[Impairments in neurocognitive functions in patients with long COVID: A systematic review]

BACKGROUND

Studies have shown impairments in neurocognitive functions which persist more than 3 months after COVID-19 (long COVID). It remains unclear what these impairments entail, how long they persist and what proportion of the patients exhibit them.

AIM

To define the specific neurocognitive profile and to determine the proportion of deficits in at least one cognitive domain in patients with long COVID.

METHOD

We conducted a systematic search in PubMed according to PRISMA 2020 guidelines with the following inclusion criteria: peer reviewed publications in which patients were assessed more than 3 months following acute COVID-19 by means of a test battery for different domains of neurocognition.

RESULTS

We found a total of 1178 papers, of which 7 cohort studies and 1 case-control study were selected. The proportion of patients having deficits in at least one domain of neurocognition ranged from 23% to 100%. Most frequent impairments were found in attention and speed of information processing, anterograde memory, working memory and executive function. Quality of the included studies was moderate.

CONCLUSION

Impairments in neurocognitive functions are highly prevalent among patients with long COVID and include various cognitive domains. We encourage further research to continue studying the complex interaction of COVID-19, neurocognitive impairments and neuropsychiatric syndromes.

High unrecognized SARS-CoV-2 exposure of newly admitted and hospitalized psychiatric patients

BACKGROUND

Patients with pre-existing mental disorders are at higher risk for SARS-CoV-2 infection and adverse outcomes, and severe mental illness, including mood and psychosis spectrum disorders, is associated with increased mortality risk. Despite their increased risk profile, patients with severe mental illness have been understudied during the pandemic, with limited estimates of exposure in inpatient settings.

OBJECTIVE

The aim of this study was to describe the SARS-CoV-2 seroprevalence and antibody titers, and pro-inflammatory cytokine concentrations of newly admitted or hospitalized psychiatric inpatients without known history of COVID-19 infection, using robust quantitative multi-antigen assessments, and compare patients' exposure to that of hospital staff.

METHODS

This multi-centric, cross-sectional study compared SARS-CoV-2 seroprevalence and titers of 285 patients (University Psychiatric Centre Duffel [UPCD] N = 194; Assistance-Publique-Hopitaux de Paris [AP-HP] N = 91), and 192 hospital caregivers (UPCD N = 130; AP-HP N = 62) at two large psychiatric care facilities between January 1st and the May 30th 2021. Serum levels of SARS-CoV-2 antibodies against Spike proteins (full length), spike subunit 1 (S1), spike subunit 2 (S2), spike subunit 1 receptor binding domain (S1-RBD) and Nucleocapsid proteins were quantitatively determined using an advanced capillary Western Blot technique. To assess the robustness of the between-group seroprevalence differences, we performed sensitivity analyses with stringent cut-offs for seropositivity. We also assessed peripheral concentrations of IL-6, IL-8 and TNF-a using ELLA assays. Secondary analyses included comparisons of SARS-CoV-2 seroprevalence and titers between patient diagnostic subgroups, and between newly admitted (hospitalization ≤ 7 days) and hospitalized patients (hospitalization > 7 days) and correlations between serological and cytokines.

RESULTS

Patients had a significantly higher SARS-CoV-2 seroprevalence (67.85 % [95% CI 62.20-73.02]) than hospital caregivers (27.08% [95% CI 21.29-33.77]), and had significantly higher global SARS-CoV-2 titers (F = 29.40, df = 2, p < 0.0001). Moreover, patients had a 2.51-fold (95% CI 1.95-3.20) higher SARS-CoV-2 exposure risk compared to hospital caregivers (Fisher's exact test, P < 0.0001). No difference was found in SARS-CoV-2 seroprevalence and titers between patient subgroups. Patients could be differentiated most accurately from hospital caregivers by their higher Spike protein titers (OR 136.54 [95% CI 43.08-481.98], P < 0.0001), lower S1 (OR 0.06 [95% CI 0.02-0.15], P < 0.0001) titers and higher IL-6 (OR 3.41 [95% CI 1.73-7.24], P < 0.0001) and TNF-α (OR 34.29 [95% CI 5.00-258.87], P < 0.0001) and lower titers of IL-8 (OR 0.13 [95% CI 0.05-0.30], P < 0.0001). Seropositive patients had significantly higher SARS-COV-2 antibody titers compared to seropositive hospital caregivers (F = 19.53, df = 2, P < 0.0001), while titers were not different in seronegative individuals. Pro-inflammatory cytokine concentrations were not associated with serological status.

CONCLUSION

Our work demonstrated a very high unrecognized exposure to SARS-CoV-2 among newly admitted and hospitalized psychiatric inpatients, which is cause for concern in the context of highly robust evidence of adverse outcomes following COVID-19 in psychiatric patients. Attention should be directed toward monitoring and mitigating exposure to infectious agents within psychiatric hospitals.

Clinical predictors of kynurenine pathway aberrations in schizophrenia and bipolar disorder

Introduction

Schizophrenia and bipolar disorder are severe mental illnesses that are known to have a considerable overlap in underlying pathophysiological mechanisms. More specifically, disturbances in the kynurenine pathway have been hypothesized as processes bridging altered immune responses and clinical manifestations of these illnesses.

Objectives

The aim of this study was to investigate the abnormalities in serum kynurenine metabolites in schizophrenic and bipolar patients and the impact of clinical factors.

Methods

Four patient groups were included in the current study: 1) Acute bipolar inpatients (n=205); 2) stable bipolar outpatients (n=116); 3) acute schizophrenia inpatients (n=111) and 4) stable schizophrenia outpatients (n=75); and one healthy control group (n=185). Clinical symptoms were established using symptom severity scales. The quantitative determination of serum kynurenine metabolites was performed using LC-MS/MS. General linear model and multivariate linear regression analyses were used to perform the statistical analysis with JMP Pro 15.

Results

In line with previous research, the results indicate that serum kynurenine metabolites are disturbed in schizophrenic and bipolar patients compared to healthy controls. Whereas no differences were observed between schizophrenia and bipolar disorder, illness state and duration of illness clearly impacted kynurenine metabolite levels. Acutely ill patients had significantly lower levels compared to stable patients, which seemed to be driven by psychotic symptoms.

Conclusions

To conclude, the results confirm the involvement of the kynurenine pathway in the pathophysiology of schizophrenia and bipolar disorder by lowered peripheral kynurenine metabolite level. In addition, an important role of acute psychotic symptoms and longer illness duration on these metabolite aberrances is demonstrated.

Disclosure

No significant relationships.

The relationship between immune and cognitive dysfunction in mood and psychotic disorder: a systematic review and a meta-analysis

BACKGROUND

In psychotic and mood disorders, immune alterations are hypothesized to underlie cognitive symptoms, as they have been associated with elevated blood levels of inflammatory cytokines, kynurenine metabolites, and markers of microglial activation. The current meta-analysis synthesizes all available clinical evidence on the associations between immunomarkers (IMs) and cognition in these psychiatric illnesses.

METHODS

Pubmed, Web of Science, and Psycinfo were searched for peer-reviewed studies on schizophrenia spectrum disorder (SZ), bipolar disorder (BD), or major depressive disorder (MDD) including an association analysis between at least one baseline neuropsychological outcome measure (NP) and one IM (PROSPERO ID:CRD42021278371). Quality assessment was performed using BIOCROSS. Correlation meta-analyses, and random effect models, were conducted in Comprehensive Meta-Analysis version 3 investigating the association between eight cognitive domains and pro-inflammatory and anti-inflammatory indices (PII and AII) as well as individual IM.

RESULTS

Seventy-five studies (n = 29,104) revealed global cognitive performance (GCP) to be very weakly associated to PII (r = -0.076; p = 0.003; I² = 77.4) or AII (r = 0.067; p = 0.334; I² = 38.0) in the combined patient sample. Very weak associations between blood-based immune markers and global or domain-specific GCP were found, either combined or stratified by diagnostic subgroup (GCP x PII: SZ: r = -0.036, p = 0.370, I² = 70.4; BD: r = -0.095, p = 0.013, I² = 44.0; MDD: r = -0.133, p = 0.040, I² = 83.5). We found evidence of publication bias.

DISCUSSION

There is evidence of only a weak association between blood-based immune markers and cognition in mood and psychotic disorders. Significant publication and reporting biases were observed and most likely underlie the inflation of such associations in individual studies.

To diagnose or not to diagnose your BPD patient

Clinicians working in every field of psychiatry will likely encounter patients with borderline personality disorder (BPD) on a regular basis. Nevertheless, diagnostic assessment and disclosure in patients suspected to suffer from BPD can be difficult and even uncomfortable to many clinicians. In a survey among psychiatrists, 57% indicated they had failed to disclose a diagnosis of BPD at some point in their careers, citing diagnostic uncertainty and concerns about stigma as key issues.¹This workshop will engage the audience in an intensive discussion of when and how to disclose a suspected diagnosis of BPD to a patient, and how to involve the patient in the diagnostic process. Dr. De Picker will demonstrate how BPD diagnostic disclosure can become a key intervention in every psychiatric setting by using a two-step process. The first step involves a review of the DSM-5 diagnostic criteria together with the patient. This is always followed by a narrative explanation using either the interpersonal hypersensitivity model or emotional vulnerability model as trait factor. With these two steps, diagnostic disclosure creates both an important validating experience for the patient and a not to be missed opportunity for psycho-education about the heritability, prognosis and treatability of borderline personality disorder which installs hope, trust and confidence. References: 1. Sisti D, Segal AG, Siegel AM, Johnson R, Gunderson J. Diagnosing, disclosing, and documenting borderline personality disorder: a survey of psychiatrists’ practices. J Pers Disord 2016; 30: 848–56.

Engineering psychiatric education 2.0 in post-pandemic europe

In the world of medical education, there is generally a lot of emphasis on following procedure and tradition, and a reluctance to challenge the norm. It takes insight and courage to question traditional approaches and paradigms: why are psychiatric training programs done the way that they are? Reverse engineering involves taking something apart and analysing its workings to figure out how it does what it does and how it can be improved. In education, reverse engineering implies one determines learning outcomes upfront and then works back from them. Applied to postgraduate psychiatric training, it requires us to determine the basic principles or core concepts resulting in the successful formation of a well-rounded psychiatrist. In times of crisis there usually is more leeway to challenge the status-quo – hence the saying “never waste a good crisis”. Indeed, if the COVID-19 crisis has taught us anything, it is that education should be meeting learners where their attention is at, and that any healthcare organisation can be transformed within weeks when given the right incentives. In this workshop, Dr. De Picker will reflect on how post-COVID European psychiatric training can reinvent itself to address long-standing concerns and unmet needs. Innovative approaches will be needed to start shaping the psychiatrists of the future.

[Heterogeneity in psychiatry training in Europe: competition or collaboration?]

The European Union strives towards a mutual recognition of qualifications for medical specialists. Already in 1993, the European Union of Medical Specialists drafted non-binding quality criteria for every medical specialty. In psychiatry, however, European standardisation and quality control of the different national training programmes is currently still lacking.<br/> AIM: To describe the heterogeneity of psychiatric postgraduate training in Europe and its ensuing challenges.<br/> METHOD: We used the scientific literature and results from surveys conducted with European trainees between 2016 and 2018. <br/> RESULTS: Psychiatric training differed throughout Europe in terms of format, content and working conditions. The minimum duration of training in the European Union ranged from 4 to 7 years. Regarding content, the position of psychotherapy differed significantly between countries. Finally, the differences in subjective learning experiences were influenced by organisational variables, such as working hours and availability of supervision.<br/> CONCLUSION: Despite all efforts to harmonise psychiatry training in Europe, in practice there has been little progress towards this goal. Nevertheless, information on the differences in training variables between countries has become more readily available, and trainees may use this knowledge to actively shape their own education.

To which countries do European psychiatric trainees want to move to and why?

BACKGROUND

There is a shortage of psychiatrists worldwide. Within Europe, psychiatric trainees can move between countries, which increases the problem in some countries and alleviates it in others. However, little is known about the reasons psychiatric trainees move to another country.

METHODS

Survey of psychiatric trainees in 33 European countries, exploring how frequently psychiatric trainees have migrated or want to migrate, their reasons to stay and leave the country, and the countries where they come from and where they move to. A 61-item self-report questionnaire was developed, covering questions about their demographics, experiences of short-term mobility (from 3 months up to 1 year), experiences of long-term migration (of more than 1 year) and their attitudes towards migration.

RESULTS

A total of 2281 psychiatric trainees in Europe participated in the survey, of which 72.0% have 'ever' considered to move to a different country in their future, 53.5% were considering it 'now', at the time of the survey, and 13.3% had already moved country. For these immigrant trainees, academic was the main reason they gave to move from their country of origin. For all trainees, the overall main reason for which they would leave was financial (34.4%), especially in those with lower (<500€) incomes (58.1%), whereas in those with higher (>2500€) incomes, personal reasons were paramount (44.5%).

CONCLUSIONS

A high number of psychiatric trainees considered moving to another country, and their motivation largely reflects the substantial salary differences. These findings suggest tackling financial conditions and academic opportunities.

How EFPT trainee-led cross-national research can change training in psychiatry

Established in 2008, the Research Working Group of the European Federation of Psychiatric Trainees (EFPT) creates a platform for trainee-led collaborative studies. Several large-scale transnational studies on training-related subjects have been initiated and carried out, driven by psychiatry trainees. Examples of recent and ongoing projects are the Brain Drain study, which investigated migratory experiences and attitudes among trainees in Europe, and the TEO-PC project, which aims to raise awareness on UEMS Psychiatric competencies as well as to compile data on trainees’ experiences and satisfaction with their national training programs.

Earlier projects leading to publications have looked into drug prescription habits of trainees [1,2] and the interactions trainees with pharmaceutical industry [3]. Besides these projects, EFPT yearly gathers reports from the representatives of the national trainees associations on the structure, content and conditions of psychiatry training in all member countries. The information obtained through these channels is used actively to guide and influence policy related to psychiatry training, through collaboration with relevant organizations involved in the creation of guidelines, and through the EFPT statements, which serve to empower trainees themselves.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The psychiatry recruitment crisis across Europe: Evaluation by the European Federation of psychiatric trainees

Introduction

Recruitment of medical students and junior doctors in to psychiatry is a long-standing concern in many countries, with low proportions of medical graduates choosing it as a specialty and ongoing stigma from within the medical profession. In some countries the reverse problem is the case, with too many doctors wishing to enter psychiatry, and insufficient training places available.

Objectives

To understand the current situation within Europe with regards to recruitment in to psychiatry and to identify existing recruitment initiatives.

Methods

The European Federation of Psychiatric Trainees conducts an annual survey of all member organisations. A delegate of each national association of psychiatric trainees is asked to identify if their country has a problem with recruitment and if so, whether there were too many or too few applicants for training places. Delegates from countries with recruitment initiatives were contacted to provide further details.

Results

In 2014, a total of 31 countries completed the survey, with 17 stating that too few medical practitioners choose psychiatry. In total 8 countries with recruitment problems reported that initiatives exist to encourage doctors to enter psychiatric training. Of these, 7 responded to describe the initiatives, which included national recruitment strategies, financial incentives, careers fairs, mentoring schemes and a whole host of other projects.

Conclusions

Recruitment in to psychiatry remains a serious problem in a significant proportion of European countries, but a wide range of initiatives exist which aim to combat this shortfall. It will be important over the coming years to establish which initiatives are most effective at increasing recruitment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.