[The value of re-evaluation and thorough family history taking for the diagnostic work-up of chorea]

The differential diagnosis of chorea encompasses a broad range of disorders. In psychiatry, tardive dyskinesia may be difficult to discern from other causes, particularly when the family history is negative. A 59-year-old man with an unclear medical history had been using risperidone for over a decade when we first saw him. He presented with severe dyskinesia in all extremities. The family history for neuropsychiatric disorders was negative. We interpreted the movement disorder as tardive dyskinesia, but later he turned out to suffer from Huntington’s disease. To improve diagnostic accuracy, we should have more frequently re-evaluated the differential diagnosis and our family history should have been more thorough. We outline the diagnostic considerations in patients presenting with chorea. Finally, we highlight the value of diagnostic re-evaluation and thorough family history taking to optimize diagnostic accuracy in neuropsychiatry.

[Towards personalized treatment with clozapine]

BACKGROUND

Clozapine is the most effective treatment for people with treatment-resistant schizophrenia. However, it is prescribed less often than guidelines indicate.

AIM

To personalize clozapine treatment, we investigated the efficacy of clozapine as first- or second-line treatment and investigated whether there are factors that were associated with efficacy and side effects.

METHOD

We collected a unique cohort of over 800 clozapine users diagnosed with a schizophrenia spectrum disorder. We meta-analyzed factors that were associated with response during clozapine treatment. Additionally, we conducted genetic association analyses to investigate the relations between side effects and symptom severity during clozapinetreatment.

RESULTS

From our meta-analyses, we found that clozapine was more effective when used as a first- or second-line treatment. Furthermore, we found that younger age, less negative symptoms and the paranoid subtype of schizophreniawere associated with a better clozapine response. Several specific locations on genes (loci) were associated with clozapine-induced agranulocytosis and neutropenia, while polygenic risk scores were associated with symptom severity.

CONCLUSION

We found that clozapine could be effective earlier in treatment and identified factors that could aid the prediction of< response to clozapine treatment in the future. These finding could contribute to the start of a personalized clozapine treatment.

[Sustainability in Flemish and Dutch mental health care]

BACKGROUND

The Flemish and Dutch (mental) health sectors cause greenhouse gas emissions and therefore will have to make an effort to reduce their climate impact.

AIM

To assess whether differences can be found in the climate policies of Flemish and Dutch mental health institutions.

METHOD

Descriptive research based on a sustainability questionnaire, in which concrete actions, objectives and ambitions in the field of sustainability were questioned at Flemish and Dutch mental health institutions.

RESULTS

59% and 38% of respectively the Flemish and Dutch institutions fully agreed that sustainability is a very important theme (with a main focus on sustainable energy transition and recycling in both regions). Statistically significant differences between both regions were only found with regard to fostering more sustainable commuting (stronger in Flanders; p < 0.0001). The climate impact of medicines and food, as well as investments in sustainable projects, received little attention.

CONCLUSION

Although a substantial part of Flemish and Dutch mental health institutions consider sustainability (very) important, a systemic ‘transformation’ will be necessary to make them climate neutral.

Examining facial emotion recognition as an intermediate phenotype for psychosis: Findings from the EUGEI study

BACKGROUND

Social cognition impairments, such as facial emotion recognition (FER), have been acknowledged since the earliest description of schizophrenia. Here, we tested FER as an intermediate phenotype for psychosis using two approaches that are indicators of genetic risk for schizophrenia: the proxy-genetic risk approach (family design) and the polygenic risk score for schizophrenia (PRS-SCZ).

METHODS

The sample comprised 2039 individuals with schizophrenia, 2141 siblings, and 2049 healthy controls (HC). The Degraded Facial Affect Recognition Task (DFAR) was applied to measure the FER accuracy. Schizotypal traits in siblings and HC were assessed using the Structured Interview for Schizotypy-Revised (SIS-R). The PRS-SCZ was trained using the Psychiatric Genomics Consortium results. Regression models were applied to test the association of DFAR with psychosis risk, SIS-R, and PRS-SCZ.

RESULTS

The DFAR-total scores were lower in individuals with schizophrenia than in siblings (RR = 0.97 [95% CI 0.97, 0.97]), who scored lower than HC (RR = 0.99 [95% CI 0.99-1.00]). The DFAR-total scores were negatively associated with SIS-R total scores in siblings (B = -2.04 [95% CI -3.72, -0.36]) and HC (B = -2.93 [95% CI -5.50, -0.36]). Different patterns of association were observed for individual emotions. No significant associations were found between DFAR scores and PRS-SCZ.

CONCLUSIONS

Our findings based on a proxy genetic risk approach suggest that FER deficits may represent an intermediate phenotype for schizophrenia. However, a significant association between FER and PRS-SCZ was not found. In the future, genetic mechanisms underlying FER phenotypes should be investigated trans-diagnostically.

[Genetic risk of mental illness: what do we know and how do we communicate this?]

Insights from psychiatric genetics research and large international psychiatric genetics consortia are promising but still remain outside the realm of clinical practice. <br> AIM: To provide an overview of developments in the field of psychiatric genetics; and to offer guidance for health professionals how to assess and manage clinical implications of these developments.<br> METHOD: In this review, we address: recent developments in psychiatric genetics, with a focus on polygenic risk scores (PRS); ethical dilemmas associated with clinical application of PRS; and basic principles of genetic counseling for psychiatric disorders.<br> RESULTS: PRS are not yet ready for implementation in clinical practice because of limited predictive value and poor generalizability. In addition, it is still unclear how genetic risk and PRS can be communicated clearly to patients and families.<br> CONCLUSION: Advances in psychiatric genetics and increased availability of genetic risk scores may lead to questions from patients and families coping with psychiatric illness. These questions may be best addressed using psychiatric genetic counseling techniques. We recommend that psychiatrists have some basic knowledge of psychiatric genetics and know how to refer their patients to a clinical geneticist. Implementing a psychiatric genetics theme in training and education may be helpful.<br>.

[Relating the history of genetics to the field of psychiatric genetics: the discovery, reading and writing of DNA]

The importance of genetics in psychiatry has been a topic of ongoing debate. The futile search for candidate genes underlying psychiatric disorders in the decades before 2007 resulted in overall disappointment. Since then, however, researchers and clinicians have witnessed the discovery of a plethora of common and rare genetic variants associated with psychiatric disorders.<br> AIM: To relate the history of general genetics to the history of psychiatric genetics, underlining how.<br> METHOD: Literature research.<br> RESULTS: The anatomical and physiological phases of this history have shaped the field of psychiatric genetics. We describe pivotal discoveries that have facilitated the uncovering, reading and writing of DNA. We then discuss several milestone discoveries in the field of psychiatric genetics. We end with an outlook on where the field of psychiatric genetics may be heading in the decades to come, arguing that a &lsquo;clinical phase&rsquo; of psychiatric genetics may be ahead of us.<br> CONCLUSION: The research with a focus on polygenic risk scores (PRS) could be translated into clinical practice in the coming years and we expect more attention to the question of how genetic variants cause psychiatric disorders. We look to future developments with some optimism.<br>.

[Interplay between genetic background and environmental factors in psychiatry: current situation and future prospects]

The hypothesis that etiopathogeneses of psychiatric disorders are determined by interplay between genetic background and environmental factors, as well their interactions can increasingly be put to direct scientific test, based on a wave of methodological, technological and knowledge developments.<br> AIM: To provide insight into and to provide perspective on some important scientific developments and facilitate challenges in this area.<br> METHOD: Narrative overview of the scientific literature and formulation of a concept and future perspective.<br> RESULTS: The overview points to concrete progress in the fields of genetic epidemiology, environmental analyses, gene-environment interactions and epigenetics in psychiatry. For example, recent studies have provided evidence for the existence of interactions and correlations between genetic and environmental factors, interdependence of risk-influencing effects of environmental factors, and translational neurobiological studies have identified biological processes that influence the impact of (or the response to) environmental influences on individuals mediate. These important steps to translate epidemiological research into testable biological hypotheses are facilitated by new techniques and the availability of large and relevant clinical and biological datasets.<br> CONCLUSION: Scientific progress on the interplay between genetic background and environmental factors enriches the conceptual framework of the etiopathogenesis of mental disorders and provides a future perspective in which we are likely to receive answers to a number of clinically relevant questions in the coming decade.<br>.

[Guidelines on genetic testing in psychiatry: an overview]

BACKGROUND

In recent years, technological advances have led to the identification of numerous genetic variations that are associated with psychiatric symptoms. Establishing a genetic cause may provide patients and family members with an explanation for the problems and in specific cases allows targeted treatment of psychiatric and somatic (co)morbidity. At present, patients with psychiatric disorders are rarely referred for genetic testing.

AIM

To provide an overview of literature and (inter)national guidelines in the field of genetic testing for patients with psychiatric disorder, and to present guidance on indications for genetic testing in clinical practice.

METHOD

A systematic search was conducted in PubMed and Embase focusing on articles with recommendations on genetic testing in psychiatric disorders. In addition, national and international guidelines on genetic testing in psychiatry were studied. The main findings were summarized in an infographic.

RESULTS

Based on the current literature and (inter)national guidelines, patients with (comorbid) intellectual disability should always be referred to a clinical geneticist. Psychiatrists should consider genetic testing in patients with other psychiatric disorders if there are &lsquo;red flags&rsquo; such as a positive family history, congenital abnormalities, developmental delay, dysmorphic features, movement disorders or cognitive decline. Psychiatrists may request genetic testing themselves or refer patients to clinical geneticists.

CONCLUSION

Psychiatric disorders may be underpinned by a genetic anomaly, particularly in patients presenting with psychiatric as well as somatic symptomatology. Psychiatrists should recognize symptoms and warning signs indicative of an underlying genetic abnormality, and know when to refer their patients for genetic testing.

The genetic basis of major depression

Major depressive disorder (MDD) is a common, debilitating, phenotypically heterogeneous disorder with heritability ranges from 30% to 50%. Compared to other psychiatric disorders, its high prevalence, moderate heritability, and strong polygenicity have posed major challenges for gene-mapping in MDD. Studies of common genetic variation in MDD, driven by large international collaborations such as the Psychiatric Genomics Consortium, have confirmed the highly polygenic nature of the disorder and implicated over 100 genetic risk loci to date. Rare copy number variants associated with MDD risk were also recently identified. The goal of this review is to present a broad picture of our current understanding of the epidemiology, genetic epidemiology, molecular genetics, and gene-environment interplay in MDD. Insights into the impact of genetic factors on the aetiology of this complex disorder hold great promise for improving clinical care.

[Validation of the Dutch Glasgow Anti- psychotic Side-Effect Scale for Clozapine]

BACKGROUND

To monitor the unique side effect pattern of clozapine, the Glasgow Antipsychotic Side-effect Scale for Clozapine (GASS-C) was developed in English and validated. This questionnaire was previously translated to Dutch, and revised, but not yet validated.

AIM

The current study concerns the validation of the second revision of the GASS-C-NL-R2 for the Dutch language.

METHOD

Two Spearman correlation tests were conducted to compare GASS-C-NL-R2 with the Dutch version of the Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) at two time p´oints. There was one week between these two time points. The test-retest reliability was determined using a Spearman correlation test and Cronbach's alpha on the GASS-C-NL-R2 between the two time points. In addition, a factor analysis was performed.

RESULTS

Spearman's correlation coefficient between the GASS-C-NL-R2 and the LUNSERS was 0.830 (p < 0.001, n = 72) at the first time point and 0.684 (p < 0.001, n = 50) at the second time point. GASS-C-NL-R2 also had a strong test-retest reliability: Spearman's correlation coefficient was 0.680 (p < 0.001; n = 46), and Cronbach's alpha was 0.847, n = 78. Factor analysis showed that all questions were relevant.

CONCLUSION

The current study shows that GASS-C-NL-R2 is a valid and reliable questionnaire to monitor side effects related to clozapine with a relatively high prevalence. Future studies should focus on the practical utility of GASS-C-NL-R2 with a larger sample size.

Demographic and clinical features as predictors of clozapine response in patients with schizophrenia spectrum disorders: A systematic review and meta-analysis

OBJECTIVES

Clozapine (CLZ) is prescribed to (relatively) treatment-resistant patients with schizophrenia spectrum disorders. Currently, it is unknown what factors predict response to CLZ. Therefore, we performed meta-analyses to identify predictors of CLZ response, hence aiming to facilitate timely and efficient prescribing of CLZ.

METHODS

A systematic search was performed in 'Pubmed' and 'Embase' until 1 January 2019. Articles were eligible if they provided data on predictors of CLZ response measured demographic and clinical factors at baseline or biochemical factors at follow-up in schizophrenia spectrum disorder patients.

RESULTS

A total of 34 articles, total number of participants = 9386; N unique = 2094, were eligible. Factors significantly associated with better CLZ response were: lower age, lower PANSS negative score and paranoid schizophrenia subtype.

CONCLUSION

The results of our meta-analyses suggest that three baseline demographic and clinical features are associated with better clozapine response, i.e. relatively young age, few negative symptoms and paranoid schizophrenia subtype. These variables may be taken into account by clinicians who consider treating a specific patient with CLZ.

[From genetic findings to clinical practice in psychiatry: how genetics may enable Precision Psychiatry]

Most psychiatric disorders are characterized by a complex genetic background where many common variants are involved. Nowadays, we are able to 'read' these variants, test for their association with phenotypes in genome-wide association studies (GWAS), and perform further downstream analyses. However, the impact of such findings on clinical psychiatry has remained largely unclear.<br/> AIM: To provide new insight into the degree of genetic overlap between psychiatric disorders and neurological disorders. And to investigate how genetic findings may impact clinical practice in psychiatry.<br/> METHOD: Bioinformatics and statistical methods were applied to perform analyses in large genetic datasets. In particular, we focused on: pathway analyses in schizophrenia; a multivariate GWAS of stress and trauma phenotypes; and genetic overlap analyses between amyotrophic lateral sclerosis (ALS) and schizophrenia. Finally, we assessed for which psychiatric disorders genetic findings are most likely to impact clinical practice in the near future.<br/> RESULTS: First, we found enrichment of common genetic variants associated with schizophrenia in synaptic signalling pathways relating to dopaminergic, acetylcholinergic and glutamatergic neurons. Second, we found that ALS and schizophrenia partly share common genetic risk. And third, we outline the clinical relevance of genetic cross-disorder studies in psychiatry, and posit that these studies have meaning for diagnostics, prognostics and treatment prediction in psychiatry.<br/> CONCLUSION: The summarized and previous genetic studies into psychiatric disorders will hopefully soon enable precision psychiatry, as genetics is a powerful tool to elucidate individualized risk profiles of patients and their responses to psychotropic medication. Genetic counselling allows clinicians to carefully balance the wide range of considerations in those patients and relatives with questions related to genetic underpinnings of disease and treatment response.

[Reaction on 'Hypomania induced by intranasal corticosteroid fluticasone spray']

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[Pancreatitis and thrombotic thrombocytopenic purpura caused by quetiapine-induced hypertriglyceridemia]

An important cause of hypertriglyceridemia in psychiatric patients is the administration of antipsychotics. Mildly elevated levels of triglycerides are seen most often, occurring shortly after treatment inception. Whether hypertriglyceridemia may be caused by alcohol use has not been fully elucidated. We describe the case of a 38-year-old woman suffering from schizophrenia who had been prescribed quetiapine for five years and consumed two glasses of alcohol daily. Upon presentation with stomach pain, lab results showed alarming triglyceride levels (8348 mg/dl). She rapidly developed both a severe pancreatitis and thrombotic thrombocytopenic purpura (ttp). We discuss how this most severe case of pancreatitis and ttp in a patient on an antipsychotic described in the literature to date should encourage prevention and early management of hypertriglyceridemia in psychiatric patients.

[In- and out-of-hospital emergency psychiatry: what is the best approach?]

A range of clinical syndromes may present with psychiatric symptoms, both in and out of hospital settings. In such situations agitation, suicidality, communication difficulties and legal aspects often play a role, making diagnosis and treatment a challenge. Based on several case studies, we illustrate how the recently-published Dutch open access source 'Acute Psychiatry' (www.acutepsychiatrie.com) can be of help in acute psychiatric presentations both within and outside psychiatric hospitals.

Peripheral blood gene expression profiles linked to monoamine metabolite levels in cerebrospinal fluid

The blood-brain barrier separates circulating blood from the central nervous system (CNS). The scope of this barrier is not fully understood which limits our ability to relate biological measurements from peripheral to central phenotypes. For example, it is unknown to what extent gene expression levels in peripheral blood are reflective of CNS metabolism. In this study, we examine links between central monoamine metabolite levels and whole-blood gene expression to better understand the connection between peripheral systems and the CNS. To that end, we correlated the prime monoamine metabolites in cerebrospinal fluid (CSF) with whole-genome gene expression microarray data from blood (N=240 human subjects). We additionally applied gene-enrichment analysis and weighted gene co-expression network analyses (WGCNA) to identify modules of co-expressed genes in blood that may be involved with monoamine metabolite levels in CSF. Transcript levels of two genes were significantly associated with CSF serotonin metabolite levels after Bonferroni correction for multiple testing: THAP7 (P=2.8 × 10^-8, β=0.08) and DDX6 (P=2.9 × 10^-7, β=0.07). Differentially expressed genes were significantly enriched for genes expressed in the brain tissue (P=6.0 × 10^-52). WGCNA revealed significant correlations between serotonin metabolism and hub genes with known functions in serotonin metabolism, for example, HTR2A and COMT. We conclude that gene expression levels in whole blood are associated with monoamine metabolite levels in the human CSF. Our results, including the strong enrichment of brain-expressed genes, illustrate that gene expression profiles in peripheral blood can be relevant for quantitative metabolic phenotypes in the CNS.

The involvement of GSK3beta in bipolar disorder: integrating evidence from multiple types of genetic studies

We aimed to get a comprehensive insight into the genetic evidence supporting the role of GSK3beta in bipolar disorder (BD). Using broad searches in NCBI's PubMed and the Genetic Association Database we looked for association, whole-genome linkage, genome-wide association, gene expression, pharmocogenomic, epigenetic, cytogenetic, and mouse model studies performed for BD until July 2009. Per gene, we rated the degree of converging evidence across these types of genetic studies. The genes most consistently associated with BD in the genetic studies we reviewed were GSK3beta , GRK3, 5-HTTLPR, GRIN3, COMT, and GLUR3. GSK3beta stood out as it was implicated in at least five types of genetic studies. Although our results are limited by design differences of included studies and possibly by publication bias, GSK3beta is a plausible candidate gene for BD from a pharmacological and a genetic perspective. Future studies investigating the effects of GSK3beta manipulation in BD seem warranted.