Investigating the shared genetic basis and causal relationships between mucosa-associated lymphoid tissue inflammation and psychiatric disorders

Background

Chronic and acute inflammation of the mucosa-associated lymphoid tissue have been positively linked to the development of psychiatric disorders in observational studies. However, it remains unclear whether this association is causal. In the present study, we investigated this association, using as proxies genetically predicted tonsillectomy, appendectomy and appendicitis on psychiatric disorders including major depressive disorder (MDD), schizophrenia (SCZ), bipolar depression (BD) and anxiety (ANX) via a two-sample Mendelian randomization (MR) analysis.

Methods

Genetic association summary statistics for tonsillectomy, appendectomy and appendicitis were sourced from FinnGen Consortium, comprising data from 342,000 participants. Genetic correlations between all exposures and outcome were calculated with Linkage Disequilibrium Score (LDSC) Regression analysis. MR estimates were then calculated to assess their impact on the risk of developing psychiatric disorders. Sensitivity analysis was employed to test for any directional pleiotropy.

Results

Our results suggest that there is no direct causal association between tonsillectomy, appendectomy or appendicitis with a heightened risk for development of psychiatric disorders. The robustness of the results of the main MR analysis was further confirmed with additional sensitivity analyses. However, a moderate inverse genetic correlation was observed between tonsillectomy and MDD traits (rg=-0.39, p-value (P)=7.5x10-5).

Conclusion

Our findings provide, for the first time, evidence that there is no causal association between tonsillectomy or appendectomy on subsequent vulnerability of developing psychiatric disorders. Future studies using larger sample size GWAS should focus on unraveling the confounding factors and mediators to investigate this relationship further.

Insights into suicidal behavior among psoriatic arthritis patients: A systematic review and a genetic linkage disequilibrium analysis

OBJECTIVES

To systematically assess the magnitude of suicidal behavior among PsA patients and identify associated risk factors. Also identify common genes or coinherited single nucleotide polymorphisms (SNPs) implicated in suicidal behavior and PsA.

METHODS

Based on the PRISMA guidelines, we conducted a systematic literature review of the online databases PubMed/Medline, Web of Science, and EMBASE from inception to May 2022. Full-text original articles that describe suicidal behavior in PsA patients were eligible. All registered genome-wide association study (GWAS) data in the GWAS catalog database for PsA and psychiatric traits, such as suicidal behavior, and depression, were downloaded for further analysis.

RESULTS

A total of 48 articles were identified, and 6 were relevant to the study question .Among the 122,160 PsA patients, 700 had suicidal behavior (0,57%). The range of age in one study was between 30 and 49 years, and 64% of PsA patients with suicidal behavior were female. Among 13,899 PsA patients 74 had suicidal ideation (0.53%) and 125 suicide attempts occurred (0.9%). In two studies, among 17,383 patients, 13 complete suicides occurred (0.07%). A genetic haplotype on chromosomal region 6p21.1, spanning from 29,597,596 to 32,251,264 Mb, contains predisposing SNPs for PsA and depression. 6p21.1-6p21.3 is the chromosomal region containing the HLA genes of classes I, II and III.

CONCLUSION

Suicide behavior in PsA patients was associated with depression and other psychiatric comorbidities. Further evidence supports a genetic origin, at least partly. Awareness of these findings can help clinicians to recognize suicide behavior and prevent suicide attempts.

Patients' perspectives related to ethical issues and risks in precision medicine: a systematic review

Background

Precision medicine is growing due to technological advancements including next generation sequencing techniques and artificial intelligence. However, with the application of precision medicine many ethical and potential risks may emerge. Although, its benefits and potential harms are relevantly known to professional societies and practitioners, patients' attitudes toward these potential ethical risks are not well-known. The aim of this systematic review was to focus on patients' perspective on ethics and risks that may rise with the application of precision medicine.

Methods

A systematic search was conducted on 4/1/2023 in the database of PubMed, for the period 1/1/2012 to 4/1/2023 identifying 914 articles. After initial screening, only 50 articles were found to be relevant. From these 50 articles, 24 articles were included in this systematic review, 2 articles were excluded as not in English language, 1 was a review, and 23 articles did not include enough relevant qualitative data regarding our research question to be included. All full texts were evaluated following PRISMA guidelines for reporting systematic reviews following the Joanna Briggs Institute criteria.

Results

There were eight main themes emerging from the point of view of the patients regarding ethical concerns and risks of precision medicine: privacy and security of patient data, economic impact on the patients, possible harms of precision medicine including psychosocial harms, risk for discrimination of certain groups, risks in the process of acquiring informed consent, mistrust in the provider and in medical research, issues with the diagnostic accuracy of precision medicine and changes in the doctor-patient relationship.

Conclusion

Ethical issues and potential risks are important for patients in relation to the applications of precision medicine and need to be addressed with patient education, dedicated research and official policies. Further research is needed for validation of the results and awareness of these findings can guide clinicians to understand and address patients concerns in clinical praxis.

Cognitive impairment in adults under compulsory psychiatric care: association with psychotic symptoms and high-dose antipsychotics

BACKGROUND

There is limited evidence on the association between cognitive function, psychotic symptoms and doses of antipsychotics in adults under compulsory psychiatric care.

AIMS

We assessed (a) the degree of cognitive impairment in adults involuntarily hospitalised for compulsory psychiatric care and (b) correlation of Montreal Cognitive Assessment (MoCA) score with psychotic symptoms, polypharmacy and prescription of high-dose antipsychotics.

METHOD

This was a nationwide, cross-sectional study, conducted at the only referral state hospital for compulsory psychiatric care in Cyprus (December 2016-February 2018). Τhe MoCA was applied for the assessment of cognitive functioning. The Positive and Negative Syndrome Scale (PANSS) was applied for the assessment of psychotic symptoms.

RESULTS

The sample comprised 187 men and 116 women. The mean MoCA score was 22.09 (reported scale range (RSR): 3-30); the mean PANSS general symptoms subscale score was 49.60 (RSR = 41-162). The participants who reported positive psychiatric history (mean 21.71, s.d. 5.37), non-adherence to pharmacotherapy (mean 21.32, s.d. 5.56) and prescription of high-dose antipsychotics (with medication prescribed as needed: mean 21.31, s.d. 5.70; without medication prescribed as needed: mean 20.71, s.d. 5.78) had lower mean MoCA scores compared with those who reported negative psychiatric history (mean 23.42, s.d. 4.51; P = 0.017), adherence to pharmacotherapy (mean 23.10, s.d. 6.61; P = 0.003) and no prescription of high-dose antipsychotics (with medication prescribed as needed: mean 22.56, s.d. 4.90; without medication prescribed as needed: mean 22.60 s.d. 4.94; P = 0.045-0.005), respectively. Mean MoCA score was mildly and inversely associated with total PANSS score (r = -0.15, P = 0.03), PANSS general (r = -0.18, P = 0.002) and PANSS negative (r = -0.16, P = 0.005) symptoms subscales, respectively.

CONCLUSIONS

Our findings support the evaluation of cognitive functioning in adults under compulsory psychiatric care via the MoCA tool, with focus on those prescribed high-dose antipsychotics, with positive mental health history and non-adherence to pharmacotherapy.

Genome-wide association studies reveal shared genetic haplotypes of autoimmune rheumatic and endocrine diseases with psychiatric disorders

BACKGROUND

Several studies have shown that autoimmune diseases are associated with psychiatric diseases like depression and psychosis. Genetic evidence supports this association. The aim of this study was to investigate if genetic variants predisposing to autoimmune diseases and psychiatric disorders are genetically linked, constructing the common haplotypes.

METHODS

All registered single nucleotide polymorphisms (SNPs) in the Genome-wide association studies ("GWAS catalog") having been associated with autoimmune rheumatic and endocrine diseases were investigated for being in linkage disequilibrium with any psychiatric disorders' associated SNPs. Analysis was performed by the LDtrait and LDhap bioinformatics tools.

RESULTS

Multiple chromosomal regions have been detected containing rheumatic/endocrine diseases' predisposing SNPs and psychiatric disorders' predisposing SNPs. The genetic haplotypes have been constructed for some of these genetic regions. Six of the autoimmune rheumatic and endocrine diseases examined here share a common haplotype with psychiatric diseases at the HLA locus 6p21-22.

CONCLUSION

Our study shows that autoimmune diseases and psychiatric diseases are genetically linked. Genetic haplotypes have been constructed, showing in detail this genetic linkage.

Involuntary psychiatric admission in Cyprus: A descriptive correlational study

INTRODUCTION

Studies on the clinical and socio-demographic characteristics of those involuntarily admitted to psychiatric settings could help professionals and researchers to develop effective, targeted interventions, alternative to compulsory psychiatric care.

AIM

The association between socio-demographic and clinical characteristics in adults under involuntary hospitalization for psychiatric treatment in the Republic of Cyprus was assessed.

METHOD

This was a descriptive, cross-sectional and correlational study. Data collection was achieved (December 2016 to February 2018) via a census sampling method. Socio-demographic and clinical data of individuals involuntarily admitted to the reference psychiatric hospital of Cyprus with psychotic symptomatology were recorded.

RESULTS

The sample encompassed 144 females and 262 males. The most frequent diagnosis was schizophrenia or a relevant psychotic disorder (72.9%). The most frequent cause of admission was "Disorganized behaviour" along with non-adherence to pharmacotherapy (53.7%). Approximately 42.8% of the participants confirmed positive substance use history, which was more frequently reported in males than in females (88.5% vs. 11.5%, respectively, p < 0.001). Additionally, males were more frequently admitted due to Disorganized behaviour with substance use compared to females (31.3% vs. 4.9%, respectively, p < 0.001), while females were more frequently admitted due to d"Disorganized behaviour with non-adherence to pharmacotherapy (70.1% vs. 44.7%, respectively, p < 0.001). Also, males were more frequently involuntarily hospitalized due to suicidal/self-harming behaviour compared to females (12.2% vs. 5.6%, respectively, p = 0.031).

CONCLUSION

Gender differences were noted in relation to clinical characteristics of the participants, highlighting the need for gender-specific interventions to decrease compulsory psychiatric care, including enhancement of adherence to therapy.

Work-Related Traumatic Stress Response in Nurses Employed in COVID-19 Settings

Nurses may be at a higher risk of experiencing work-related traumatic stress response during the COVID-19 pandemic compared to other clinicians. This study aimed to investigate the correlations between work-related trauma symptoms and demographic factors, psychosocial hazards and stress response in a census sample of nurses working in COVID-19 settings in Cyprus. In this nationwide descriptive and cross-sectional study, data were collected between April and May 2020 using a questionnaire that included sociodemographic, educational and employment and work-related variables, as well as a modified version of the Secondary Traumatic Stress Scale (STSS) for the assessment of work-related trauma symptoms during the pandemic. Overall, 233 nurses participated (with a response rate of 61.3%) and 25.7% of them reported clinical work-related trauma symptoms (STSS-M > 55; actual scale range: 17-85). The mean value for emotional exhaustion was 7.3 (SD: 2.29; visual scale range: 1-10), while the value for distress that was caused by being avoided due to work in COVID-19 units was 6.98 (SD: 2.69; visual scale range: 1-10). Positive associations were noted between trauma symptoms and both emotional exhaustion and distress from being avoided by others due to work in a COVID-19 setting and a negative association was also found between trauma symptoms and satisfaction from organizational support variables (all p < 0.002). Working in COVID-19 settings during the pandemic is a stressful experience that has been linked to psychologically traumatic symptoms Thus, supportive measures are proposed for healthcare personnel, even in countries with low COVID-19 burden.

HPA-axis dysregulation is not associated with accelerated epigenetic aging in patients with hypersexual disorder

BACKGROUND

Hypersexual disorder (HD) - a nonparaphilic sexual desire disorder with impulsivity component - was evaluated for inclusion as a diagnosis in the DSM-5 and the diagnosis compulsive sexual behavior disorder is included as an impulse control disorder in the ICD-11. Hypothalamic-pituitary-adrenal (HPA)-axis hyperactivity is believed to affect cellular senescence and has been implicated in HD. No previous study investigated HD or HPA-axis dysregulation in relation to measures of epigenetic age (EA) acceleration.

METHODS

This study reports on a case-control study set-up from a well-characterized cohort, contrasting EA predictors in relation to 60 HD patients and 33 healthy volunteers (HV) and 19 mixed HD/HV exhibiting dexamethasone suppression test (DST) non-suppression to 73 mixed HD/HV DST controls. The genome-wide methylation pattern was measured in whole blood from 94 subjects using the Illumina Infinium Methylation EPIC BeadChip and preprocessed according to specialized protocols suitable for epigenetic age estimation. The online DNAm Age Calculator (https://dnamage.

GENETICS

ucla.edu/) was implemented to retrieve various EA predictors, which were compared between the in-silico generated subgroups.

RESULTS

Quality control analyses indicated strong correlations between the EA measure DNA methylation GrimAge (DNAm GrimAge - the EA clock most reliably associated with mortality risk) and chronological age in all sub-groups. The study was adequately powered to detect differences of 2.5 and 3.0 years in DNAm GrimAge minus age in relation to both HD and HPA-axis dysregulation, respectively. Baseline DNAm GrimAge exceeded chronological age by 2.8 years on average across all samples. No EA acceleration marker was associated with HD or DST suppression status (p > 0.05).

CONCLUSION

EA acceleration markers shown to be strongly predictive of physiological dysregulation and mortality-risk, are not related to HD or DST non-suppression status (measured after 0.5 mg dexamethasone). The independency of HPA-axis dysregulation to EA acceleration does not support the biological relevance of this dosage-regimen when applied to patients with HD. These findings do not support the notion of accelerated cellular senescence in HD. Studies stratifying DST non-suppressors according to established dosage-regimens in somatic settings are needed to fully elucidate the putative contribution of HPA-axis dysregulation to EA.

Accelerated epigenetic aging in suicide attempters uninfluenced by high intent-to-die and choice of lethal methods

Suicide attempts (SA) are associated with excess non-suicidal mortality, putatively mediated in part by premature cellular senescence. Epigenetic age (EA) estimators of biological age have been previously demonstrated to strongly predict physiological dysregulation and mortality risk. Herein, we investigate if violent SA with high intent-to-die is predictive of epigenetics-derived estimates of biological aging. The genome-wide methylation pattern was measured using the Illumina Infinium Methylation EPIC BeadChip in whole blood of 88 suicide attempters. Subjects were stratified into two groups based on the putative risk of later committed suicide (low- [n = 58] and high-risk [n = 30]) in dependency of SA method (violent or non-violent) and/or intent-to-die (high/low). Estimators of intrinsic and extrinsic EA acceleration, one marker optimized to predict physiological dysregulation (DNAmPhenoAge/AgeAccelPheno) and one optimized to predict lifespan (DNAmGrimAge/AgeAccelGrim) were investigated for associations to severity of SA, by univariate and multivariate analyses. The study was adequately powered to detect differences of 2.2 years in AgeAccelGrim in relation to SA severity. Baseline DNAmGrimAge exceeded chronological age by 7.3 years on average across all samples, conferring a mean 24.6% increase in relation to actual age. No individual EA acceleration marker was differentiated by suicidal risk group (p > 0.1). Thus, SA per se but not severity of SA is related to EA, implicating that excess non-suicidal mortality in SA is unrelated to risk of committed suicide. Preventative healthcare efforts aimed at curtailing excess mortality after SA may benefit from acting equally powerful to recognize somatic comorbidities irrespective of the severity inherent in the act itself.

High Plasma Oxytocin Levels in Men With Hypersexual Disorder

CONTEXT

Hypersexual disorder (HD) involves excessive, persistent sexual behaviors related to various mood states and the diagnosis compulsive sexual behavior disorder is included as an impulse control disorder in the 11th revision of the International Classification of Diseases. Although the neurobiology behind the disorder is not clear, some studies suggest dysregulated hypothalamic-pituitary-adrenal axis. Oxytocin acts as counterregulatory neuroendocrine hormone to cortisol and is also involved in sexual behavior.

OBJECTIVE

We hypothesized that oxytocin may play a role in the pathophysiology of HD with compensatory actions to cortisol.

DESIGN

Longitudinal.

SETTING

ANOVA clinic (Karolinska University Hospital).

PATIENTS OR OTHER PARTICIPANTS

64 males with HD and 38 age-matched healthy volunteers.

MAIN OUTCOME MEASURES

Plasma oxytocin levels, measured with radioimmunoassay; Hypersexual Disorder Screening Inventory; and Hypersexual Disorder: Current Assessment Scale for assessing hypersexual symptoms.

INTERVENTIONS

A patient subgroup (n = 30) completed the manual-based group-administered cognitive-behavioral therapy (CBT) program for HD, and posttreatment oxytocin levels were measured.

RESULTS

Hypersexual men (n = 64) exhibited significantly higher oxytocin plasma levels (mean ± SD: 31.0 ± 9.9 pM) compared with healthy volunteers (16.9 ± 3.9 pM; P < 0.001). There were significant positive correlations between oxytocin levels and the rating scales measuring hypersexual behavior. Patients who completed CBT treatment (n = 30) had a significant reduction of oxytocin plasma levels from pretreatment (30.5 ± 10.1 pM) to posttreatment (20.2 ± 8.0 pM; P < 0.001).

CONCLUSIONS

The results suggest that the hyperactive oxytocinergic system in hypersexual men may be a compensatory mechanism to attenuate hyperactive stress.

Depressive symptoms in higher education students during the COVID-19 pandemic: the role of containment measures

Background

Students are a vulnerable group for the indirect impact of the COVID-19 pandemic, particularly their mental health. This paper examined the cross-national variation in students’ depressive symptoms and whether this can be related to the various protective measures implemented in response to the initial stage of the COVID-19 outbreak.

Methods

Student data stem from the COVID-19 International Student Well-being Study, covering 26 countries during the first wave of the COVID-19 pandemic. Country-level data on government responses to the COVID-19 pandemic were retrieved from the Oxford COVID-19 Tracker. Multilevel analyses were performed to estimate the impact of the containment and economic support measures on students’ depressive symptoms (n = 78 312).

Results

School and workplace closures, and stay-at-home restrictions were positively related to students’ depressive symptoms during the COVID-19 pandemic, while none of the economic support measures significantly related to depressive symptoms. Countries’ scores on the index of these containment measures explained 1.5% of the cross-national variation in students’ depressive symptoms (5.3%). This containment index’s effect was stable, even when controlling for the economic support index, students’ characteristics, and countries’ epidemiological context and economic conditions.

Conclusions

Our findings raise concerns about the potential adverse effects of existing containment measures (especially the closure of schools and workplaces and stay-at-home restrictions) on students’ mental health.

Mental Health and Adherence to COVID-19 Protective Behaviors among Cancer Patients during the COVID-19 Pandemic: An International, Multinational Cross-Sectional Study

A population-based cross-sectional study was conducted during the first COVID-19 wave, to examine the impact of COVID-19 on mental health using an anonymous online survey, enrolling 9565 individuals in 78 countries. The current sub-study examined the impact of the pandemic and the associated lockdown measures on the mental health, and protective behaviors of cancer patients in comparison to non-cancer participants. Furthermore, 264 participants from 30 different countries reported being cancer patients. The median age was 51.5 years, 79.9% were female, and 28% had breast cancer. Cancer participants reported higher self-efficacy to follow recommended national guidelines regarding COVID-19 protective behaviors compared to non-cancer participants (p < 0.01). They were less stressed (p < 0.01), more psychologically flexible (p < 0.01), and had higher levels of positive affect compared to non-cancer participants. Amongst cancer participants, the majority (80.3%) reported COVID-19, not their cancer, as their priority during the first wave of the pandemic and females reported higher levels of stress compared to males. In conclusion, cancer participants appeared to have handled the unpredictable nature of the first wave of the pandemic efficiently, with a positive attitude towards an unknown and otherwise frightening situation. Larger, cancer population specific and longitudinal studies are warranted to ensure adequate medical and psychological care for cancer patients.

Association of clinical characteristics, disease activity and health-related quality of life in SLE patients with major depressive disorder

OBJECTIVE

To determine the contributing factors associated with major depressive disorder (MDD) in SLE patients and examine the association between disease-specific health-related quality of life [lupus quality of life (LupusQoL)] domains and MDD.

METHODS

Depression was assessed by the patient health questionnaire (PHQ)-9, and scores ≥10 indicate MDD. Demographic data, LupusQoL domains, clinical and other features of the SLE patients were described and compared between MDD (PHQ-9 ≥10) and non-MDD (PHQ-9 <10) groups using χ2 tests for categorical variables and Wilcoxon rank sum tests for non-normal continuous variables. The risk of MDD was evaluated for the patient and physician-reported features individually using log-binomial models to estimate relative risks and 95% confidence limits.

RESULTS

Eighty-eight patients with SLE met eligibility criteria, with a mean (range) age of 48.6 (19-80), mostly female (80%) and with a mean disease duration of 13.2 years. Compared with the non-MDD group, patients with MDD (n = 32, 36%) were more likely to have the following SLE manifestations: mucocutaneous, vascular, ocular, pulmonary and musculoskeletal involvement. Self-rated health described as poor/fair was markedly associated with MDD (P < 0.001, relative risk = 0.48). Based on relative risks, higher pain visual analogue score, and patient and physician global assessment scores were also linked to MDD. The LupusQoL domain scores were notably lower in the MDD patients, with a statistically significant reduction in all LupusQoL domains.

CONCLUSION

Predictors of MDD in SLE patients include higher scores in pain and global assessment, poor or fair self-reported health, and specific organ involvement. These findings may help clinicians to recognize and manage MDD promptly.

The COVID-19 International Student Well-Being Study (C-19 ISWS)

Abstract. The COVID-19 pandemic has had a great impact on the mental health and well-being of different populations including young adults. This study replicates and extends previous research by evaluating the impact of the COVID-19 pandemic on the well-being of college students in Cyprus, a Mediterranean island with unique sociocultural and genetic characteristics, and to identify risk factors related to the poor mental health of university students. Behavioral changes in the students before and during the quarantine period were also examined. A total of 387 university students completed an online survey coordinated by the Young Universities of Europe (YUFE) network. Results indicated that most of the sample (89.3%) reported depressive symptoms. Academic stress and academic satisfaction were associated with depressive symptoms and loneliness. Specifically, students with greater academic stress and lower academic satisfaction reported more symptoms of depression and felt lonelier. Younger students with poorer economic capital were more likely to feel depressed, and younger college students with higher academic stress were more likely to feel lonely. The results of t-test analyses indicated that quarantine affected students’ time and type of study turning to online studies and to moderate physical activities. The present study’s findings add to the existing literature and support the development of new measures to support students, both financially as well as psychologically.

HPA axis dysregulation is associated with differential methylation of CpG-sites in related genes

DNA methylation shifts in Hypothalamic-pituitary-adrenal (HPA) axis related genes is reported in psychiatric disorders including hypersexual disorder. This study, comprising 20 dexamethasone suppression test (DST) non-suppressors and 73 controls, examined the association between the HPA axis dysregulation, shifts in DNA methylation of HPA axis related genes and importantly, gene expression. Individuals with cortisol level ≥ 138 nmol/l, after the low dose (0.5 mg) dexamethasone suppression test (DST) were classified as non-suppressors. Genome-wide methylation pattern, measured in whole blood using the EPIC BeadChip, investigated CpG sites located within 2000 bp of the transcriptional start site of key HPA axis genes, i.e.: CRH, CRHBP, CRHR-1, CRHR-2, FKBP5 and NR3C1. Regression models including DNA methylation M-values and the binary outcome (DST non-suppression status) were performed. Gene transcripts with an abundance of differentially methylated CpG sites were identified with binomial tests. Pearson correlations and robust linear regressions were performed between CpG methylation and gene expression in two independent cohorts. Six of 76 CpG sites were significantly hypermethylated in DST non-suppressors (nominal P < 0.05), associated with genes CRH, CRHR1, CRHR2, FKBP5 and NR3C1. NR3C1 transcript AJ877169 showed statistically significant abundance of probes differentially methylated by DST non-suppression status and correlated with DST cortisol levels. Further, methylation levels of cg07733851 and cg27122725 were positively correlated with gene expression levels of the NR3C1 gene. Methylation levels of cg08636224 (FKBP5) correlated with baseline cortisol and gene expression. Our findings revealed that DNA methylation shifts are involved in the altered mechanism of the HPA axis suggesting that new epigenetic targets should be considered behind psychiatric disorders.

Combined Use of Web-Based and In-Person Education on Ill Health Self-management Skills in Adults With Bipolar Disorder: Protocol for a Mixed Methods Study

BACKGROUND

Addressing the enhancement of ill health self-management skills in adults diagnosed with bipolar disorder may be considered an important intervention for health care systems worldwide.

OBJECTIVE

This protocol describes the study "Management of my Bipolarity" (MoB), which aims to develop an educational intervention for adults with bipolar disorder and assess its effectiveness. The objectives include (a) a literature review on bipolar disorder educational interventions; (b) a qualitative exploration of the educational needs of people with bipolar disorder; (c) development of an educational intervention based on objectives (a) and (b) (ie, the MoB educational intervention); and (d) exploration of the effectiveness of the intervention regarding participants' knowledge of their mental health condition and enhancement of their ill health self-management skills. The MoB educational intervention will consist of an in-person and a web-based intervention in the form of a digital platform.

METHODS

The proposed interventional study is a combination of a qualitative and a quantitative design (mixed methods study). A focus group and content analysis will be implemented for the qualitative assessment of the educational needs of adults with bipolar disorder. The intervention will be developed based on the qualitative data of the study and relevant literature. The effectiveness of the acquired knowledge and self-management skills will be assessed according to (a) substance use behavior, (b) health locus of control, (c) impulse control, (d) adherence to pharmacotherapy, (e) relapse prevention, (f) improvement of quality of life, and (g) bipolar disorder knowledge level via structured instruments in the quantitative part of the study using descriptive and inferential statistics (SPSS version 24.0).

RESULTS

A total of 13 patients with bipolar disorder have been interviewed (8 women, 5 men) to identify educational needs to be covered through the intervention. Moreover, a literature review on bipolar disorder educational interventions has been completed. These data have been incorporated in the design of the MoB in-person intervention and the digital platform. The digital platform is live, and the development of the MoB in-person intervention was completed at the end of 2020. The recruitment of the participants for the intervention (40 patients) and the control group (40 patients) began during the first semester of 2021. Moreover, by tracking the platform for 1.5 years, we have recorded that 2180 users have visited the platform with an average session duration of almost 2 minutes. Mobile and tablet devices are being used by 70% of the visitors.

CONCLUSIONS

Since new parameters regarding educational interventions will be explored, these findings are expected to provide evidence that participation in structured educational interventions offers patients the opportunity to improve adherence to pharmacotherapy and increase their quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04643210; https://clinicaltrials.gov/ct2/show/NCT04643210.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25168.

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

BACKGROUND

Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients.

AIMS

We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns.

METHOD

This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded.

RESULTS

Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included.

CONCLUSIONS

A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

Depressive symptoms in involuntary hospitalized patients in Cyprus: Socio-demographic and psychopathological characteristics

Τhe severity and variation of depressive symptoms (DS), among psychotic individuals under involuntary hospitalization is unclear. We investigated the socio-demographic and clinical characteristics of psychotic adults with DS involuntarily hospitalized for compulsory treatment in Cyprus. We also evaluated the psychometric properties (internal consistency, known-group and discriminant validity) of the HDRS-17 and HAM-A for the assessment of depressive and anxiety symptoms, respectively. A descriptive correlational study with cross-sectional comparisons was applied. Data on demographics, cognitive functioning (MoCA scale), depressive (HDRS-17 scale), anxiety (HAM-A scale) and psychotic (PANSS scale) symptoms were collected (December 2016 -February 2018). Following informed consent, the sample included 406 patients. Among them, 21 males and 23 females reported DS (HDRS-17 total score ≥8). The latter were mainly Greek-Cypriots (61.4%), 45-65 years old (38.6%), single (77.3%), unemployed (72.7%), mainly admitted due to aggressiveness towards others (47.7%), most frequently diagnosed with a bipolar disorder (59.1%). The mean score (M) in the HDRS-17 was 30.72 (scale range: 8-50; Standard Deviation [SD]: 10.42). The highest mean score (M) per item was in the variables "Suicide behavior"'(M:3.09; SD:1.09) and "Depressive mood" (M=2.95; SD=1.07). The DS group (HDRS-17 score≥8) reported higher PANSS positive symptoms subscale score (t-test, p=0.003) and HAM-A total score (t-test, p=0.05) compared to the non-DS group (HDRS-17 score<8). In multivariable logistic regression analysis only female sex [OR (95%CI) = 3.28 (1.33.-8.04), p=0.01)] and a mood disorder diagnosis [OR95% CI: 15.22(4.13.-56.14), p<0.0001)] retained a statistically significant association with DS. Cronbach' s alpha was 0.827 for the HDRS, and 0.763 for the HAM-A. The present findings partially support the known-group validity of the HDRS-17 and the ΗΑΜ-Α, and the discriminant validity of the HDRS-17 in psychotic patients under involuntary hospitalization. Additionally, the most frequent diagnosis in the DS group was a bipolar disorder, and the most frequent admission cause was aggressiveness towards others; it is possible that the majority of the DS group participants were patients with a bipolar disorder in episodes with mixed features, presenting simultaneously depressive symptoms and aggressiveness. Further studies on relapse prevention regarding this clinical group are proposed, as well as studies on specificity and sensitivity of the HDRS-17 and HAM-A.

POS0711 SUICIDAL BEHAVIOUR IN SLE PATIENTS: A SYSTEMATIC LITERATURE REVIEW

Background:

Previous studies have demonstrated that SLE patients have a higher risk of suicidal behaviour, including suicidal ideation, attempt and complete suicide (1,2). Data describing the SLE patients’ clinical characteristics and risk factors of suicidal behaviour are lacking.

Objectives:

To determine the magnitude of suicidal behaviour among SLE patients and to examine predictors associated with suicidal behaviour.

Methods:

According to the PRISMA guidelines, we conducted a systematic literature review of the online databases, PubMed/Medline, EMBASE, and Web of Science, from inception to December 2020 (Figure 1). Full-text original articles that examined the relationship between SLE patients with suicidal behaviour were eligible for our review. Two reviewers independently review articles to assess eligibility using the Newcastle-Ottawa Scale and the Joanna Briggs Institute tools. Systematic reviews, metanalysis, narrative review, case reports, case series, including less than 10 patients and conference abstracts, were excluded.

Results:

Of the 64 articles identified, 22 were relevant to the study question; cross-sectional (n=8) and prospective cohorts (n=6) were the most frequently retrieved studies. Among the 27106 SLE patients with SLE, 802 had suicidal behaviour (2.9%), and of those, 87.9% were female. Suicide attempt occurred in 573/802 (71.4%) and complete suicide in 18/802 (2,3%). Major depressive disorder (MDD) was the most frequently reported coexisting psychiatric condition associated with suicidal behavior, followed by psychosis and social phobia. Several clinical manifestations were linked to suicidal behaviour, particularly neuropsychiatric lupus, mucocutaneous, renal involvement and serositis. Further, high scores in disease activity and damage indices were associated with suicidal behaviour.

Conclusion:

Suicidal behavior in SLE patients was associated with MDD, NPSLE, active disease and damage. Awareness of these findings can guide clinicians to recognize suicide behavior promptly and prevent suicide attempts.

References:

[1]Hajduk A, Nowicka-Sauer K, Smoleńska Ż, Czuszyńska Z, Zdrojewski Z. Prevalence and correlates of suicidal thoughts in patients with neuropsychiatric lupus. Lupus. 2016 Feb;25(2):185-92. doi: 10.1177/0961203315603136.

[2]Buji RI, Abdul Murad NA, Chan LF, Maniam T, Mohd Shahrir MS, Rozita M, Shamsul AS, Mohamad Hussain R, Abdullah N, Jamal R, Nik Jaafar NR. Suicidal ideation in systemic lupus erythematosus: NR2A gene polymorphism, clinical and psychosocial factors. Lupus. 2018 Apr;27(5):744-752. doi: 10.1177/0961203317742711.

Figure 1.

A PRISMA chart describing the inclusion/exclusion process

Disclosure of Interests:

None declared

Response to COVID-19 in Cyprus: Policy changes and epidemic trends

OBJECTIVES

In late July, Cyprus experienced the second epidemic wave of COVID-19. We present the steps taken by the government and evaluate their effect on epidemic trends.

MATERIALS

Cyprus Press and Information Office data were analysed. Using an R-based forecasting program, two models were created to predict cases up to 01/09/2020: Model 1, which utilised data up to 09/06/2020, when airports reopened to foreign travelers with COVID-19 screening; and Model 2, which utilised data until 24/06/2020, when screening for passengers from low-transmission countries was discontinued.

RESULTS

PIO data revealed no significant policy changes between 24/06/2020 and 31/07/2020. Prediction models were robust and accurate (Model 1, R²  = 0.999, P < .001; Model 2, R²  = 0.998, P < .001). By August 30th, recorded cases exceeded those predicted by Model 1 by 24.47% and by Model 2 by 20.95%, with P values <.001 for both cases.

CONCLUSIONS

The significant difference between recorded cases and those projected by Models 1 and 2 suggests that changes in epidemic trends may have been associated with policy changes after their respective dates. Discontinuation of major restrictions such as airport reopening, can destabilise the control of the epidemic, and may concomitantly necessitate a reevaluation of the current epidemic status. In the face of an evolving situation such as the COVID-19 pandemic, states are forced to balance the imposing of restrictions against their impact on the economy.

Impact of the COVID-19 pandemic on the mental health of health care workers in CYPRUS

Introduction

The coronavirus disease 2019 (COVID-19) has a great impact on health care workers (HCWs) who are exposed to high levels of stress and trauma leading to negative mental health outcomes, including stress-related symptoms and depressive symptoms.

Objectives

The aim of this study was to investigate the prevalence of depressive symptoms, anxiety and post traumatic stress symptoms related to to the COVID 19 pandemic in Cyprus.

Methods

In this cross-sectional study, we report on mental health outcomes among HCWs in Cyprus. Data were collected between May 3rd and May 27th, 2020, using an online questionnaire that included demographics, the 9-item Patient Health Questionnaire (PHQ-9), assessing depressive symptoms, the Impact of Events Scale Revised (IES-R) measuring PTSD symptoms and the 10 item Perceived Stress Scale (PSS) measuring stress.

Results

424 Health Care Workers (HCWs) participated in the study. 79 HCWs (18,6%) scored in PHQ-9 above the cut-off for depression while 62 HCWs (14,6%) scored high enough in IES-R indicating a diagnosis of post-traumatic stress disorder. The prevalence of depression and PTSD symptoms were significantly higher among nurses compared to doctors and other HCWs. (20.7% versus 10.8%; adjusted prevalence ratio, 1.70 [95% CI, 1.06 to 2.73]), after adjustment for age and sex.

Conclusions

Even in countries like Cyprus with minimum impact of the COVID-19 pandemic, the impact on the mental health of HCWs is substantial with nurses being more vulnerable.

Impact of the COVID-19 Pandemic on the Mental Health of Healthcare Workers

The coronavirus disease 2019 (COVID-19) has a great impact on healthcare workers (HCWs) that includes negative mental health outcomes, such as post-traumatic stress, anxiety and depressive symptoms. In this cross-sectional study, we report on mental health outcomes among HCWs in Cyprus. Data were collected between 3 May and 27 May 2020, with the use of an online questionnaire that included demographics (sex, age, occupation, education, work sector, years of work experience), the 9-item Patient Health Questionnaire (PHQ-9) which assesses depressive symptoms, the Impact of Events Scale Revised (IES-R), which measures post-traumatic stress disorder (PTSD) symptoms, and the-10 item Perceived Stress Scale (PSS-10) which quantifies stress responses. Participants (42% physicians, 24% nurses, 18% physiotherapists, 16% classified as “other”) were 58% of female gender and aged 21–76. A total of 79 (18.6%) and 62 HCWs (14.6%) reported clinically significant depressive (PHQ-9 ≥ 10) and post-traumatic stress (IES-R > 33) symptoms respectively. Nurses were more likely than physicians to suffer from depression (adjusted prevalence ratio 1.7 (1.06–2.73); p = 0.035) and PTSD (adjusted prevalence ratio 2.51 (1.49–4.23); p = 0.001). Even in a country with a rather low spread of the COVID-19, such as Cyprus, HCWs reported a substantial mental health burden, with nurses reporting increased depressive and PTSD symptoms compared to other HCWs.

Brief international cognitive assessment for multiple sclerosis (BICAMS) cut-off scores for detecting cognitive impairment in multiple sclerosis

BACKGROUND

Cognitive impairment (CI) affects 35-65% of multiple sclerosis (MS) patients. The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) has been proposed as a highly feasible and cost-effective tool for cognitive impairment (CI) screening in MS. The tool yields scores that should, ideally, readily convey patients' cognitive status to the clinicians.

METHODS

To this aim, this study sought for cut-off scores of the three BICAMS test in a sample of 960 MS patients. We used three definitions for CI: 1.5, 1,65 and 2 standard deviations below the mean. Receiver operating characteristic (ROC) statistics helped us determine the capacity of BICAMS to diagnose CI. Optimal cut-offs were determined by the delta distance. Positive and negative predictive values, along with overall accuracy were also calculated.

RESULTS

Symbol Digit Modalities Test (SDMT) and California Verbal Learning Test-II (CVLT-II) showed a diagnostic accuracy ranging from 74.6 to 77.4%, across the three CI definitions. The accuracy of Brief Visuospatial Memory Test-Revised (BVMT-R) was over 88%. SDMT had a balanced sensitivity, while CVLT-II and BVMT-R had higher specificities than sensitivities at detecting CI. More specifically, BVMT-R showed 100% specificity for all CI definitions. Raw cut-off scores for BICAMS tests are also provided within the manuscript, along with the diagnostic calculations.

CONCLUSIONS

In this study, we confirmed that BICAMS is a good screening tool for CI and that simple cut-offs can be used in the everyday neurological practice.

The Role of Perceived Organizational Support in Mental Health of Healthcare Workers During the COVID-19 Pandemic: A Cross-Sectional Study

Background: Data support the link between the coronavirus disease 2019 (COVID-19) pandemic and mental distress in healthcare workers (HCWs). Although previous studies have documented the association between organizational policies and employees' psychological and mental status, there is still scant evidence regarding the effect of perceived organizational support (POS) on mental distress in HCWs during the pandemic. Aims: The present study aimed to assess the association between POS and mental distress in HCWs during the COVID-19 pandemic. The role of POS in stress, depressive and trauma symptoms in HCWs was investigated. Methods: This was an online cross-sectional study in 424 HCWs. Data were collected during the first wave of the pandemic, and included demographics, a 7-item questionnaire assessing POS, the "Patient Health Questionnaire" assessing depressive symptoms, the "Impact of Events Scale Revised," measuring post-traumatic stress disorder (PTSD) symptoms and the "Perceived Stress Scale" assessing perceived stress. Results: The mean POS score was 3.33 [standard deviation:1.85; range 0-7]. Younger (p < 0.001), less experienced (p < 0.001), female (p = 0.002), and non-physician HCWs (p = 0.031) were more likely to report lower self-perceived organizational support than older, male, more experienced physicians. Self-perceived organizational support was significantly and negatively associated with and self-assessed intensity of stress, depressive and traumatic symptoms, after adjusting for putative confounders (p < 0.001). Discussion: Self-perceived organizational support was significantly associated with HCWs' self-assessed mental status during the pandemic. Organizational support and mental distress should be addressed simultaneously in HCWs during the COVID-19 pandemic to increase resilience among them.

Burnout among medical students in Cyprus: A cross-sectional study

OBJECTIVES

The primary aim was to estimate the burnout prevalence among all medical students at the Medical School of the University of Cyprus. Secondary aims were to ascertain the predictors of burnout and its relationship with lifestyle habits, sleep quality and mental health.

BACKGROUND

Burnout in the healthcare sector has drawn significant scientific attention over the last few years. Recent research underscored the large burden of profession-related burnout among medical students.

MATERIALS AND METHODS

An anonymous questionnaire was administered to all 189 eligible candidates. This included demographic and lifestyle characteristics. Sleep quality was assessed via the Pittsburg Sleep Quality Index, mental health was assessed via the mental health (MH) domain of the 36-item Short Form Health Survey (SF-36) and burnout with the Maslach Burnout Inventory-Student Survey (MBI-SS).

RESULTS

Overall response rate was 96.3%. The burnout prevalence was 18.1%. There was a significant linear effect of between the year of studies and the burnout frequency [F(1) = 5.09, p = 0.024], implying that with increasing academic year there were more students with burnout, especially after the 4th year of education which signifies the beginning of clinical education. Students with burnout were more likely to have poor sleep quality (90.9% vs. 60.8%, odds ratio 4.33, p = 0.023) and worse mental health (MH score 40.2 ± 17.7 vs 62.9 ± 20.3, p<0.001). Alcohol consumers had more symptoms of cynicism and less feelings of efficacy than non-alcohol consumers. Moreover, less feelings of efficacy were significantly associated with more alcohol consumption among alcohol consumers.

CONCLUSIONS

Burnout is prevalent in medical students and increases significantly during the clinical years. Students with burnout have worse sleep and mental health and might use alcohol as a coping mechanism. Implementing prevention strategies of burnout may be beneficial.

Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder

INTRODUCTION

Hypersexual disorder as suggested to be included in the Diagnostic and Statistical Manual of Mental Disorders-5 integrates aspects of sexual desire deregulation, impulsivity, and compulsivity. However, it is unknown how it affects gonadal activity and the function of the hypothalamus-pituitary-gonadal (HPG) axis.

AIM

The aim of this study was to investigate testosterone and luteinizing hormone (LH) levels in hypersexual men compared with healthy controls. Furthermore, we investigated associations between epigenetic markers and hormone levels.

METHODS

Basal morning plasma levels of testosterone, LH, and sex hormone-binding globulin (SHBG) were assessed in 67 hypersexual men (mean age: 39.2 years) compared with 39 age-matched healthy controls (mean age: 37.5 years). The Sexual Compulsivity Scale and the Hypersexual Disorder: Current Assessment Scale were used for assessing hypersexual behavior, the Montgomery-Åsberg Depression Scale-self rating was used for depression severity, and the Childhood Trauma Questionnaire (CTQ) was used for assessing history of childhood adversity. The genome-wide methylation pattern of more than 850 K CpG sites was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. CpG sites located within 2,000 bp of the transcriptional start site of hypothalamus pituitary adrenal (HPA) and HPG axis-coupled genes were included.

MAIN OUTCOME MEASURES

Testosterone and LH plasma levels in association with clinical rating and a secondary outcome was the epigenetic profile of HPA and HPG axis-coupled CpG sites with testosterone and LH levels.

RESULTS

LH plasma levels were significantly higher in patients with hypersexual disorder than in healthy volunteers. No significant differences in plasma testosterone, follicle stimulating hormone, prolactin, and SHBG levels were found between the groups. There were no significant associations between DNA methylation of HPA and HPG axis-coupled genes and plasma testosterone or LH levels after multiple testing corrections.

CONCLUSIONS

Subtle dysregulation of the HPG axis, with increased LH plasma levels but no difference in testosterone levels may be present in hypersexual men. Chatzittofis A, Boström AE, Öberg KG, et al. Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder. Sex Med 2020;8:243-250.

Hypermethylation-associated downregulation of microRNA-4456 in hypersexual disorder with putative influence on oxytocin signalling: A DNA methylation analysis of miRNA genes

Hypersexual disorder (HD) was proposed as a diagnosis in the DSM-5 and the classification ‘Compulsive Sexual Behavior Disorder’ is now presented as an impulse-control disorder in ICD-11. HD incorporates several pathophysiological mechanisms; including impulsivity, compulsivity, sexual desire dysregulation and sexual addiction. No previous study investigated HD in a methylation analysis limited to microRNA (miRNA) associated CpG-sites. The genome wide methylation pattern was measured in whole blood from 60 subjects with HD and 33 healthy volunteers using the Illumina EPIC BeadChip. 8,852 miRNA associated CpG-sites were investigated in multiple linear regression analyses of methylation M-values to a binary independent variable of disease state (HD or healthy volunteer), adjusting for optimally determined covariates. Expression levels of candidate miRNAs were investigated in the same individuals for differential expression analysis. Candidate methylation loci were further studied for an association with alcohol dependence in an independent cohort of 107 subjects. Two CpG-sites were borderline significant in HD – cg18222192 (MIR708)(p < 10E-05,p_FDR = 5.81E-02) and cg01299774 (MIR4456)(p < 10E-06, p_FDR = 5.81E-02). MIR4456 was significantly lower expressed in HD in both univariate (p < 0.0001) and multivariate (p < 0.05) analyses. Cg01299774 methylation levels were inversely correlated with expression levels of MIR4456 (p < 0.01) and were also differentially methylated in alcohol dependence (p = 0.026). Gene target prediction and pathway analysis revealed that MIR4456 putatively targets genes preferentially expressed in brain and that are involved in major neuronal molecular mechanisms thought to be relevant for HD, e.g., the oxytocin signalling pathway. In summary, our study implicates a potential contribution of MIR4456 in the pathophysiology of HD by putatively influencing oxytocin signalling.

Epigenetic Changes in the CRH Gene are Related to Severity of Suicide Attempt and a General Psychiatric Risk Score in Adolescents

The aim of this study, comprising 88 suicide attempters, was to identify hypothalamic-pituitary-adrenal (HPA) -axis coupled CpG-sites showing methylation shifts linked to severity of the suicide attempt. Candidate methylation loci were further investigated as risk loci for a general psychiatric risk score in two cohorts of adolescents (cohort 1 and 2). The genome-wide methylation pattern was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. Subjects were stratified into high-risk and low-risk groups based on the severity of the suicidal behavior. We included CpG sites located within 2000 basepairs away from transcriptional start site of the following HPA-axis coupled genes: corticotropin releasing hormone (CRH), corticotropin releasing hormone binding protein (CRHBP), corticotropin releasing hormone receptor 1 (CRHR1), corticotropin releasing hormone receptor 2 (CRHR2), FK506-binding protein 51 (FKBP5) and the glucocorticoid receptor (NR3C1). The methylation state of two corticotropin releasing hormone (CRH)-associated CpG sites were significantly hypomethylated in the high-risk group of suicide attempters (n = 31) (cg19035496 and cg23409074) (p < 0.001). Adolescent cohort 1 and 2 consisted of 129 and 93 subjects, respectively, and were stratified by the in silico generated DAWBA measurements of a general psychiatric risk score into high-risk group (>~50% risk) or controls. In adolescent cohort 2, cg19035496 was hypermethylated in subjects with a high general psychiatric risk score. Our results show epigenetic changes in the CRH gene related to severity of suicide attempt in adults and a general psychiatric risk score in adolescents.

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Two CRH-associated CpG sites were significantly hypomethylated in the high-risk group of suicide attempters.

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In adolescent cohort, cg19035496 was hypermethylated in subjects with a high general psychiatric risk score.

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Epigenetic modulatory effects on the HPA axis dysregulation are associated with psychiatric illness and suicidal behavior.

In this study, comprising 88 suicide attempters, we aimed to identify epigenetic changes in stress system linked to severity of the suicide attempt. In the next step, we investigated if the same epigenetic changes could be detected in adolescents with high risk for psychiatric illness. The methylation pattern was measured in blood and subjects were stratified into high-risk and low-risk groups based on the severity of the suicidal behavior. One corticotropin releasing hormone (CRH)-a key regulator of stress system-associated CpG site showed less methylation in the high-risk group and was hypermethylated in adolescents with a high general psychiatric risk score. Epigenetic changes in the CRH gene were related to severity of suicide attempt in adults and a general psychiatric risk score in adolescents.

Interpersonal violence, early life adversity, and suicidal behavior in hypersexual men

Background and aims There are significant gaps in knowledge regarding the role of childhood adversity, interpersonal violence, and suicidal behavior in hypersexual disorder (HD). The aim of this study was to investigate interpersonal violence in hypersexual men compared with healthy volunteers and the experience of violence in relation to suicidal behavior. Methods This case-control study includes 67 male patients with HD and 40 healthy male volunteers. The Childhood Trauma Questionnaire - Short Form (CTQ-SF) and the Karolinska Interpersonal Violence Scale (KIVS) were used for assessing early life adversity and interpersonal violence in childhood and in adult life. Suicidal behavior (attempts and ideation) was assessed with the Mini-International Neuropsychiatric Interview (version 6.0) and the Montgomery-Åsberg Depression Rating Scale - Self-rating. Results Hypersexual men reported more exposure to violence in childhood and more violent behavior as adults compared with healthy volunteers. Suicide attempters (n = 8, 12%) reported higher KIVS total score, more used violence as a child, more exposure to violence as an adult as well as higher score on CTQ-SF subscale measuring sexual abuse (SA) compared with hypersexual men without suicide attempt. Discussion Hypersexuality was associated with interpersonal violence with higher total scores in patients with a history of suicide attempt. The KIVS subscale exposure to interpersonal violence as a child was validated using the CTQ-SF but can be complemented with questions focusing on SA for full assessment of early life adversity. Conclusion Childhood adversity is an important factor in HD and interpersonal violence might be related to suicidal behavior in hypersexual men.

Methylation of HPA axis related genes in men with hypersexual disorder

Hypersexual Disorder (HD) defined as non-paraphilic sexual desire disorder with components of compulsivity, impulsivity and behavioral addiction, and proposed as a diagnosis in the DSM 5, shares some overlapping features with substance use disorder including common neurotransmitter systems and dysregulated hypothalamic-pituitary-adrenal (HPA) axis function. In this study, comprising 67 HD male patients and 39 male healthy volunteers, we aimed to identify HPA-axis coupled CpG-sites, in which modifications of the epigenetic profile are associated with hypersexuality. The genome-wide methylation pattern was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip, measuring the methylation state of over 850K CpG sites. Prior to analysis, the global DNA methylation pattern was pre-processed according to standard protocols and adjusted for white blood cell type heterogeneity. We included CpG sites located within 2000bp of the transcriptional start site of the following HPA-axis coupled genes: Corticotropin releasing hormone (CRH), corticotropin releasing hormone binding protein (CRHBP), corticotropin releasing hormone receptor 1 (CRHR1), corticotropin releasing hormone receptor 2 (CRHR2), FKBP5 and the glucocorticoid receptor (NR3C1). We performed multiple linear regression models of methylation M-values to a categorical variable of hypersexuality, adjusting for depression, dexamethasone non-suppression status, Childhood Trauma Questionnaire total score and plasma levels of TNF-alpha and IL-6. Of 76 tested individual CpG sites, four were nominally significant (p<0.05), associated with the genes CRH, CRHR2 and NR3C1. Cg23409074-located 48bp upstream of the transcription start site of the CRH gene - was significantly hypomethylated in hypersexual patients after corrections for multiple testing using the FDR-method. Methylation levels of cg23409074 were positively correlated with gene expression of the CRH gene in an independent cohort of 11 healthy male subjects. The methylation levels at the identified CRH site, cg23409074, were significantly correlated between blood and four different brain regions. CRH is an important integrator of neuroendocrine stress responses in the brain, with a key role in the addiction processes. Our results show epigenetic changes in the CRH gene related to hypersexual disorder in men.

CSF and plasma testosterone in attempted suicide

Very few studies have assessed testosterone levels in the cerebrospinal fluid in suicide attempters. Aggressiveness and impulsivity are common behavioural traits in suicide attempters. Dual-hormone serotonergic theory on human impulsive aggression implies high testosterone/cortisol ratio acting on the amygdala and low serotonin in the prefrontal cortex. Our aim was to examine the CSF and plasma testosterone levels in suicide attempters and in healthy volunteers. We also assessed the relationship between the testosterone/cortisol ratio, aggressiveness and impulsivity in suicide attempters. 28 medication-free suicide attempters and 19 healthy volunteers participated in the study. CSF and plasma testosterone sulfate and cortisol levels were assessed with specific radio-immunoassays. The Karolinska Scales of Personality was used to assess impulsivity and aggressiveness. All patients were followed up for cause of death. The mean follow-up period was 21 years. Male suicide attempters had higher CSF and plasma testosterone levels than age- matched male healthy volunteers. There were no significant differences in CSF testosterone levels in female suicide attempters and healthy female volunteers. Testosterone levels did not differ significantly in suicide victims compared to survivors. In male suicide attempters, the CSF testosterone/cortisol ratio showed a significant positive correlation with both impulsivity and aggressiveness. Higher CSF testosterone levels may be associated with attempted suicide in young men through association with both aggressiveness and impulsivity, a key endophenotype in young male suicide attempters.

CSF and plasma oxytocin levels in suicide attempters, the role of childhood trauma and revictimization

OBJECTIVE

Some studies have reported an inverse relationship between childhood adversity and oxytocin levels. The purpose of this study was to assess the relationship between CSF and plasma oxytocin levels and lifetime trauma history in suicide attempters. We hypothesised lower CSF and plasma oxytocin levels in suicide attempters with high exposure to interpersonal violence and negative childhood emotional climate.

METHODS

28 medication free suicide attempters participated in the study. CSF and plasma morning basal levels of oxytocin were assessed with specific radioimmunoassays. The Karolinska Interpersonal Violence Scale (KIVS) was used to elicit lifetime trauma history and revictimization status and the childhood emotional climate factor was derived from the socialization subscale of the Karolinska Scales of Personality.

RESULTS

Correlations between exposure to interpersonal violence as a child and as an adult and CSF and plasma oxytocin levels were not significant. Revictimized suicide attempters had significantly lower plasma oxytocin levels and more negative childhood emotional climate compared to non-revictimized suicide attempters.

CONCLUSIONS

Our results indicate a complex relationship between life time trauma and the oxytocin system.

CSF 5-HIAA, cortisol and DHEAS levels in suicide attempters

The serotonin system and the hypothalamic-pituitary-adrenal (HPA) axis are involved in the biological vulnerability to suicidal behaviour. Altered levels of dehydroepiandrosterone (DHEA) and its sulphate ester DHEAS have been reported in neuropsychiatric conditions. The aim of this study was to investigate CSF levels of 5-Hydroxyindoleacetic acid (5-HIAA) and CSF and plasma levels of cortisol and DHEAS in 28 medication free suicide attempters and 19 healthy volunteers. Another aim was to investigate the relationship between neuroendocrine measures and childhood trauma in suicide attempters. As the study design includes a longitudinal part, we investigated whether CSF cortisol, 5-HIAA or DHEAS would predict subsequent suicide. We hypothesized higher cortisol levels in suicide attempters and lower CSF 5-HIAA levels and higher cortisol levels in suicide victims. Suicide attempters had higher CSF and plasma cortisol levels compared to healthy volunteers. Male suicide attempters had higher CSF DHEAS levels and female suicide attempters had lower CSF 5-HIAA levels compared to male and female healthy volunteers respectively. Exposure to interpersonal violence as a child showed a negative correlation with CSF cortisol/DHEAS ratio adjusted for age, gender and depression severity in a regression analysis. Suicide victims tended to have low CSF 5-HIAA and high CSF cortisol. Abused suicide victims had higher CSF cortisol compared to suicide victims with low exposure to interpersonal violence as a child. The results underlie the important role of the serotonergic system and HPA axis in suicidal behaviour and suggest that CSF DHEAS may be elevated in male suicide attempters.

Low CSF oxytocin reflects high intent in suicide attempters

Data from animal studies suggest that oxytocin is an important modulating neuropeptide in regulation of social interaction. One human study has reported a negative correlation between CSF oxytocin levels, life history of aggression and suicidal behaviour. We hypothesized that CSF oxytocin levels would be related to suicidal behaviour, suicide intent, lifetime interpersonal violence and suicide risk. 28 medication free suicide attempters and 19 healthy volunteers participated in this cross sectional and longitudinal study. CSF and plasma morning basal levels of oxytocin were assessed with specific radio-immunoassays. The Beck Suicide Intent Scale (SIS), the Freeman scale and the Karolinska Interpersonal Violence Scale (KIVS) were used to assess suicide intent and lifetime violent behaviour. All patients were followed up for cause of death. The mean follow-up was 21 years. Suicide attempters had lower CSF oxytocin levels compared to healthy volunteers p=0.077. In suicide attempters CSF oxytocin showed a significant negative correlation with the planning subscale of SIS. CSF oxytocin showed a significant negative correlation with suicide intent, the planning subscale of SIS and Freeman interruption probability in male suicide attempters. Correlations between plasma oxytocin levels and the planning subscale of SIS and Freeman interruption probability were significant in male suicide attempters. Lifetime violent behaviour showed a trend to negative correlation with CSF oxytocin. In the regression analysis suicide intent remained a significant predictor of CSF oxytocin corrected for age and gender whereas lifetime violent behaviour showed a trend to be a predictor of CSF oxytocin. Oxytocin levels did not differ significantly in suicide victims compared to survivors. CSF oxytocin may be an important modulator of suicide intent and interpersonal violence in suicide attempters.