed 2-year follow up. We report a naturalistic 5-year follow up of five patients who received VNS implant for resistant depression (3 patients with major depressive disorder and 2 with bipolar disorder).

METHODS

Response was defined as a reduction of the 17-item HDRS total score ≥50% with respect to baseline, remission as a score ≤7.

RESULTS

Response and remission rates were both 40% (2/5) after 1 year, and 60% (3/5) at 5 years. Two patients withdrew from the study because of side effects or inefficacy of stimulation.

CONCLUSIONS

Our case series showed that long-term VNS may be effective in reducing severity of depression in a small but significant minority of patients, although two patients had stimulation terminated because of adverse effects and/or refusal to continue the study.

Combined treatment of borderline personality disorder with interpersonal psychotherapy and pharmacotherapy: predictors of response

Borderline personality disorder (BPD) is characterized by affective instability, impulsive behaviors, and disturbed interpersonal relationships. A previous study of our group found that combined therapy with interpersonal psychotherapy adapted to BPD (IPT-BPD) and fluoxetine was superior to single pharmacotherapy in BPD patients. The aim of the present study was to examine what clinical factors predicted response to combined therapy in patients evaluated in the previous efficacy study. The subgroup of 27 patients allocated to combined therapy was analyzed. Patients were treated for 32 weeks with fluoxetine 20-40 mg/day plus IPT-BPD. Patients were assessed at baseline and week 32 with an interview for demographic and clinical variables, CGI-S, HDRS, HARS, SOFAS, BPDSI, and SAT-P. Statistical analysis was performed with multiple regression. The difference of CGI-S score between baseline and week 32 (∆CGI-S) was the dependent variable. Factors significantly and independently related to ∆CGI-S were the BPDSI total score and the items abandonment, affective instability, and identity. Patients with more severe BPD psychopathology and with a higher degree of core symptoms such as fear of abandonment, affective instability, and identity disturbance have a better chance to improve with combined therapy with fluoxetine and IPT-BPD.

Increased uric acid levels in bipolar disorder subjects during different phases of illness

BACKGROUND

Recent evidence indicates the possible involvement of adenosine and the purinergic system in the pathophysiology of bipolar disorder (BD). The aim of this study is to compare serum uric acid (UA) levels in a large group of BD patients (in mania, depression and euthymia) vs. a control group of patients with different psychiatric disorders.

METHODS

150 BD (SCID-I; DSM-IV) patients were compared to 150 age- and gender-matched subjects with MDD, OCD, or Schizophrenia. Mean serum UA values were compared with the ANOVA, with Bonferroni's post-hoc tests.

RESULTS

Mean serum UA levels (5.06 ± 1.45 vs. 4.17 ± 1.05 mg/dL) and rates of hyperuricaemia (30.7% vs. 6.7%) were significantly higher in the bipolar than in the control group. No differences were detected between bipolars in different phases of illness, with all three groups (manic, depressive and euthymic bipolars) showing significantly higher UA levels as compared to controls. No correlations were found between UA levels and YMRS or HAM-D scores. Mean UA levels were also higher in bipolars never exposed to mood stabilizers vs. controls (5.08 ± 1.43 vs. 4.17 ± 1.05 mg/dL), with no differences compared to other bipolars.

LIMITATIONS

Our study suffers from the lack of a healthy comparison group; moreover, longitudinal data are missing.

CONCLUSIONS

Our study provides further evidence of a purinergic dysfunction associated with BD, in all phases of the illness. It is possible that increased UA levels are a trait marker of higher vulnerability to bipolar disorder, and are even more increased during mania (mostly in the first manic episode of drug-naïve patients).

Effects of maintenance lithium treatment on serum parathyroid hormone and calcium levels: a retrospective longitudinal naturalistic study

OBJECTIVE

The aim of this retrospective longitudinal naturalistic study was to evaluate the effects of maintenance lithium treatment on parathyroid hormone (PTH) and calcium levels.

METHODS

A retrospective longitudinal naturalistic study design was used. Data were collected from the database of a tertiary psychiatric center covering the years 2010-2014. Included were bipolar patients who had never been exposed to lithium and had lithium started, and who had PTH, and total and ionized calcium levels available before and during lithium treatment. Paired t-tests were used to analyze changes in PTH and calcium levels. Linear regressions were performed, with mean lithium level and duration of lithium exposure as independent variables and change in PTH levels as dependent variable.

RESULTS

A total 31 patients were included. The mean duration of lithium treatment was 18.6±11.4 months. PTH levels significantly increased during lithium treatment (+13.55±14.20 pg/mL); the rate of hyperparathyroidism was 12.9%. Neither total nor ionized calcium increased from baseline to follow-up; none of our patients developed hypercalcemia. Linear regressions analyses did not show an effect of duration of lithium exposure or mean lithium level on PTH levels.

CONCLUSION

Lithium-associated stimulation of parathyroid function is more common than assumed to date. Among parameters to be evaluated prior to lithium implementation, calcium and PTH should be added.

Recurrence rates of bipolar disorder during the postpartum period: a study on 276 medication-free Italian women

The postpartum period is considered a time of heightened vulnerability to bipolar disorder. The primary goal of this study was to examine the frequency and the polarity of postpartum episodes in a clinical sample of women with bipolar disorder who were medication-free during their pregnancies. In addition, we sought to examine whether there are differences in terms of clinical features of bipolar disorder between women with and without postpartum episodes. Lastly, we analyzed the potential relationship between polarity of the postpartum episodes and clinical features of bipolar disorder. The presence/absence of postpartum episodes and their characteristics were obtained from medical records of 276 women with bipolar disorder who were medication-free during their pregnancies. Two hundred seven women (75.0 %) had a history of one or more postpartum mood episodes: depressive (79.7 %), (hypo)manic (16.4 %), or mixed episodes (3.9 %). Psychotic symptoms during postpartum episodes were associated with depression in 37 (22.4 %) patients, with mania in 19 (67.8 %) patients, and with mixed episodes in 7 (87.5 %) patients. Postpartum manic and mixed episodes were significantly associated with type I disorder and with psychotic features. Our findings indicate high risk of clinically ascertained mood episodes during postpartum period in bipolar women who are not treated during pregnancy.

[Interpersonal psychotherapy: a model of intervention for borderline personality disorder]

Interpersonal psychotherapy (IPT) was proposed in 1984 by Klerman and colleagues. It is a time-limited psychotherapy (12-16 sessions), diagnosis-focused, based on a medical model. Psychiatric symptoms develop in an interpersonal context. Acting on this context, it is possible to induce remission and prevent subsequent recurrences. IPT is aimed at the resolution of the interpersonal crisis, improving social functioning and psychiatric symptoms. At first, it was addressed to treat major depression, not psychotic or bipolar. Later IPT has been applied to a growing number of psychiatric disorders, because of their frequent and remarkable interpersonal dimension. However, specific adaptations of IPT have been required to consider the different clinical characteristics of these disorders. To date, among Axis II disorders, only borderline personality disorder (BPD) has been a target of IPT. The frequent comorbidity with mood disorders and the relational problems due to BPD core symptoms are the main reasons for the proposal of an adapted model of IPT: the IPT-BPD. This model has a longer duration (34 sessions), and is designed to deal with chronicity of BPD, poor therapeutic alliance and the high risk of suicide and self-harm of these patients. Although studies aimed to test the efficacy of IPT in borderline patients were performed with promising results, replication of findings in larger samples is required.

Efficacy of omega-3 fatty acids in the treatment of borderline personality disorder: a study of the association with valproic acid

Omega-3 fatty acids have received increasing interest due to their effects in stabilizing plasmatic membranes and regulating cell signaling. The efficacy of omega-3 fatty acids in psychiatric disorders, in particular mood disorders, has been studied. There have been two trials on eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) in the treatment of borderline personality disorder (BPD). The present 12-week controlled trial aimed to assess the efficacy of the association of EPA and DHA with valproic acid, compared to single valproic acid, in 43 consecutive BPD outpatients. Participants were evaluated at baseline and after 12 weeks with: Clinical Global Impression - Severity (CGI-S), Hamilton Scales for depression and anxiety (HAM-D, HAM-A), Social and Occupational Functioning Assessment Scale (SOFAS), borderline personality disorder severity index (BPDSI), Barratt Impulsiveness Scale - version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), Self-Harm Inventory (SHI) and Dosage Record Treatment Emergent Symptom Scale (DOTES).

Lithium-associated hyperparathyroidism and hypercalcaemia: a case-control cross-sectional study

BACKGROUND

Lithium is recommended as a first-line treatment for Bipolar Disorder (BD). Thyroid and renal alterations are well known lithium side-effects, while effects on parathyroids are less studied. The aim of this case-control cross-sectional study is to compare parathyroid hormone (PTH) and calcium levels in lithium-exposed bipolar patients and in subjects who had never been exposed to lithium.

METHODS

112 BD patients were enrolled, 58 on lithium since at least 1 month (mean exposure 60.8 ± 74.8 months) and 54 in the control group. Blood exams included complete blood count, PTH, total and ionized calcium, TSH, T3 and T4, creatinine, urea, sodium and potassium, and lithium serum levels. The Student's t-test and the Pearson's Chi-square test were used for bivariate analyses. A linear regression model was used to analyze the relationship between the duration of exposure to lithium and PTH and calcium levels.

RESULTS

PTH and ionized calcium levels were significantly higher in lithium-exposed patients; the proportions of subjects with hyperparathyroidism (8.6%) and hypercalcaemia (24.1%) were significantly greater in lithium-exposed patients. The linear regression analyses showed a significant effect of exposure to lithium in months on ionized calcium levels but not on PTH levels.

LIMITATIONS

Given the cross-sectional design of the study we could not identify the exact time of occurrence of hyperparathyroidism.

CONCLUSIONS

Our results indicate that lithium-associated stimulation of parathyroid function is more common than assumed to date. Among parameters to be evaluated prior to lithium implementation and during long-term lithium maintenance, calcium (and eventually PTH) should be added.

Severe obsessive-compulsive disorder (OCD): socio-demographic and clinical features

Aim: the aim of the study is to evaluate the socio-demographic and clinical features with prognostic value in predicting evolution in severe OCD.Materials and methods: patients with a main diagnosis of OCD were recruited according to DSM-IV criteria. Socio-demographic and clinical features were assessed by mean of a semi-structured interview and clinical rating scales (Y-BOCS, HAM-A, HAM-D and SCID-II). Two subgroups were compared according to the severity of symptoms (severe vs mild-moderate).Results: the total sample was made up of 450 OCD subjects aged 34.5±12.1, with a mean age of onset 22.3±9.1; 215 subjects (47.8%) were females. Patients with severe OCD (Y-BOCS ≥ 32) showed a more insidious onset and a more chronic course compared to patients with mild-moderate symptoms. Other predictors of increased OCD severity were washing and hoarding compulsions. Lastly, the severity of the obsessive-compulsive condition was higher when it was associated either with mood disorders or with Axis II disorders (particularly Cluster A).Discussion: our study shows a correlation between severe OCD and severity predictors such as functional impairment and mood disorders. Furthermore washing and hoarding symptoms, lifetime comorbity with mood disorders and Cluster A personality disorders seem to predict OCD severity.

[Brain stimulation therapies for treatment-resistant depression]

Treatment-resistant depression (TRD) is a major public health problem, affecting patients, their close relatives, and the society as a whole. Despite recent developments in psychopharmacotherapy, more than 50% of depressed patients fail to reach complete remission even when adequately treated. Neurostimulation therapies are an open field in research for the treatment of TRD, involving the delivery of physical interventions either through electric current or a magnetic field to target selective or generalized brain regions. In this paper we review evidences for four brain-stimulation therapies, i.e. electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS) and deep brain stimulation (DBS), and we enlighten several new approaches regarding ECT, rTMS and epidural cortical stimulation (EpCS). ECT is the form of neurostimulation with the most extensive evidence, rTMS and VNS have a much smaller evidence base. There is emerging evidence that DBS is effective for otherwise TRD, but this is still an investigational approach. Other approaches are anecdotal reports. ECT and rTMS can be considered as a first-line treatment under specific circumstances. Evidence supporting VNS is less consistent and DBS remains an investigational treatment. Other techniques are promising, but double-blind studies are warranted to evaluate these new approaches to TRD.

Metabolic syndrome and obsessive-compulsive disorder: a naturalistic Italian study

OBJECTIVE

The increased risk for metabolic syndrome (MetS) in individuals with schizophrenia and bipolar disorder has been documented. No study examined MetS in patients with obsessive-compulsive disorder (OCD), despite the fact that a great proportion of them are treated with antipsychotic addition. The aim of our study was to investigate the prevalence and the sociodemographic and clinical correlates of MetS in an Italian sample of patients with OCD.

METHOD

Subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, OCD and a Yale-Brown Obsessive-Compulsive Scale score ≥ 16 were included. Sociodemographic and clinical characteristics, current and lifetime pharmacological treatments, lifestyle information, and comorbidity for cardiovascular diseases and diabetes were collected. MetS was diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III modified criteria.

RESULTS

We enrolled 104 patients with OCD. MetS was present in 21.2% (95% confidence interval: 13.7%-30.3%) of the sample. Abdominal obesity was present in 36.5%, hypertension in 42.3%, high triglycerides in 23.1%, low high-density lipoprotein cholesterol levels in 22.1% and fasting hyperglycemia in 4.8% of the sample. MetS was associated with cigarette smoking (duration of cigarette smoking), absence of physical activity, a higher body mass index and a greater proportion of obesity. Among pharmacological treatments, MetS was associated with the duration of the exposure (lifetime) to antipsychotics.

CONCLUSIONS

This is the first study that examined the prevalence and correlates of MetS in a sample of patients with OCD. Our cross-sectional evaluation found a prevalence of MetS higher than those reported in the Italian general population, although the confidence interval encompasses the general population estimate reported. Patients with OCD on antipsychotic treatment are particularly at risk for MetS and should be carefully monitored for metabolic abnormalities and cardiovascular complications.

Prosody recognition and audiovisual emotion matching in schizophrenia: the contribution of cognition and psychopathology

This study aimed to evaluate the ability to decode emotion in the auditory and audiovisual modality in a group of patients with schizophrenia, and to explore the role of cognition and psychopathology in affecting these emotion recognition abilities. Ninety-four outpatients in a stable phase and 51 healthy subjects were recruited. Patients were assessed through a psychiatric evaluation and a wide neuropsychological battery. All subjects completed the comprehensive affect testing system (CATS), a group of computerized tests designed to evaluate emotion perception abilities. With respect to the controls, patients were not impaired in the CATS tasks involving discrimination of nonemotional prosody, naming of emotional stimuli expressed by voice and judging the emotional content of a sentence, whereas they showed a specific impairment in decoding emotion in a conflicting auditory condition and in the multichannel modality. Prosody impairment was affected by executive functions, attention and negative symptoms, while deficit in multisensory emotion recognition was affected by executive functions and negative symptoms. These emotion recognition deficits, rather than being associated purely with emotion perception disturbances in schizophrenia, are affected by core symptoms of the illness.

[Combined treatments in obsessive-compulsive disorder: current knowledge and future prospects]

AIM

Serotonin reuptake inhibitors (SRIs) and/or cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). The study discuss whether: a) combining both treatments ab initio is more effective than either monotherapy alone; and b) a sequential treatment is effective both in responder and non responder patients.

METHODS

Have been carried out a search on Medline/PubMed database, selecting clinical randomized controlled studies in English. Have been examined 9 randomized controlled studies where combined treatment ab initio was compared to CBT alone, and 6 where combination treatment was compared to SRI alone. No controlled studies were found for sequential treatments in OCD. Have been then examined naturalistic studies, 2 including responder patients and 7 including non responder patients.

RESULTS

Of the 9 studies, 7 didn't find any additional benefit of combining treatments as compared to CBT alone; in 1 study the combination strategy resulted more effective than CBT alone in children and adolescents, and in another in severely depressed adult patients with OCD. As compared to SRIs alone, combining treatments was not more effective in 4 studies, while in 2 studies it was more effective. All studies concerning sequential treatments found evidence of efficacy of this strategy.

DISCUSSION

Combining ab initio CBT and SRI has not been found to be clearly superior of either therapy alone, except for patients with severe depression and for children and adolescents. On the contrary, a sequential strategy may be used successfully both to treat residual symptoms in responders and to determine clinical response in resistant patients.

[OCD during pregnancy and post partum]

AIM

Obsessive-compulsive disorder (OCD) can occur with specific characteristics during the pregnancy/postpartum period. The presence of OCD in a such delicate period in a woman's life can lead to severe suffering of the patient herself, of her relatives and the newborn. The purpose of this article is to offer a comprehensive review of scientific literature concerning the relationship between OCD and pregnancy/post partum.

METHODS

Literature was identified by searching in Medline (Medical Literature Analysis and Retrieval System On-line), using the PubMed search engine. The keywords used were "obsessive-compulsive disorder", "pregnancy", "post partum period", "perinatal period".

RESULTS

The last trimester of pregnancy and the post partum period are at increased risk of onset of OCD, especially in susceptible individuals. During pregnancy/post partum, OCD is characterized by typical clinical features: obsessions (in particular aggressive and/or contamination) are more frequent than compulsions (checking and/or washing); further, if untreated, the symptomatology tends to persist and/or recur during any subsequent pregnancies.

DISCUSSION

From the literature it appears that the diagnosis of OCD during pregnancy/post partum should be performed as soon as possible, both to ensure the correct patient and family psychoeducation, and timely access to psychopharmacological treatment and/or psychotherapy.

Stressful life events and obsessive-compulsive disorder: clinical features and symptom dimensions

The potential role of stressful life events (SLEs) in the genesis of obsessive-compulsive disorder (OCD) has been suggested by several authors, but whether the number or the severity or the type of SLEs preceding the onset of OCD has a triggering effect is unclear. Further, sociodemographic and clinical features of OCD preceded by SLEs, and the relationship between type of SLEs and type of obsessive-compulsive symptomatology remain mainly unexplored. The aims of this study were to compare the clinical features of OCD with and without SLEs preceding it and to examine the relationship between type of SLEs and OCD symptom dimensions. The number and type of SLEs which occurred before the onset of OCD were determined in 329 patients: the raters had to decide whether an occurrence 12 months before the onset of OCD would fit any of the 61 items on Paykel's list, and each event reported was carefully investigated in order to determine the exact time of occurrence. At least one event preceded the onset of OCD in 200 patients (60.8%), and this was significantly associated with female gender, abrupt onset of the disorder and somatic obsessions. Moreover, LogReg Analysis identified three specific traumatic events ("hospitalization of a family member", "major personal physical illness", "loss of personally valuable object") significantly associated with a symptom dimension (symmetry obsessions, repeating, ordering/arranging, counting, and checking compulsions). Additional evidence regarding the association among SLE-preceded OCD, female gender, somatic obsessions and symmetry/ordering symptoms should be obtained to advance the understanding of OCD.

Nosographic classification of mood disorders: from symptoms to diagnosis and treatment

Mood disorders represent a main health concern, due to their high prevalence in the general population and because they are related to a severe worsening of quality of life and psychosocial functioning of those who are affected. Because of the importance of such diseases, that, according to WHO, might become the major cause of morbidity by 2020, an efficacious, targeted and precise approach is essential in everyday clinical practice. This article reviews the methods of diagnostic approach, with the aim of describing the different phases of nosographic classification of mood disorders and their meaning. In particular, the most reliable classification distinguishes between unipolar (major depressive disorder) and bipolar (type I and II) disorders: the right differential diagnosis is important because there are great differences in the optimal management of these conditions (antidepressants vs. mood stabilizers) and diagnostic errors can potentially worsen the patient’s prognosis. In conclusion, the right nosographic classification allows the right therapeutic and prognostic approach. This may result in higher rates of remission and response, thus improving patient’s quality of life and overall wellness.http://dx.doi.org/10.7175/rhc.v3i3.200

Serum lipids, metabolic syndrome and lifetime suicide attempts in patients with bipolar disorder

OBJECTIVE

Bipolar disorder is associated with a high risk of suicide. Many clinical characteristics and, recently, biomarkers have been studied with the aim to find useful predictors of suicidality. The role of serum lipids has also been explored albeit with conflicting results; however, few studies have been focused on patients with bipolar disorder. Aim of our study is to investigate whether serum cholesterol, triglycerides, HDL-c and metabolic syndrome are associated with lifetime suicide attempts in a large naturalistic sample of patients with bipolar disorder.

METHODS

220 patients with bipolar disorder were included. History of lifetime suicide attempts was systematically and retrospectively assessed for each patient. Blood exams testing total cholesterol, triglycerides, and HDL-c levels were performed, and metabolic syndrome was diagnosed according to NCEP ATP-III modified criteria. Serum lipid levels and metabolic syndrome were compared in patients with or without history of suicide attempt. According to a theory that links impulsivity and violence with low cholesterol, the association between lipid levels and violent suicidal behavior was also assessed.

RESULTS

Lifetime suicide attempts rate was 32.3%. There were no statistically significant differences between patients with and without lifetime suicide attempts in cholesterol, triglycerides, HDL-c levels, and the prevalence of metabolic syndrome. No differences in the same variables were found in violent suicide attempters compared with nonviolent ones. Clinical characteristics such as gender, low education, higher number of manic and depressive episodes, and taking more medications for bipolar disorder were associated with lifetime suicide attempts.

CONCLUSIONS

Our results do not support the hypothesis of a strong association between serum lipid levels and suicide in patients with bipolar disorder.

A randomized, single-blind, comparison of duloxetine with bupropion in the treatment of SSRI-resistant major depression

INTRODUCTION

For patients who continue to experience depressive symptoms despite an adequate antidepressant SSRI trial, across-class switch is considered one of the best treatment options. The goal of the present work was to compare in terms of efficacy two different dual-action compounds, duloxetine and bupropion, in patients who failed to respond in two consecutive antidepressant trials with SSRIs.

METHODS

The patients were allocated randomly to duloxetine (120 mg daily) or bupropion extended release (300 mg daily). The intended medication period was 6 weeks. The primary measure of efficacy was depressive symptoms severity.

RESULTS

A total of 49 participants were randomly assigned to duloxetine 120 mg (n=27) or bupropion 300 mg (n=22). The ITT efficacy patient sample consisted of 46 patients. Relatively high response and remission rates in treatment groups were found: from 60 to 70% of patients responded to treatment, and approximately 30 to 40% were in remission by the endpoint (week 6). No statistically significant difference emerged between the two groups at any post-baseline assessment, neither on mean scores of rating scales nor on qualitative efficacy measures.

LIMITS

Limitations of the study are the lack of a placebo arm, difficult to include owing to ethical reasons, and the relatively small size of the sample.

CONCLUSIONS

These preliminary results seem to support the hypothesis that in patients unresponsive to SSRIs the administration of antidepressants with different mechanisms of action is an effective switching strategy. Further studies are needed in light of the challenge posed by resistant depression.

Paliperidone ER in the Treatment of Borderline Personality Disorder: A Pilot Study of Efficacy and Tolerability

Antipsychotics are recommended for the treatment of impulsive dyscontrol and cognitive perceptual symptoms of borderline personality disorder (BPD). Three reports supported the efficacy of oral risperidone on BPD psychopathology. Paliperidone ER is the metabolite of risperidone with a similar mechanism of action, and its osmotic release reduces plasmatic fluctuations and antidopaminergic effects. The aim of this study is to evaluate efficacy and safety of paliperidone ER in BPD patients. 18 outpatients with a DSM-IV-TR diagnosis of BPD were treated for 12 weeks with paliperidone ER (3-6 mg/day). They were assessed at baseline, week 4, and week 12, using the CGI-Severity item, the BPRS, the HDRS, the HARS, the SOFAS, the BPD Severity Index (BPDSI), and the Barratt Impulsiveness Scale (BIS-11). Adverse events were evaluated with the DOTES. Paliperidone ER was shown to be effective and well tolerated in reducing severity of global symptomatology and specific BPD symptoms, such as impulsive dyscontrol, anger, and cognitive-perceptual disturbances. Results need to be replicated in controlled trials.

[Lithium and anticonvulsants in the treatment of mania and in the prophylaxis of recurrences]

INTRODUCTION

A mood stabilizer is an agent effective in treating both poles of the illness and at the same time being able to prevent both manic and depressive episodes in bipolar disorder. According to a broader definition, a mood stabilizer should be effective in decreasing the frequency or severity of any type of episode in bipolar disorder, without worsening the frequency or severity of episodes of opposite polarity. According to this, anticonvulsants and atypical antipsychotics can be considered as mood stabilizers.

AIM AND METHODS

In this paper we review the use of lithium and other anticonvulsants that have proved effective in randomized controlled trials of the treatment of manic episodes and prevention of recurrences of bipolar disorder.

RESULTS

Lithium and valproate are considered as first-line treatment options for acute mania while evidence regarding carbamazepine is insufficient to consider it as a first-line agent. Patients who fail to respond to first-line treatments may benefit from the adjunct of an atypical antipsychotic such as olanzapine, quetiapine, risperidone or aripiprazole. Lithium retains the strongest evidence of efficacy in the prophylaxis of manic episodes, lamotrigine in the prevention of depressive episodes. Valproate and carbamazepine have no indication for long-term treatment of bipolar disorder.

DISCUSSION

Lithium can still be considered a gold standard in the treatment of manic episodes as well as in the prophylaxis of recurrences. Other anticonvulsants should be employed in particular situations, such as valproic acid in the treatment of mania and lamotrigine in the prevention of depressive recurrences.

Age-specific prevalence of metabolic syndrome in Italian patients with bipolar disorder

AIM

Metabolic syndrome (MetS) is highly prevalent in patients with bipolar disorder (BD). Little research has evaluated the risk profile of MetS and cardiovascular disease in different gender and age groups in these patients. Our aim is to evaluate the prevalence of MetS in Italian patients with BD stratified by gender and age, and to determine the correlates of MetS.

METHODS

Subjects with BD were included and stratified by sex and age according to the following age groups: <30; 30-39; 40-49; 50-59; ≥ 60 years. Socio-demographic and clinical characteristics, lifestyle information, and comorbidity for cardiovascular diseases and diabetes were collected. MetS was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III modified criteria.

RESULTS

MetS was evaluated in 200 patients, with a prevalence of 26.5%. Men had higher rates of hypertension and hypertriglyceridemia, women had more abdominal obesity. Women had a peak of prevalence in the ≥ 60 years group, while men displayed high rates even in the young age groups. In young patients, MetS was associated with Cluster B personality disorders and less physical exercise.

CONCLUSION

Our paper highlights the importance of evaluating MetS even in young patients with bipolar disorder, especially males. The strong association with lack of physical exercise suggests that the implementation of healthy behaviors might be relevant in order to prevent MetS and future adverse cardiovascular outcomes.

Neuropsychiatric symptoms underlying caregiver stress and insight in Alzheimer's disease

OBJECTIVE

Cluster analysis based on Alzheimer's disease (AD) neuropsychiatric profile demonstrated validity on caregiver burden, nursing-home placement and survival. The aims of our study were to explore the validity of this approach on caregiver burden, lack of insight and cognitive impairment and to examine the impact of neuropsychiatric profiles on these variables.

METHOD

A data-driven approach (two-step cluster analysis) identified groups of patients based on similarities of their neuropsychiatric symptom profile, as assessed by the Neuropsychiatric Inventory (NPI). ANOVAs and chi(2) tests were used to compare groups with regard to continuous and categorical variables. Linear regressions tested the relationships between NPI and clinical variables.

RESULTS

Psychotic/behavioral, depressive and minimally symptomatic clusters differed for caregiver burden and lack of insight. Patients in the minimally symptomatic cluster showed better insight than those in the depressive cluster. Caregivers of the psychotic/behavioral cluster experienced the highest burden. We found positive relationships between NPI and lack of insight in the depressive and minimally symptomatic clusters and between NPI and caregiver burden in all three clusters. Caregiver burden was influenced by the type of symptoms.

CONCLUSIONS

The cluster analysis was valid for lack of insight and caregiver burden. Symptoms predominant on caregiver burden could become targets for therapy.

No effect of adding brief dynamic therapy to pharmacotherapy in the treatment of obsessive-compulsive disorder with concurrent major depression

BACKGROUND

Until now no studies have investigated the benefits of adding brief dynamic therapy (BDT) to medication in obsessive-compulsive disorder (OCD), while a number of recent investigations have demonstrated the efficacy of supplemental BDT among patients with major depressive disorders (MDD). The objective of the present study was to explore the efficacy of BDT combined with pharmacotherapy in comparison with pharmacotherapy alone in the treatment of OCD with concurrent MDD.

METHODS

A 12-month randomized clinical trial compared a standard selective serotonin reuptake inhibitor treatment with (n = 27) or without (n = 30) supplemental BDT in patients with OCD and concurrent MDD. Supplemental BDT was added during the first 16-week trial; all patients continued to be treated with only pharmacotherapy in the following continuation phase. The primary efficacy assessments were the Yale-Brown Obsessive Compulsive Scale and the 17-item Hamilton Rating Scale for Depression; the secondary efficacy measures included the Clinical Global Impression scale and the Global Assessment of Functioning. The data analysis was conducted on the 'intent-to-treat (ITT) efficacy patient sample'.

RESULTS

Fifty patients completed the study. No difference between the 2 treatment groups was found at any point by any assessment method in the ITT study sample.

CONCLUSIONS

Supplemental BDT in the treatment of patients with OCD with concurrent MDD who are receiving effective medication has no significant clinical effect on both obsessive and depressive symptoms.

Obsessive-compulsive disorder and cyclothymic temperament: an exploration of clinical features

BACKGROUND

Bipolar disorder comorbidity in obsessive-compulsive disorder (OCD) has relevant implications on the symptomatological expression, complications and pharmacologic treatment of the disorder. Relatively few data exist on OCD comorbid with soft-bipolar forms. The aims of the study are to evaluate affective temperaments in patients with OCD and to analyze differences in socio-demographic and clinical characteristics according to the presence or absence of cyclothymic temperament.

METHODS

The sample consisted of 167 patients with a principal diagnosis of OCD (DSM-IV-TR). Affective temperaments have been evaluated through the Italian semistructured interview version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-I).

RESULTS

A total of 90 patients (53.9%) were diagnosed with a dominant affective temperament. Cyclothymic affective temperament (CT) was the most represented in the sample of OCD patients (19.2%). Patients with CT showed significant lower mean age at onset, higher scores at the HAM-A, more repeating compulsions, higher rates of eating disorder comorbidity, OCD spectrum disorder comorbidity and higher rates of Axis II comorbidity (particularly Cluster A).

LIMITATIONS

Recruitment of OCD patients from a tertiary center. Absence of an investigation about treatment implications associated with cyclothymic temperament.

CONCLUSIONS

Patients with OCD and CT could be more severe and complicated compared to patients without CT. Moreover, individuals with OCD spectrum disorders may be vulnerable to bipolarity. Systematic assessment of affective temperament is necessary to detect OCD with such a soft-bipolar comorbidity.

Family accommodation in obsessive-compulsive disorder: Relation to symptom dimensions, clinical and family characteristics

Family accommodation is the term used to indicate the process whereby family members of patients with obsessive-compulsive disorder (OCD) assist or participate in the patients' rituals. Family accommodation is a relatively under-researched phenomenon in OCD but an important one because it may be predictive of poor treatment outcome. This study systematically examined several socio-demographic and clinical variables that are associated with family accommodation in a well-characterized sample of adult patients and their healthy family members. Experienced clinicians administered the Family Accommodation Scale (FAS) to 141 psychopathology-free family members cohabiting with 97 patients with OCD. The items of the FAS were first subjected to principal component analysis (PCA) and the resulting domains of family accommodation (Participation, Modification, and Distress and Consequences) introduced as dependent variables in a series of multiple regression models assessing the relationship between family accommodation domains and a wide range of clinical variables, including Axis I and II psychopathology and symptom dimensions derived from the Yale-Brown Obsessive-Compulsive Scale (YBOCS) Symptom Checklist. The results showed that family accommodation was common, with the provision of reassurance, participation in rituals and assisting the patient in avoidance being the most frequent practices (occurring on a daily basis in 47%, 35%, and 43% of family members, respectively). The PCA of the YBOCS Symptom Checklist yielded four symptom dimensions, which were identical to those previously identified in the international literature. Multiple linear regression analyses showed that a higher score on the contamination/washing symptom dimension and a positive family history for an anxiety disorder other than OCD (referring to a family member other than the participant in this study) predicted greater scores on several domains of family accommodation. Our study confirms that family accommodation is frequent and distressing in psychopathology-free family members cohabiting with adult OCD patients. Family accommodation is particularly frequent and distressing when the patient has prominent contamination/washing symptoms and/or when another family member has a history of an anxiety disorder. Such families may be more likely to benefit from family-based interventions but this remains to be tested in controlled trials.

Outcome and length of stay in psychiatric hospitalization, the experience of the University Clinic of Turin

BACKGROUND

Given the current tendency to shorten psychiatric hospitalization and change its organization, an issue could be raised regarding its outcomes.

PURPOSE

To analyze features related to length of stay in a short-term inpatient treatment, to study outcomes and to evaluate the diagnosis-specific effects of hospitalization.

METHOD

A sample of 310 consecutive hospitalized patients, with psychotic disorder, depressive disorder and bipolar disorder (DSM IV-TR), was recruited at the University Psychiatric Clinic, Service for Cognitive Disorders, Department of Neuroscience, University of Turin. Severity of illness was rated using the brief psychiatry rating scale (BPRS). We evaluated relations between length of stay and clinical and socio-demographic features (linear regression) and possible differences confronting BPRS scores at admission and discharge in the different diagnostic subgroups (ANOVA for repeated measures).

RESULTS

All the sample of patients showed a significant improvement in symptomatology during hospitalization. Worse symptomatology in anxiety-depression domain of BPRS at admission in the whole sample was positively correlated with length of stay. A longer length of stay was also shown in patients with diagnosis of depressive disorder. Finally, a different pattern of improvement of BPRS (total score and domains) was shown between the different diagnostic groups.

CONCLUSION

Brief hospitalization in our service was shown to be highly effective. Different diagnostic groups had different response to hospitalization, showing faster improvement in characteristic symptomatology, but the anxiety-depression domain showed the highest percentage of change for all the diagnostic groups. We therefore suppose that hospitalization has two effects: a specific (due to tailored therapies) and a non-specific one (due to non-specific therapy and to a placebo-like effect).

Relative contributions of psychotic symptoms and insight to quality of life in stable schizophrenia

The purpose of this study was to examine the relative contributions of psychotic symptomatology such as delusions and hallucinations, and insight to quality of life (QOL) in a sample of outpatients with stable schizophrenia. Eighty-three consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. We performed a path analysis using a multiple regression technique to assess the specific effect of psychotic symptomatology on QOL and the possible mediating role of insight. Our findings suggested that (i) psychotic symptomatology was negatively correlated to both QOL and the two dimensions of insight we considered (awareness of symptoms and attribution of symptoms); (ii) the impact of insight on QOL was not uniform as attribution of symptoms positively predicted QOL, while the effect of symptom awareness was negative; (iii) when the mediation effect of insight was taken into account, psychotic symptomatology was no longer a significant predictor of QOL on its own. These results suggested a complex pattern of relationships between different dimensions of insight, QOL and psychotic symptomatology. Different dimensions of insight could be related to different aspects of outcome, and this would need to be reflected in rehabilitation programs.

Efficacy and tolerability of duloxetine in the treatment of patients with borderline personality disorder: a pilot study

Guidelines of the American Psychiatric Association for borderline personality disorder (BPD) indicate selective serotonin reuptake inhibitors and the serotonin and noradrenaline reuptake inhibitor (SNRI) venlafaxine for treating affective dysregulation and impulsive behavioural dyscontrol symptoms. The SNRI duloxetine has been studied in patients with major depression, generalized anxiety disorder and fibromyalgia, showing particular efficacy on somatic complaints. This study investigates duloxetine in the treatment of patients with BPD. Eighteen outpatients with a DSM-IV-TR diagnosis of BPD were treated with open-label duloxetine, 60 mg/day, for 12 weeks. Patients were assessed at baseline, week 4 and 12 with the CGI Severity item, the BPRS, the HAM-D, the HAM-A, the SOFAS, the BPD Severity Index (BPDSI) and the HSCL-90-Somatization Subscale (HSCL-90 SOM). Adverse effects were evaluated using the Dosage Record Treatment Emergent Symptom Scale. Statistics were performed with the analysis of variance. Significant P values were <or=0.05. Fourteen patients completed the study. Four patients (22.2%) discontinued treatment in the first 4 weeks because of non-compliance. A significant change was found for: BPRS, HAM-D, SOFAS, BPDSI total score and items 'impulsivity', 'outbursts of anger' and 'affective instability' and HSCL-90 SOM. Adverse effects were mild headache and nausea. Initial results suggest that duloxetine is an effective and well-tolerated treatment for BPD, with positive effects on somatic symptoms.

Cyclothymic temperament and major depressive disorder: a study on Italian patients

BACKGROUND

Classical authors had hypothesized that affective temperaments represent the subclinical manifestations of mood disorders: in particular, cyclothymic and hyperthymic temperaments have been considered as a subthreshold variant of bipolar disorder. The aim of our study is to test the presence of affective temperaments in a group of Italian patients with major depressive disorder (MDD), and to test the association between cyclothymic temperament and well-established validators of bipolar disorder diagnosis such as age at onset and family history of bipolar disorder.

METHODS

Patients with diagnosis of major depressive disorder (DSM-IV-TR) were included in the study. Affective temperaments have been evaluated through the Italian semistructured interview version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-I). In order to improve the accuracy of family history and age at onset reports, close family members of the patients were also interviewed.

RESULTS

104 of patients included in the study have completed the temperament interview. 25.5% were diagnosed with a dominant affective temperament. Cyclothymic affective temperament was the most represented in the sample of MDD patients (12.3%); depressive, hyperthymic and irritable temperaments have been detected respectively in 7.5%, 2.8% and 2.8% of patients. Patients with CT showed a significantly lower age at onset of MDD than "pure" MDD patients (31.9 vs. 40.9 years; p=0.049) and higher rates of family history of bipolar disorder in first degree relatives (15.4% vs. 0%; p=0.001).

LIMITATIONS

The major limitation of this study was the lack of a group of bipolar depressives, which would have been useful in order to confirm the similarities of age at onset and bipolar family history with cyclothymic MDD.

CONCLUSIONS

Our data confirm previous reports in a sample of accurately screened patients with unipolar major depression: we found that patients with a cyclothymic temperament had an earlier age at onset and a higher family history for bipolar disorder than patients without any dominant affective temperament. Further research is needed to ascertain whether patients with "unipolar" cyclothymic MDD respond to mood stabilizers.

Clinical predictors of health-related quality of life in obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a serious mental disorder that has severe impact on a person's quality of life and those living with a person with OCD. This study systematically examined the clinical variables that are predictive of several domains of quality of life in a large, well-characterized sample of patients attending a specialized treatment unit in Italy.

METHODS

The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was administered to 151 patients with OCD and their scores were compared to published Italian norms. A principal component analysis was performed on the 13 major categories of the Yale-Brown Obsessive-Compulsive Scale (YBOCS) Symptom Checklist to derive symptom dimension scores. The association between various domains of quality of life and a wide range of clinical variables, including symptom dimension scores, was examined using multiple regression models.

RESULTS

Compared to published Italian norms, patients with OCD showed impairment in most domains of quality of life, particularly social functioning. The principal component analysis of the YBOCS Symptom Checklist yielded 5 symptom dimensions that were identical to those previously identified in the international literature. Fewer years of education, higher depression scores (Hamilton Rating Scale for Depression), higher YBOCS obsessions scores, and higher scores on the contamination/washing symptom dimension independently predicted a poorer score on the physical health component of the SF-36. Higher YBOCS compulsions scores, the presence of a current mood disorder, and higher anxiety scores (Hamilton Rating Scale for Anxiety) predicted a poorer score on the mental health component of the SF-36.

CONCLUSIONS

Our study confirms that quality of life is severely impaired in patients with OCD. The identification of predictors of quality of life in OCD can help clinicians to adapt their treatment protocols to cater for the individual needs of their patients.

Adaptation of interpersonal psychotherapy to borderline personality disorder: a comparison of combined therapy and single pharmacotherapy

OBJECTIVE

Combined treatment with interpersonal psychotherapy (IPT) and antidepressants (ADs) has been found more effective than single pharmacotherapy in patients with major depression and concomitant borderline personality disorder (BPD). The aim of our study is to investigate whether combined treatment with a modified version of IPT is still superior to ADs when treating patients with a single diagnosis of BPD.

METHOD

Fifty-five consecutive outpatients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis of BPD were enrolled. They were randomly assigned to 2 treatment arms for 32 weeks: fluoxetine 20 to 40 mg per day plus clinical management; and fluoxetine 20 to 40 mg per day plus IPT adapted to BPD (IPT-BPD). Eleven patients (20%) discontinued treatment owing to noncompliance. Forty-four patients completed the treatment period. They were assessed at baseline, and at week 16 and 32 with: a semi-structured interview for demographic and clinical variables; Clinical Global Impression Scale (CGI-S); Hamilton Depression Rating Scale (HDRS); Hamilton Anxiety Rating Scale (HARS); Social and Occupational Functioning Assessment Scale (SOFAS); BPD Severity Index (BPD-SI); and a questionnaire for quality of life (Satisfaction Profile [SAT-P]). A univariate general linear model was performed with 2 factors: duration and type of treatment. P values of less than 0.05 were considered significant.

RESULTS

Remission rates did not differ significantly between subgroups. Duration, but not type of treatment, had a significant effect on CGI-S, HDRS, SOFAS, and total BPD-SI score changes. Combined therapy was more effective on the HARS; the items: interpersonal relationships, affective instability, and impulsivity of BPD-SI; and the factors: psychological functioning and social functioning of SAT-P.

CONCLUSIONS

Combined therapy with adapted IPT was superior to fluoxetine alone in BPD patients, concerning a few core symptoms of the disorder, anxiety, and quality of life.

Investigation of CNR1 and FAAH endocannabinoid gene polymorphisms in bipolar disorder and major depression

Experimental data suggest that the endogenous cannabinoid system is involved in mood regulation, but no study has been performed so far to investigate the role of endocannabinoid genes in the susceptibility to major depression (MD) and/or bipolar disorder (BD). We assessed the CB1 receptor gene (CNR1) single nucleotide polymorphism (SNP) rs1049353 (1359 G/A) and the fatty acid amide hydrolase (FAAH) gene rs324420 SNP (cDNA 385C to A) for their associations with MD and/or BD in 83 Caucasian patients with recurrent MD, 134 Caucasian individuals with BD, and 117 Caucasian healthy subjects. The distribution of the CNR1 1359 G/A genotypes and alleles significantly differed among the groups (chi(2)=12.595; df=4, P=0.01 for genotypes; chi(2)=13.773; df=2, P=0.001 for alleles) with MD patients showing a higher frequency of both AG, GG genotypes and A allele as compared to healthy controls. The distribution of the FAAH cDNA 385C to A genotypes, according to the CC dominant model (AA+AC vs. CC), significantly differed among the groups (chi(2)=6.626; df=2, P=0.04), with both BD patients and MD patients showing a non-significant slightly higher frequency of the AC genotype. These findings, although preliminary, suggest that the CNR1 1359 G/A and the FAAH cDNA 385C to A gene variants may contribute to the susceptibility to mood disorders.

[Bipolar disorders and metabolic syndrome: a clinical study in 185 patients]

AIMS

This study aimed to evaluate the prevalence of metabolic syndrome (MetS) in Italian patients with bipolar disorder (BD) and to determine the sociodemographic and clinical correlates of MetS in this patient population.

METHODS

185 subjects with BD I, II, NAS, cyclothymic disorder and schizoaffective disorder, bipolar subtype were included. Sociodemographic and clinical characteristics, lifestyle information (alcohol and smoking habits and rate of physical exercise) and comorbidity for cardiovascular diseases and diabetes were collected. Patients were assessed for MetS according to American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI) criteria.

RESULTS

MetS was present in 27.9% of the sample. Abdominal obesity was present in 48.9%, hypertension in 53.8%, high triglycerides in 36.6%, low HDL-C levels in 33.3% and fasting hyperglycemia in 11.5% of the sample. Of the investigated variables, age, duration of illness, rate of obesity and cardiovascular disease were higher in patients with MetS. MetS was also associated with the absence of physical activity.

CONCLUSIONS

MetS is highly prevalent in Italian patients with BD. Our 27.9% prevalence rate is similar to the rates reported in other European studies and lower than that in US studies. Elderly and obese patients with BD are at particularly high risk for MetS. The absence of physical exercise is also associated to MetS.

Exploring the role of face processing in facial emotion recognition in schizophrenia

OBJECTIVE

Impairment in emotion perception represents a fundamental feature of schizophrenia with important consequences in social functioning. A fundamental unresolved issue is the relationship between emotion perception and face perception. The aim of the present study was to examine whether facial identity recognition (Identity Discrimination) is a factor predicting facial emotion recognition in the context of the other factors, known as contributing to emotion perception, such as cognitive functions and symptoms.

METHODS

We enrolled 58 stable schizophrenic out-patients and 47 healthy subjects. Facial identity recognition and emotion perception were assessed with the Comprehensive Affect Testing System. Different multiple regression models with backward elimination were performed in order to discover the relation of each significant variable with emotion perception.

RESULTS

In a regression including the six significant variables (age, positive symptomatology, Identity Discrimination, attentive functions, verbal memory-learning, executive functions) versus emotion processing, only attentive functions (standardised β = 0.264, p = 0.038) and Identity Discrimination (standardised β = 0.279, p = 0.029) reached a significant level. Two partial regressions were performed including five variables, one excluding attentive functions and the other excluding Identity Discrimination. When we excluded attentive functions, the only significant variable was Identity Discrimination (standardised β = 0.278, p = 0.032). When we excluded Identity Discrimination, both verbal memory-learning (standardised β = 0.261, p = 0.042) and executive functions (standardised β = 0.253, p = 0.048) were significant.

CONCLUSIONS

Our results emphasised the role of face perception and attentional abilities on affect perception in schizophrenia. We additionally found a role of verbal memory-learning and executive functions on emotion perception. The relationship between those above-mentioned variables and emotion processing could have implications for cognitive rehabilitation.

Quality of life and psychopathology during the course of schizophrenia

OBJECTIVE

This study evaluated a population of outpatients with stable schizophrenia to analyze if relationships between patterns of symptomatology and quality of life (QOL) change during the time course of illness.

METHODS

We recruited 168 outpatients with stable schizophrenia, and we further divided our sample into 3 groups of patients (<or=36, 37-72, and >72 months of illness). Psychiatric assessment included the Quality of Life Scale, the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, and the Clinical Global Impression-Severity Scale. All clinical variables significantly related to Quality of Life Scale scores were subsequently analyzed using a multiple stepwise regression to assess their independent contribution to QOL in the 3 patient groups.

RESULTS

Quality of life and symptoms profiles were similar among patient groups. After controlling for potentially confounding variables, multiple regression revealed that depressive symptoms appeared to have a stronger relationship with QOL during the early 3-year course of the illness. In the period between 4 and 6 years of illness, negative symptoms were the most reliable predictors of QOL. After the 6-year course of illness, negative symptoms remained the most reliable predictors of QOL, together with severity of illness, whereas positive and depressive symptoms had a minor role.

CONCLUSIONS

Despite similar QOL and symptoms profiles, these findings suggested that relationships among patterns of symptomatology and QOL change during the course of schizophrenia.

Rationale and design of an independent randomised controlled trial evaluating the effectiveness of aripiprazole or haloperidol in combination with clozapine for treatment-resistant schizophrenia

BACKGROUND

One third to two thirds of people with schizophrenia have persistent psychotic symptoms despite clozapine treatment. Under real-world circumstances, the need to provide effective therapeutic interventions to patients who do not have an optimal response to clozapine has been cited as the most common reason for simultaneously prescribing a second antipsychotic drug in combination treatment strategies. In a clinical area where the pressing need of providing therapeutic answers has progressively increased the occurrence of antipsychotic polypharmacy, despite the lack of robust evidence of its efficacy, we sought to implement a pre-planned protocol where two alternative therapeutic answers are systematically provided and evaluated within the context of a pragmatic, multicentre, independent randomised study.

METHODS/DESIGN

The principal clinical question to be answered by the present project is the relative efficacy and tolerability of combination treatment with clozapine plus aripiprazole compared with combination treatment with clozapine plus haloperidol in patients with an incomplete response to treatment with clozapine over an appropriate period of time. This project is a prospective, multicentre, randomized, parallel-group, superiority trial that follow patients over a period of 12 months. Withdrawal from allocated treatment within 3 months is the primary outcome.

DISCUSSION

The implementation of the protocol presented here shows that it is possible to create a network of community psychiatric services that accept the idea of using their everyday clinical practice to produce randomised knowledge. The employed pragmatic attitude allowed to randomly allocate more than 100 individuals, which means that this study is the largest antipsychotic combination trial conducted so far in Western countries. We expect that the current project, by generating evidence on whether it is clinically useful to combine clozapine with aripiprazole rather than with haloperidol, provides physicians with a solid evidence base to be directly applied in the routine care of patients with schizophrenia.

Axis II comorbidity in euthymic bipolar disorder patients: no differences between bipolar I and II subtypes

BACKGROUND

Bipolar disorder type II (BDII) has been considered since its distinction from bipolar disorder type I (BDI) as a milder form, on the basis of cross-sectional symptoms intensity. Longitudinal data, on the contrary, do suggest that it is at least as severe as BDI, if not even more chronic and impairing. Few studies investigated differences in Axis II comorbidity in bipolar disorder patients according to bipolar subtypes, and none examined patients during prolonged euthymia. The aim of the study was to determine comorbidity rates for personality disorders in euthymic bipolar subjects, comparing bipolar type I and II disorders (BDI and BDII).

METHODS

186 DSM-IV (SCID-I) bipolar disorder subjects were enrolled; all patients were euthymic for at least two months, as confirmed by a HAM-D<8 and a YMRS<6. Axis II comorbidity was evaluated through SCID-II. Differences in Axis II comorbidity rates were examined with the Pearson's Chi-square test.

RESULTS

Of the subjects included, 71 had BDI and 115 BDII. At least a personality disorder was present in 42.5% of all bipolars, 43.7% of BDI and 41.7% of BDII. No differences were detected between the two subgroups for any single personality disorder.

LIMITATIONS

We relied only on the patients' reports in assessing personality disorders; the sample was made of subjects referred to a tertiary centre who were able to maintain euthymia.

CONCLUSIONS

Our study confirms the high comorbidity rates for personality disorders in bipolar subjects and provides evidence that BDII, with regard to Axis II comorbidity, is as severe as BDI.