Transcranial magnetic stimulation and post-traumatic stress disorder

Introduction

Post-traumatic stress disorder (PTSD) is a psychiatric disorder characterized by symptoms from four clusters after exposure to a traumatic event: re-experiencing symptoms including flashbacks and nightmares, hyperarousal, avoidance of internal and external stimuli related to trauma, and negative alterations in mood and cognition. As a noninvasive intervention that uses induction of electromagnetic fields to modulate cortical circuitry, TMS has a substantial body of literature demonstrating safety, tolerability, and efficacy in depression and potentially PTSD.

Objectives

Our aim is to perform a non-systematic review of the literature regarding TMS and PTSD

Methods

A semi-structured review was conducted on Pubmed concerning TMS and PTSD

Results

The majority of studies utilize repetitive TMS targeted to the right dorsolateral prefrontal cortex (DLPFC) at low frequency (1 Hz) or high frequency (10 or 20 Hz), however others have used alternative frequencies, targeted other regions, or trialed different stimulation protocols utilizing newer TMS modalities such as theta-burst TMS (TBS). It is encouraging that were positive outcomes have been shown, and often sustained for up to -3 months, nevertheless there is a paucity of long-term studies directly comparing available approaches.

Conclusions

TMS appears safe and effective for PTSD, although important steps are needed to operationalize optimal approaches for patients.

Disclosure

No significant relationships.

Valproate-induced hypothyroidism in schizoaffective disorder

Introduction

Valproate is widely used in the treatment of maniac and mixed episodes and is well known to be safe with side effects being mostly related to hepatic disorders and psychomotor retardation.

Objectives

Raising attention to valproate-induced hypothyroidism that despite the increasing evidence tends to be neglected.

Methods

Here, we report a case of a 55-year-old woman, with a previous diagnosis of schizophrenia, treated for many years with 200mg of zuclopenthixol triweekly and 2mg of risperidone daily. Patient developed a maniac episode characterized by elevated mood, sense of grandiosity, increased energy and psychomotor activity, disinhibition and insomnia. No laboratory abnormalities were detected and inpatient treatment was initiated with paliperidone up to 12mg/day and valproate 1000mg/day.

Results

Patient showed progressive clinical recovery attaining full remission within 2 weeks. Despite the absence of clinical side effects and the valproate serum levels of 74.9μg/mL (range 50–100μg/mL), laboratory testing found progressive reduction F-T4 down to 0.45ng/dL (range 0.8–1.5 ng/dL) and a concomitant upregulation of TSH to 73.99mUI/L (range 0.55–4.8mUI/L). Thyroid autoantibodies and thyroid echography were negative. Considering that patient was previously medicated with risperidone, it was suspected that her hypothyroidism was caused by valproate. Normalization of thyroid function was observed after 21 days valproate withdrawal. Patient is currently being treated with 150 mg paliperidone (monthly) with no recurrence of mood or psychotic episodes and maintain normal thyroid function.

Conclusions

Our case emphasizes the need for extended laboratory testing upon prescription of new pharmacological medications as severe analytic alterations can take place in the absence of immediate clinical manifestation.

Disclosure

No significant relationships.

Group therapy in Schizophrenia. What’s the evidence?

Introduction

The American Psychiatric Association and NICE’s Guidelines for schizophrenia recommend psychosocial interventions as adjuvants to pharmacological treatment, highlighting the role of cognitive behavioral therapy for psychosis, psychoeducation, family intervention, cognitive remediation, autonomy training, social skills training, and supported employment. Although highly recommended in their individual forms current guidelines make no definitive statement about their group applicability.

Objectives

The goal of this work was to critically review the evidence of group interventions in schizophrenia

Methods

Non-systematic review of the literature with selection of scientific articles published in the past 10 years; by searching Pubmed and Medscape databases using the combination of MeSH descriptors. The following MeSH terms were used: “schizophrenia”, “group therapy”.

Results

Group therapy has shown important benefits in different conditions over the years, likely through mechanisms such as peer motivation, controlled confrontation, increased insight and even a tendency to homogenous results between group participants through peer influence. These results have been reproduced in schizophrenia though the benefits of applying group concepts to structured psychosocial interventions is still under study.

Conclusions

Recent evidence suggests some evidence-based interventions can be applicable in group form, namely social skills training, cognitive remediation, psychoeducation, and multifamily groups, synergizing the already known benefits with newer therapy models and decreasing costs for patients and healthcare systems. Adequate controlled studies between individual and group therapy will shed further light on this matter.

Disclosure

No significant relationships.

The role of Mediterranean Diet in mental health in pandemic times

Introduction

In late 2019, an epidemic outbreak emerges in China caused by a new coronavirus with high transmission and human infection potential which in March 2020, was characterized by WHO as a pandemic. The lockdown has repercussions on the population’s well-being, reflected in their food choices. There is a tendency to increase the consumption of energy dense food, rich in fat and carbohydrates, which are related to an increased risk of depression.

Objectives

The main goal of this non-systematic literature review was to understand the impact of the Mediterranean Diet on Mental Health promotion in SARSCoV-2 pandemic.

Methods

Literature from Pubmed database were searched, with the following keywords: COVID-19, Depression, Anxiety, Mental Health and Mediterranean Diet.

Results

Studies indicate that a diet based on the Mediterranean Diet is associated with a decreased risk of developing depressive symptoms, especially when there is moderate to high adherence to this dietary pattern. High consumption of plant and fish foods, reduced consumption of sugary products, processed and red meats and the use of olive oil as a fat source, are principles of the Mediterranean diet, associated with an improvement in endothelial function, increased levels of eicosanoids and serotonin synthesis and regulation of serotonin which seem to explain this protective effect.

Conclusions

In addition to decreasing the risk of obesity, diabetes, and hypertension, comorbidities associated with the most serious disease of COVID-19, the Mediterranean Diet seems to play an important role in promoting mental health, with a decreased risk of developing depressive symptoms.

Disclosure

No significant relationships.

How to manage antipsychotic-induced akathisia

Introduction

Akathisia is a relatively common adverse effect of antipsychotics although some second-generation antipsychotics are known to have a lower liability for the condition. The core feature of akathisia is mental unease characterized by a sense of agitation, usually accompanied by motor restlessness, which can cause patients to pace up and down and be unable to stay seated for more than a short time. An association between this discomfiting subjective experience and suicidal ideation has been postulated but remains uncertain.

Objectives

Our aim is to perform a non-systematic review of the literature regarding the current understanding of antipsychotic-induced akathisia and its management.

Methods

A semi-structured review was conducted on Pubmed concerning the relationship between akathisia and antipsychotics.

Results

All antipsychotics drugs can cause akathisia. The management of antipsychotic-induced akathisia should include a dose reduction of the antipsychotic treatment or a switch to quetiapine or olanzapine. If ineffective, a trial with propranolol may be useful as well as the addition of a 5-HT_2A antagonist like mirtazapine or mianserine. At last the inclusion of a benzodiazepine may be helpful albeit the risk of dependence and anticholinergics mainly when other extrapyramidal symptoms are present.

Conclusions

High‐dose antipsychotic medication, antipsychotic polypharmacy and rapid increase in antipsychotic dosage should be avoided to prevent akathisia. There is limited evidence for any pharmacological treatment for akathisia such as switching to an antipsychotic medication with a lower liability for the condition, or adding a beta‐adrenergic blocker, a 5‐HT_2A antagonist or an anticholinergic agent although some patients may benefit from such interventions.

Mechanisms linking gut microbiota to depression

Introduction

The gut microbiota constitute the largest and most diverse community in the body which is primarily responsible for the maintenance of the intestinal wall integrity and the protection against pathogens. Besides having an important role in the regulation of host energy metabolism, the gut microbiota can also influence neurodevelopment, modulate behavioral and might contribute to the development of psychiatry disorders.

Objectives

The authors elaborated a narrative literature review to understand how gut microbiota can influence depression.

Methods

Using PubMed as the database, a research was conducted about how Gut Microbiota relates with Depression.

Results

The microbiota-gut-brain axis encompasses the strong bidirectional communication between the gut microbiota and the CNS. Multiple mechanisms may be involved in this bilateral communication, including immune, endocrine and neural pathways. Permutations in the gut microbiome composition trigger microbial lipopolysaccharides production that activates inflammatory responses. Cytokines send signals to the vagus nerve, which links the process to the hypothalamic-pituitary-adrenal axis that consequently causes behavioral effects. Beyond this, gut microbiota have the capacity to produce many neurotransmitters and neuromodulators such as serotonin and can induce the secretion of the brain-derived neurotrophic factor, an important plasticity-related protein that promotes neuronal growth, development and survival.

Conclusions

Neuroinflammatory processes like those that occur in depression are deeply modulated by peripheral inflammatory stimuli, especially those from the intestinal microbiota. However, the knowledge is currently limited and the information available is not enough to understand the exact mechanisms. Therefore, more studies are required to show how gut microbiota influences the human brain.

Disclosure

No significant relationships.

Hopelessness in patients with schizophrenia

Introduction

Individuals with schizophrenia have a shortened average life expectancy, with a lifetime risk of suicide around 5%.

Objectives

Here we present a case of a patient diagnosed with schizophrenia who developed depressive symptoms with suicidal ideation, reactive to psychotic symptoms. Considering this specific case, the factors that contribute to the increased risk of suicide in these patients are reviewed.

Methods

Relevant clinical information was extracted from the patient’s clinical process. In addition, we searched Pubmed^R database with the terms “Schizophrenia”, “Hopelessness” and “Suicide”.

Results

A 40-year-old male patient, single and unemployed presents a progressive psychotic condition, with 20 years of evolution, with an impact on social and work behaviour. As a background he has a history of depressive episodes with suicidal ideation at the age of 36, following psychotic symptoms. This is a patient with preserved cognitive functioning combined with a high level of education, who understands the impact of his reality on his functioning. In this context, he develops feelings of hopelessness, that are the risk factor for suicide, most consistently reported in patients with schizophrenia.

Conclusions

This case assesses a patient with schizophrenia who has several factors, that contribute to an increased risk of suicide, focusing on hopelessness. In the future, it may be interesting to study in more detail the individual weight of each factor, so that it is possible to accurately predict the individual risk of each patient and, consequently, it is possible to implement preventive strategies.

Effects of psilocybin-assisted therapy on treatment-resistant depression

Introduction

Major depressive disorder is a highly prevalent clinical condition, affecting more than 300 million individuals worldwide. About 1/3 of patients with MDD fail to achieve remission despite treatment with multiple antidepressants and are considered to have treatment-resistant depression (TRD). Novel antidepressants with rapid and sustained effects on mood and cognition could represent a breakthrough in the TRD and may potentially improve or save lives. Psilocybin, a classic hallucinogen, more commonly found in the Psilocybe mushrooms has a combined serotonergic and glutamatergic action. The preliminary evidence of antidepressant effects of psilocybin-assisted therapy indicates the potential of psilocybin-assisted therapy as a novel antidepressant intervention.

Objectives

The authors elaborate a narrative literature review about the effects of Psilocybin-based therapy on patients diagnosed with treatment-resistant depression.

Methods

PubMed database searched using the terms “Treatment-Resistant Depression AND Psilocybin” and targeting clinical trials. References of selected articles and review articles were also assessed.

Results

2 articles evaluate psilocybin effects in 32 patients with TRD and showed that two doses of psilocybin alongside psychological support significantly reduces depressive symptoms. All patients presented some reduction in symptoms from baseline to one week after the second dose and reproduced immediate and substantial improvements in depression that ultimately could sustain up to 6 months.

Conclusions

Psilocybin-assisted therapy is a very appealing new possibility in the treatment of depression. However, due to the small populations of the existing trials, future studies are needed to prove this positive association and to fully understand Psilocybin’s mechanisms of actions and effects.

Disclosure

No significant relationships.

Systematic review of racial and ethnic disparities pertaining treatment in mental healthcare amongst incarcerated patients

Introduction

Research has shown that ethnic/racial minorities have a higher risk of homelessness, involvement with the criminal system, psychiatric misdiagnosis, treatment delay, and being prescribed first (versus second) generation antipsychotics.

Objectives

To investigate if the disparities found in the community are replicated in incarcerated patients.

Methods

Systematic review on PubMed for articles that fulfilled criteria for 4 domains: prison, psychosis, race/ethnic, and treatment.

Results

Forty-one articles matched the search criteria. Of those, 24 were irrelevant; 2 were inaccessible. Fifteen articles were considered; most highlighted the interplay between the criminal system, homelessness, mental disorders, and ethnic/racial minorities. Five articles highlighted differences in treatment. One stated that African-Americans and Asians were less likely than Whites to have access to mental health services. Concerning treatment for substance use disorders, one study found Hispanic inmates were more often engaged in treatment, followed by Caucasians and lastly, African-Americans; a different study reported the percentage of Whites and Blacks receiving treatment was similar, while Latinos were under-represented. Whites were most likely to have mental health counseling/substance use treatment as part of their sentence. A study from New-Zealand stated that treatment for mental disorders was less common for Maoris, in whom suicidal thoughts were often unrecognized. The last study reported a higher risk of self-harm for foreign patients, coupled with non-recognition/misinterpretation of symptoms.

Conclusions

Racial/ethnic inequalities show that disparities in healthcare are pervasive in all settings. More studies are needed to better understand the complex nature of this problem.

Disclosure

No significant relationships.

A social and ecological assessment of tropical land uses at multiple scales: the Sustainable Amazon Network

Science has a critical role to play in guiding more sustainable development trajectories. Here, we present the Sustainable Amazon Network (Rede Amazônia Sustentável, RAS): a multidisciplinary research initiative involving more than 30 partner organizations working to assess both social and ecological dimensions of land-use sustainability in eastern Brazilian Amazonia. The research approach adopted by RAS offers three advantages for addressing land-use sustainability problems: (i) the collection of synchronized and co-located ecological and socioeconomic data across broad gradients of past and present human use; (ii) a nested sampling design to aid comparison of ecological and socioeconomic conditions associated with different land uses across local, landscape and regional scales; and (iii) a strong engagement with a wide variety of actors and non-research institutions. Here, we elaborate on these key features, and identify the ways in which RAS can help in highlighting those problems in most urgent need of attention, and in guiding improvements in land-use sustainability in Amazonia and elsewhere in the tropics. We also discuss some of the practical lessons, limitations and realities faced during the development of the RAS initiative so far.

Prenatal diagnosis of abdominal enteric duplications

Alimentary tract duplications are rare congenital malformations with few reports of the antenatal sonographic appearance. Early diagnosis is of paramount importance to prevent complications. We present a case of a cystic gastric duplication diagnosed antenatally at 31 weeks' gestation, which was treated successfully. Simultaneously, we review all published cases of prenatally diagnosed enteric duplications.