Comparison of male and female non-refugee immigrants with psychosis: clinical, sociodemographic, and migration-related differences and impact on stress

PURPOSE

To compare social, clinical, and migration-related factors between male and female immigrants with psychotic disorders and to determine the association between these variables and stress in the last year.

METHODS

We administered the Holmes and Rahe Social Readjustment Scale to evaluate psychological stress in 99 non-refugee immigrants (26 women, 73 men) who presented ≥ one psychotic episode (ICD-10 criteria). We compared the two groups in terms of sociodemographic, clinical, cultural, and migration-related variables. A multivariable analysis using a linear regression model (stepwise method) was performed to evaluate potential associations between these variables and stress.

RESULTS

Women were more likely to be married and divorced, had less access to welfare payments, and lower unemployment and homeless rates than men. The most common psychiatric diagnosis was psychosis not otherwise specified with more women being affected (61.5% in women vs. 45.2% in men), but the diagnosis of schizophrenia was more common in men (38.4% vs 15.4%). Both groups exhibited very high levels of stress in the past year (mean total distress score > 300). In women, stress was significantly associated with age at first migration and be a racialized person. By contrast, among men stress was significantly associated with language barrier and comorbidity with a physical disorder.

CONCLUSIONS

The results of this study reveal important differences between men and women immigrants. These findings underscore the importance of understanding how gender-specific roles and social expectations intersect with the timing and nature of migration to influence stress levels differently in immigrant women and men with psychotic disorders.

Outcome assessment of a complex mental health intervention in the workplace. Results from the MENTUPP pilot study

OBJECTIVE

Multicomponent interventions are recommendable to achieve the greatest mental health benefits, but are difficult to evaluate due to their complexity. Defining long-term outcomes, arising from a Theory of Change (ToC) and testing them in a pilot phase, is a useful approach to plan a comprehensive and meaningful evaluation later on. This article reports on the pilot results of an outcome evaluation of a complex mental health intervention and examines whether appropriate evaluation measures and indicators have been selected ahead of a clustered randomised control trial (cRCT).

METHODS

The MENTUPP pilot is an evidence-based intervention for Small and Medium Enterprises (SMEs) active in three work sectors and nine countries. Based on our ToC, we selected the MENTUPP long-term outcomes, which are reported in this article, are measured with seven validated scales assessing mental wellbeing, burnout, depression, anxiety, stigma towards depression and anxiety, absenteeism and presenteeism. The pilot MENTUPP intervention assessment took place at baseline and at 6 months follow-up.

RESULTS

In total, 25 SMEs were recruited in the MENTUPP pilot and 346 participants completed the validated scales at baseline and 96 at follow-up. Three long-term outcomes significantly improved at follow-up (p < 0.05): mental wellbeing, symptoms of anxiety, and personal stigmatising attitudes towards depression and anxiety.

CONCLUSIONS

The results of this outcome evaluation suggest that MENTUPP has the potential to strengthen employees' wellbeing and decrease anxiety symptoms and stigmatising attitudes. Additionally, this study demonstrates the utility of conducting pilot workplace interventions to assess whether appropriate measures and indicators have been selected. Based on the results, the intervention and the evaluation strategy have been optimised.

¿Do we prescribe less clozapine to immigrant psychotic patients compared to non-immigrant psychotic patients?

Introduction

Clozapine, the first atypical antipsychotic, is a highly effective medication for patients with treatment-resistant schizophrenia. Robust evidence describes important risk for psychosis in immigrant population(2). Despite this, some studies suggest that immigrant patients are less treated and misdiagnosed due to cultural barriers(3,4). Clozapine and Electroconvulsive therapy tend to be less prescribed in immigrants(3). However, few studies assess differences in clozapine prescription between immigrants and non-immigrant psychotic inpatients.

Objectives

To describe and compare clozapine prescription between psychotic patients and non-psychotic patients in a sample of Acute and Chronic inpatients.

Methods

Patients who have presented, according to DSM-V criteria, one or more non-affective psychotic episodes, were recruited in Acute and Chronic inpatients units leading to a total sample of 198 patients. Immigrant condition was defined as “a person who comes to live permanently in a foreign country”. Demographic characteristics of patients, clinical data and main pharmacological treatment were recorded through a questionnaire. Comparative analysis was performed with IBM SPSS Statistics using Chi-Square Test and t-Student test.

Results

From a total of 198patients clozapine was prescribed to 31(15,7%). From the total immigrant sample only 7,1% had prescribed clozapine compared to 24,2% from the locals(p<0.005). Significant differences in diagnosis associated to clozapine were found between both groups : Schizophrenia(57,1%immigrants, 57,1%locals), Schizoaffective disorder(14,3%immigrants, 41,7%locals) and Non specific psychosis (28,3%immigrants, 8,3%locals).

Conclusions

According to our results, immigrant psychotic inpatients receive less clozapine prescription compared to non-immigrant psychotic patients. There results should be considered to study barriers for clozapine prescription in this population and offer a treatment based in equality.

Disclosure

No significant relationships.

Four-month incidence of suicidal thoughts and behaviors among healthcare workers after the first wave of the Spain COVID-19 pandemic

Healthcare workers (HCW) are at high risk for suicide, yet little is known about the onset of suicidal thoughts and behaviors (STB) in this important segment of the population in conjunction with the COVID-19 pandemic. We conducted a multicenter, prospective cohort study of Spanish HCW active during the COVID-9 pandemic. A total of n = 4809 HCW participated at baseline (May-September 2020; i.e., just after the first wave of the pandemic) and at a four-month follow-up assessment (October-December 2020) using web-based surveys. Logistic regression assessed the individual- and population-level associations of separate proximal (pandemic) risk factors with four-month STB incidence (i.e., 30-day STB among HCW negative for 30-day STB at baseline), each time adjusting for distal (pre-pandemic) factors. STB incidence was estimated at 4.2% (SE = 0.5; n = 1 suicide attempt). Adjusted for distal factors, proximal risk factors most strongly associated with STB incidence were various sources of interpersonal stress (scaled 0-4; odds ratio [OR] range = 1.23-1.57) followed by personal health-related stress and stress related to the health of loved ones (scaled 0-4; OR range 1.30-1.32), and the perceived lack of healthcare center preparedness (scaled 0-4; OR = 1.34). Population-attributable risk proportions for these proximal risk factors were in the range 45.3-57.6%. Other significant risk factors were financial stressors (OR range 1.26-1.81), isolation/quarantine due to COVID-19 (OR = 1.53) and having changed to a specific COVID-19 related work location (OR = 1.72). Among other interventions, our findings call for healthcare systems to implement adequate conflict communication and resolution strategies and to improve family-work balance embedded in organizational justice strategies.

Comparison of developmental trauma between immigrant and non-immigrant psychotic patients

Introduction

Meta-analytic evidence suggests that migrants have higher risk for psychotic disorders. Likewise, growing evidence relate developmental trauma (emotional, sexual, physical abuse and neglect in childhood or adolescence) as a causal factor for psychotic symptoms. However, few studies examine developmental trauma in migrant populations.

Objectives

The aim of this study is to describe and compare developmental trauma exposure prevalence between immigrant and non-immigrant psychotic patients in Barcelona.

Methods

Patients who have presented, according DSM-V criteria, one or more non-affective psychotic episodes, were recruited in Acute and Chronic inpatients units at Hospital del Mar (Barcelona), leading to a total sample of 77 patients. Demographic characteristics of patients, clinical data and main pharmacological treatment were recorded through a questionnaire. Developmental trauma exposure was assessed by Childhood Trauma Questionnaire (CTQ). Comparative analysis was performed with IBM SPSS using Chi-Square Test and t-Student test.

Results

From a total of 77 patients, 43 were immigrants and 34 were non-immigrants. Exposure to traumatic events showed significant differences between immigrants and non-immigrant in Child emotional abuse (64,4% immigrants, 35,3% non-immigrant), Child physical abuse (51,2% immigrants, 14,7% non-immigrant), Child Sexual Abuse (41,9% immigrants, 11,8% non-immigrant) and physical neglect (62,8% immigrants, 26,5% non-immigrant). Emotional neglect exposure was no significant between both groups. Total mean CTQ score was 37,53 in immigrants group and 52,60 in non-immigrant group.

Conclusions

According to our results, there are important and significant differences in developmental trauma exposure between immigrant and non-immigrant psychotic patients. These results should be considered by clinicians in order to design assessment program for this population.

Disclosure

No significant relationships.

¿Do immigrant psychotic patients receive less psychotherapy assessment compared to non-immigrant psychotic patients?

Introduction

Migration is a highly defining life event which can lead to mental distress. It constitutes an overall risk factor for psychiatric disorders. However, psychotherapeutic treatment in immigrant patients is considered to be more complex, and the outcome appears to be less favorable than in patients without a migration background.

Objectives

The aim of this study is to compare psychotherapy assessment between immigrant and non-immigrant psychotic patients in Barcelona.

Methods

Patients who have presented, according DSM-V criteria, one or more non-affective psychotic episodes, were recruited in Acute and Chronic inpatients units at Hospital del Mar (Barcelona), leading to a total sample of 77 patients. Demographic characteristics of patients, clinical data and main pharmacological treatment were recorded through a questionnaire. Database information was completed with electronic medical records. Comparative analysis was performed with IBM SPSS using Chi-Square and t-Student test

Results

From a total of 77 patients, 43 were immigrants and 34 were non-immigrants. From the total immigrants only 30,2% received psychotherapy compared to 79,4% from the non-immigrants. The most prevalent therapy received in both groups was cognitive behavioural therapy. From the immigrants group only 2,3% received psychoeducation compared to 11,8% from the non-immigrant group.

Conclusions

According to our results, there are important and significant differences in psychotherapy assessment in migrant psychotic patients. In order to improve the mental health treatment of immigrant patients, the reasons for this poor outcome need to be investigated. These results should be considered by clinicians in order to design assessment program for this population.

Disclosure

No significant relationships.

Follow-up protein profiles in urine samples during the course of obstructive feline idiopathic cystitis

Feline idiopathic cystitis (FIC) is a common lower urinary tract disorder in cats, which often recurs. Published reports document increased urine fibronectin and thioredoxin concentrations in cats with FIC compared with healthy control cats. Therefore, these proteins might be of interest in the pathophysiology of FIC. The purpose of the present study was to evaluate variations in these urine proteins throughout the course of FIC by assessing their concentrations in urine specimens from cats with a history of obstructive FIC. Urine total protein (TP) was measured using the Bradford assay, while urine fibronectin and thioredoxin concentrations were determined by Western blot analysis. Urine TP was significantly higher in cats with obstructive FIC at presentation (day 0) than in healthy control cats (P<0.01). There were significant decreases in urine TP in cats with obstructive FIC after 3 months (P<0.01). Significantly higher urine fibronectin (P<0.01) and thioredoxin (P<0.05) concentrations were demonstrated in cats with FIC at day 0 compared to control cats, but there was no significant change over time (P>0.05). Increased concentrations of these proteins over time might reflect ongoing structural and pathological alterations to functional processes in the urinary bladders of cats with obstructive FIC.

Bipolar depressed patients show both failure to activate and failure to de-activate during performance of a working memory task

BACKGROUND

Bipolar depression has been found to be associated with changes in prefrontal cortex activity during performance of cognitive tasks. However, the role of task-related de-activations has been little investigated.

METHOD

Forty-one bipolar depressed patients and 41 matched normal controls underwent fMRI scanning while performing baseline, 1-back and 2-back versions of the n-back task. Linear models were used to obtain maps of within-group activations and areas of differential activation between the groups.

RESULTS

The bipolar depressed patients showed reduced activation in the dorsolateral prefrontal cortex (DLPFC) bilaterally and several other regions. After controlling for differences in task performance only differences in the DLPFC and cerebellum remained. Left DLPFC activation was inversely correlated with Hamilton and MADRS scores. The patients showed failure to de-activate in the medial prefrontal cortex, an area corresponding to the anterior medial node of the default mode network.

LIMITATIONS

To confirm default mode network dysfunction demonstration of resting-state connectivity abnormalities would also be required. The study was carried out on treated patients, and did not assess for presence of depressive symptoms in the healthy controls.

CONCLUSIONS

Both prefrontal cortical and default mode network dysfunction appear to characterise bipolar depression. The former, but not the latter, is associated with symptom severity.

Failure of de-activation in the medial frontal cortex in mania: evidence for default mode network dysfunction in the disorder

OBJECTIVES

Manic patients have been found to show reduced activation in the prefrontal cortex and other regions during performance of cognitive tasks. However, little is known about de-activations associated with the disorder. This study aimed to examine, at the whole-brain level, abnormal patterns of task-related activation and de-activation during performance of a working memory task.

METHODS

Twenty-nine DSM-IV bipolar patients and 46 healthy controls underwent fMRI during performance of the n-back task. The patients were scanned while they were in a manic episode. Linear models were used to obtain maps of within-group activations and areas of differential activation between the groups.

RESULTS

The manic patients showed reduced activation compared to the controls in the bilateral dorsolateral prefrontal cortex and the right parietal cortex. They also showed failure of de-activation in the medial frontal cortex, extending to the temporal poles and parts of the limbic system bilaterally. The failure of activation in the dorsolateral prefrontal cortex disappeared when differences in task performance were controlled for in the analysis. However, the medial frontal failure of de-activation survived controlling for this.

CONCLUSIONS

This study suggests that, in addition to reduced prefrontal activation, failure of de-activation is an important functional imaging abnormality in mania. This, together with its location in the medial prefrontal cortex, implies default mode network dysfunction in the disorder.

True blue: S-opsin is widely expressed in different animal species

Colour vision in animals is an interesting, fascinating subject. In this study, we examined a wide variety of species for expression of S-opsin (blue sensitive) and M-/L-opsin (green-red sensitive) in retinal cones using two novel monoclonal antibodies specific for peptides from human opsins. Mouse, rat and hare did not express one of the investigated epitopes, but we could clearly prove existence of cones through peanut agglutinin labelling. Retinas of guinea pig, dog, wolf, marten, cat, roe deer, pig and horse were positive for S-opsin, but not for M-/L-opsin. Nevertheless all these species are clearly at least dichromats, because we could detect further S-opsin negative cones by labelling with cone arrestin specific antibody. In contrast, pheasant and char had M-/L-opsin positive cones, but no S-opsin expressing cones. Sheep, cattle, monkey, men, pigeon, duck and chicken were positive for both opsins. Visual acuity analyzed through density of retinal ganglion cells revealed least visual discrimination by horses and highest resolution in pheasant and pigeon. Most mammals studied are dichromats with visual perception similar to red-green blind people.

Executive dysfunction and memory impairment in schizoaffective disorder: a comparison with bipolar disorder, schizophrenia and healthy controls

BACKGROUND

Deficits in memory and executive performance are well-established features of bipolar disorder and schizophrenia. By contrast, data on cognitive impairment in schizoaffective disorder are scarce and the findings are conflicting.

METHOD

We used the Wechsler Memory Scale (WMS-III) and the Behavioural Assessment of the Dysexecutive Syndrome (BADS) to test memory and executive function in 45 schizophrenic patients, 26 schizomanic patients and 51 manic bipolar patients in comparison to 65 healthy controls. The patients were tested when acutely ill.

RESULTS

All three patient groups performed significantly more poorly than the controls on global measures of memory and executive functioning, but there were no differences among the patient groups. There were few differences in memory and executive function subtest scores within the patient groups. There were no differences in any test scores between manic patients with and without psychotic symptoms.

CONCLUSIONS

Schizophrenic, schizomanic and manic patients show a broadly similar degree of executive and memory deficits in the acute phase of illness. Our results do not support a categorical differentiation across different psychotic categories with regard to neuropsychological deficits.

Anticonvulsant drugs in bipolar disorder

Although much progress has been made in successfully treating bipolar disorder, there is increasing awareness of the limitations of traditional treatment regimens such as lithium and neuroleptics. The large family of anticonvulsant drugs, however, appears to be capable of providing new treatment options, not only as medication of second choice in patients refractory to treatment, but often as a treatment standard with high efficacy and low incidence of side effects. Besides established mood stabilizers such as carbamazepine and valproate, new antiepileptic drugs are entering the field with promising initial results in the treatment of bipolar patients. Furthermore, bringing to light the mechanisms of action of anticonvulsants and the similarities between anticonvulsants effective in bipolar disorder may also deepen our understanding of the pathophysiological basis of the disorder.

Rates and clinical correlates of treatment non-adherence in schizoaffective bipolar patients

OBJECTIVE

To analyze demographical, clinical, and therapeutic variables that may be associated with pharmacological non-adherence in a sample of schizoaffective patients, bipolar type.

METHOD

Adherence to treatment and its clinical correlates were assessed at the end of a 10-year follow-up in 76 patients meeting DSM-IV-TR diagnosis of schizoaffective disorder, bipolar type. Adherent and poorly adherent patients were compared regarding clinical and therapeutic variables.

RESULTS

The rate of poorly adherent patients was 32/76 (41.2%) of the sample. Adherent patients were more likely to have presented an affective episode at illness onset and to have fewer purely - non-affective - psychotic episodes. Demographic or other clinical variables were not found to be associated to treatment adherence. Family history for psychiatric disorders or suicide did not correlate either, and neither did any specific pharmacological agent.

CONCLUSION

Rates of non-adherence in schizoaffective disorder are high. Adherence seems to be associated to a more affective course of illness (affective first episode and fewer purely psychotic episodes). Patients with more prominent schizophrenia-like characteristics could be at higher risk for poor adherence and need to be closely followed and monitored. Even when properly treated, schizoaffective disorder is a disabling and severe disorder with high risk for recurrences.

First-episode psychosis is characterized by failure of deactivation but not by hypo- or hyperfrontality

BACKGROUND

It is not known whether first-episode psychosis is characterized by the same prefrontal cortex functional imaging abnormalities as chronic schizophrenia.

METHOD

Thirty patients with a first episode of non-affective functional psychosis and 28 healthy controls underwent functional magnetic resonance imaging (fMRI) during performance of the n-back working memory task. Voxel-based analyses of brain activations and deactivations were carried out and compared between groups. The connectivity of regions of significant difference between the patients and controls was also examined.

RESULTS

The first-episode patients did not show significant prefrontal hypo- or hyperactivation compared to controls. However, they showed failure of deactivation in the medial frontal cortex. This area showed high levels of connectivity with the posterior cingulate gyrus/precuneus and parts of the parietal cortex bilaterally. Failure of deactivation was significantly greater in first-episode patients who had or went on to acquire a DSM-IV diagnosis of schizophrenia than in those who did not, and in those who met RDC criteria for schizophrenia compared to those who did not.

CONCLUSIONS

First-episode psychosis is not characterized by hypo- or hyperfrontality but instead by a failure of deactivation in the medial frontal cortex. The location and connectivity of this area suggest that it is part of the default mode network. The failure of deactivation seems to be particularly marked in first-episode patients who have, or progress to, schizophrenia.

Six-month functional outcome of a bipolar disorder cohort in the context of a specialized-care program

OBJECTIVES

A marked disparity between functional recovery and symptomatic improvement has been demonstrated in bipolar disorder. However, most of the previous studies have been conducted in the United States, and there is little prospective research from Europe on this topic. The main objective of the present six-month follow-up study was to assess functioning in a sample of Spanish bipolar disorder patients following an acute episode or subsyndromal state. Additionally, we also evaluated the sensitivity to change of the Functioning Assessment Short Test (FAST).

METHODS

A total of 97 bipolar disorder patients with syndromal (n = 59) or subsyndromal (n = 38) symptoms were evaluated using the 17-item Hamilton Depression Rating Scale and Young Mania Rating Scale. The FAST was the primary measure to assess multiple areas of psychosocial functioning. Functioning was evaluated at four different time periods: baseline, 21 days, three months, and six months.

RESULTS

A significant improvement in global functioning was found in the whole sample over the six-month period, as indicated by a reduction of FAST total score (mean ± standard deviation) from 39.97 ± 15.10 to 30.65 ± 16.93 (F = 36.104, p = 0.0001). This was also evident in all areas of functioning studied. However, only 26.4% of remitted patients (n = 42) achieved functional recovery, while 79.6% of the total sample (N = 97) experienced clinical remission of acute symptoms.

CONCLUSIONS

Although many patients presented syndromal recovery, only a minority of them achieved favorable functioning in multiple areas, even after specialized mental health care. Furthermore, the FAST scale was sensitive to detect minimal changes in functioning in both short (21 days) and long (6 months) periods, which may be relevant to the use of this scale in clinical trials.

Effects of atypical antipsychotics on neurocognition in euthymic bipolar patients

BACKGROUND

Different factors may influence cognitive functioning in bipolar disorder such as the effect of subsyndromal symptoms, the history of psychotic symptomatology or substance abuse, negative symptomatology, chronicity, sleep disturbances, and hormonal factors. The effect of pharmacologic treatment on cognition is still uncertain because of an insufficient number of studies examining this issue.

OBJECTIVE

The aims of this study were to compare neuropsychologic performance of treated bipolar patients with that of controls, including unmedicated patients and healthy subjects, as well as to evaluate possible neurocognitive differences among 3 different atypical antipsychotics.

RESEARCH DESIGN AND METHODS

A total of 119 subjects were included in the study. Of 79 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition euthymic bipolar patients, 68 were treated with one atypical antipsychotic, quetiapine (n = 12), olanzapine (n = 26), or risperidone (n = 30). Sixteen patients were drug-free. The 4 groups were compared with a sample of drug-naïve patients and a healthy control group (n = 35) on several clinical and neuropsychologic variables, especially on the domains of attention, verbal memory, and executive functions. Euthymia was defined by a score of 6 or less at the Young Mania Rating Scale and a score of 8 or less at the Hamilton Depression Rating Scale for at least 6 months.

RESULTS

The 5 groups did not differ in age, years of education, sex distribution, or estimated premorbid IQ. The 4 patients groups did not differ in chronicity, age of onset, total number of episodes, and number of hospitalizations. No differences were found regarding antipsychotic dosages between the groups. Bipolar patients performed poorly on most neuropsychologic measures as compared with healthy controls. After controlling for Hamilton Depression Rating Scale symptoms, no significant change in the results was observed. Because many patients with antipsychotic treatment had a history of psychotic symptoms, we performed multivariate analysis of covariance controlling for this variable. Bipolar patients taking 1 of the 3 antipsychotics presented with dose-independent significant deficits in most cognitive tasks compared with healthy controls. After several head-to-head group comparisons, the patients receiving quetiapine showed a better performance in learning task, short-term memory, and recognition task assessed with the California Verbal Learning Test and verbal fluency (P < .05).

CONCLUSIONS

Our results confirm the findings of previous studies of cognitive deficits in bipolar disorder. Untreated euthymic patients showed better cognitive performance than did patients on atypical antipsychotics. Some iatrogenic-pharmacologic effect, therefore, cannot be excluded, but quetiapine seemed to be less associated with impairment in measures of verbal memory than olanzapine or risperidone. We suggest to use drugs in bipolar disorder with a lower risk of cognitive adverse effects. However, randomized controlled trials are urgently needed to give a definite answer to this critical problem.

Lamotrigine: when and where does it act in affective disorders? A systematic review

Recent published data and treatment guidelines have created uncertainty about the use of lamotrigine in affective disorders, especially in acute bipolar depression. Furthermore, unpublished data on lamotrigine in mania, mixed episodes, unipolar depression and rapid cycling are still waiting to be integrated into the literature. Therefore, we critically reviewed the position of lamotrigine in the acute and long-term treatment of affective disorders. Studies were identified by searching English language articles published in MEDLINE using the key words: lamotrigine, bipolar depression, unipolar depression, mania, mixed episode, long-term treatment, rapid-cycling. Results of unpublished trials were obtained from the GlaxoSmithKline website. Lamotrigine showed efficacy in the prophylaxis of bipolar disorder, more so in depressive than manic episodes. There was no evidence of effectiveness in the acute treatment of mania, mixed episodes, unipolar depression or rapid-cycling bipolar I disorder. Its effect in the acute treatment of bipolar depression is at most small. Based on current evidence, lamotrigine is indicated for the prophylaxis of bipolar disorder with predominantly depressive episodes. Its effectiveness in the acute treatment of bipolar depression is open to debate, and practical considerations limit its usefulness here. There are no grounds for recommending its use in manic or mixed states, in rapidly-cycling bipolar I or in unipolar depression.

[Chronic venous insufficiency in postthrombotic syndrome and varicose veins]

Venous disorders have a high prevalence and require approximately 1% of health budgets of industrialized countries. The postthrombotic syndrome (PTS) is defined by subjective symptoms and morphologic trophical skin changes following deep venous thrombosis. Prevention of venous thromboembolism in risk situations, easy availability of diagnostic tools (D-dimers, colour-coded duplex sonography) and early detection of deep venous thrombosis, as well as immediate therapeutic anticoagulation along with leg compression during the acute phase and over a two year period of time significantly reduce the incidence of PTS. Chronic venous insufficiency (CVI) includes trophical skin and soft tissue pathologies of the lower leg due to venous hypertension in the distal venous system of the lower extremity. Roughly, two main causes can be distinguished. (A) Deep venous insufficiency (A1 in postthrombotic syndrome; A2 in primary deep venous insufficiency) and (B) superficial venous reflux, usually varicose veins. Compression therapy, surgical ablation of superficial venous reflux, and tangential ablation with split skin graft (shave treatment) of refractory venous ulcers are the mainstays in the treatment of CVI.

An investigation of temperamental traits in patients with somatoform disorder: do they belong in the affective spectrum?

BACKGROUND

About 10% of the general population report multiple and persisting physical symptoms resulting in extensive screening but with no organic explanation found.

OBJECTIVE

The authors sought to determine whether these somatoform-disorder patients show characteristics of the affective disorder spectrum, with the cyclothymic temperament likely showing the highest specificity for somatoform disorder.

METHOD

This study examined temperamental traits and current mood states of 44 general-hospital inpatients diagnosed with somatoform disorder.

RESULTS

There was a higher prevalence of abnormal temperamental traits in patients with somatoform disorder.

CONCLUSION

Based on the idea of a continuum between temperament and affective disorders, the results should trigger further research on this issue possibly leading to novel treatment options in the future.

Preliminary results of a fine-grain analysis of mood swings and treatment modalities of bipolar I and II patients using the daily prospective life-chart-methodology

OBJECTIVE

The study aimed to increase the knowledge about the detailed course differences between different forms of bipolar disorder.

METHOD

Using the prospective life-chart-clinician version, we compared the fine-grain analysis of mood swings and treatment modalities of 18 bipolar II with 31 bipolar I patients.

RESULTS

During an observational period of a mean of 26 months we observed an increase of euthymic days, and a decrease of (sub)depressive and (hypo)manic days. Days in a (sub)depressed state were more frequent than days of (hypo)mania as well as days of subdepression or hypomania in comparison to days of full-blown depression or mania. Bipolar II patients showed an increase in hypomanic days receiving more frequently antidepressants. Bipolar I patients, with a decrease of manic days, were significantly taking more often mood stabilizers.

CONCLUSION

Treatment in a specialized bipolar clinic improves the overall outcome, but bipolar II disorder seems to be still treated sub-optimally with a possible iatrogenic increase of hypomanic days.

Abnormal temperament in patients with morbid obesity seeking surgical treatment

BACKGROUND

Obesity and its related disorders are growing epidemic across the world. Research on links between the bipolar spectrum and obesity has proliferated in the last few years. As some forms of abnormal temperament are considered as subtypes of the soft bipolar spectrum, we aimed to evaluate abnormal temperaments in morbidly obese patients.

METHODS

Using a short version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego, we investigated abnormal depressive, cyclothymic, hyperthymic, irritable or anxious temperament in 213 patients with morbid obesity compared to a control group of 90 patients admitted prior to organ transplantation. Additionally, the Beck-Depression Inventory (BDI) and the Self-Report Manic Inventory (SRMI) were applied to assess current mood status.

RESULTS

The obese group showed statistically significantly more psychiatric comorbidities compared to the control group. Abnormal temperaments were significantly more often observed in patients with morbid obesity rather than in controls. Cyclothymic, irritable and anxious temperaments showed specificity to obesity. Obese patients had significantly higher scores on the BDI, while no difference for SRMI scores was found among the whole groups. All temperaments were positively correlated with BDI and SRMI in the obese group.

LIMITATIONS

The control group was not matched for demographic characteristics.

CONCLUSIONS

Our results need replication but indicate an affective overlap in the form of abnormal temperament and depressive symptoms in obese patients, whereas mood swings should be evaluated and early mood stabilization considered for patients with significant weight gain to prevent obesity or to reduce already existing overweight. Studies of mood stabilizers and prospective observations would shed further insight on this complex interface of a major clinical and public health issue.

Anticonvulsants in the treatment of aggression in the demented elderly: an update

INTRODUCTION

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity.

METHODS

Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate.

RESULTS

To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate.

CONCLUSION

So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.

Ethical questions in human clinical psychopharmacology: should the focus be on placebo administration?

Of all ethical issues in clinical trial designs, only placebo use is dealt with acrimony and unwarranted, rhetoric emphasis. Many misconceptions are biased and may hamper research in the mechanisms of healing and recovery if placebo is banned from clinical trials, as some influential ethicists propose. Current treatments in psychiatry are by no means optimal and may vary in their effect across studies, rendering difficult to find the best available therapeutic method with which to compare new drugs. Because drugs possess specific mechanisms, it is not possible to compare drugs with different mechanisms as to their relevance in the pathophysiology of a given disorder. Placebo acts through non-specific mechanisms and is the ideal control for any disorder whose pathophysiology is relatively unknown and its treatment is still suboptimal. Sticking to short-term patient benefit in a trial reflects an individualistically oriented thinking in contemporary ethics and is likely to limit further research and efforts to better understand the mechanisms of disease and drug action, but also those related to general body reactance and self-healing, which are enhanced by placebo administration. Because in history ethics are swinging between two opposed views, it is possible that in the near future, the balance will move towards communitarianism, which is more likely to better serve long-term patient needs. Ethicists should also consider some other aspects of human experimentation, such as the consistency of research lines and the trend to substitute older drugs with their metabolites or enantiomers.

Weight gain in bipolar disorder: pharmacological treatment as a contributing factor

OBJECTIVE

The aim of this paper was to review the association of most commonly used psychopharmacological drugs with weight gain in bipolar disorder.

METHOD

Information was retrieved from a PubMed/Medline literature search reviewing weight gain in pharmacological studies in bipolar disorder.

RESULTS

Obesity and overweight in bipolar disorder are partly related to prescribed drugs with a strong effect of clozapine and olanzapine. Lesser but still relevant weight gain is caused by quetiapine, risperidone, lithium, valproate, gabapentin and by some antidepressants. Ziprasidone, aripiprazole, carbamazepine and lamotrigine do not seem to cause significant overweight.

CONCLUSION

Careful monitoring of weight changes in patients before and after drug prescription should be implemented in the clinical routine and drugs which potentially cause weight gain should be avoided in overweight patients with bipolar disorder. Furthermore, eating habits and daily activities should be targeted as they may also have a significant impact on overall health and weight-related issues.

[Diabetic nephropathy and ACE inhibitors]

The life expectancy of patients with type 2 diabetes and diabetic nephropathy is reduced; the main cause of death is cardiovascular disease. The majority of patients with renal replacement therapy are type 2 diabetics. Inhibition of the renin-aldosterone-angiotensin system is beneficial in diabetes mellitus. It reduces the incidence and slows the progression of nephropathy. ACE inhibitors are the accepted standard of care for nephropathy in type-1 diabetics; the role of ACE inhibitors versus angiotensin-receptor-blockers in type 2 diabetes is less clear. Large studies from the last 15 years and meta-analyses show a reduction of mortality of about 20% with ACE inhibitors in type 2 diabetic nephropathy; angiotensin-receptor-blockers have no documented effect on mortality yet, but do also slow the progression of nephropathy in type 2 diabetics. From these data and because of economic considerations, ACE inhibitors should be first choice therapy for diabetic nephropathy in type 2 diabetes mellitus.

Cognitive impairment in schizoaffective disorder: a comparison with non-psychotic bipolar and healthy subjects

OBJECTIVE

Only a few studies have examined specifically the neuropsychological performance of schizoaffective patients.

METHOD

The sample consisted of 34 euthymic DSM-IV schizoaffective patients, who were compared with 41 euthymic bipolar patients without history of psychotic symptoms and 35 healthy controls. Euthymia was defined by a score of 6 or less at the Young Mania Rating Scale and a score of 8 or less at the Hamilton Depression Rating Scale for at least 6 months. Patients were compared with several clinical, occupational, and neuropsychological variables such as executive function, attention, verbal and visual memory and the two groups were contrasted with 35 healthy controls on cognitive performance. The three groups were compared using mancova after checking the potential role of several co-variables.

RESULTS

Schizoaffective patients showed greater impairment than controls and bipolar patients, in several domains, including verbal memory, executive function, and attentional measures. Bipolar patients without history of psychosis performed similar to the controls except for verbal fluency.

CONCLUSION

Schizoaffective disorder carries more neurocognitive impairment than non-psychotic bipolar disorder and more occupational difficulties.

[Electroconvulsive therapy in the treatment of bipolar depression]

Since its introduction, electroconvulsive therapy is a treatment used in mood disorders, especially in the depressive phases of bipolar disorder. The advance of this technique has made it a useful and current option both in the treatment of acute phases as in the prevention of recurrences. The objective of this revision is to collect available data about the use of electroconvulsive therapy in bipolar depression. Its indications, effectiveness, prediction and patterns of response are included in this work, together with its complications, adverse events and drug interactions. Differences in response between bipolar and unipolar depression are also discussed.

Antiepileptic drugs and mood stability

This paper will discuss different definitions of the term "mood stabilizer" and highlight in detail the antiepileptic drugs carbamazepine, valproate and lamotrigine with respect to their relative strengths in stabilizing mood in bipolar patients. These drugs are heterogeneous in their mechanisms of action and in their efficacy to stabilize patients with epilepsy and the various mood states in bipolar disorder. Lamotrigine has obtained approval in several countries for the indication of preventing bipolar depressive episodes, which raises the question of differential efficacy of other antiepileptic drugs as mood stabilizers in the prevention of either depressive or hypo-/manic episodes. A Medline Search to 2006 was conducted for controlled acute and maintenance studies of the three scientifically and clinically most established antiepileptic drugs carbamazepine, valproate and lamotrigine. The medications discussed in this review only partly fulfill definitions of a mood stabilizer, and we suggest that future research should focus on combined treatment strategies.

Defining Cytochemical Markers for Different Cell Types in the Equine Retina

The major cell types in the mammalian retina are photoreceptors, amacrine, horizontal, bipolar, ganglion and Mueller glial cells. Most of the specific cell types are conserved, but cytochemical markers vary between species. The aim of our study was to characterize cytochemically distinctive markers for different cell types in the equine retina. We were able to define specific markers for equine Mueller glial cells and photoreceptor cells. Furthermore, we describe markers for large ganglion cells, horizontal and amacrine cells and a subpopulation of bipolar cells. Additionally, discrimination between the inner plexiform layer and nerve fibre layer can be achieved by expression of syntaxin and neurofilament 200 respectively.

[Prophylaxis of bipolar disorder]

Until recently, the psychopharmacological treatment alternatives for bipolar maintenance treatment were limited to lithium, which seems of special usefulness in a classical manifestation of the illness with mood-stabilising and anti-suicidal properties. With atypical features like psychotic symptoms or rapid cycling, lithium seems to be less useful. This led to further research into alternative options as carbamazepine, valproate or lamotrigine as well as atypical neuroleptics, thyroid hormones or innovative substances like omega fatty acids. This article summarises the current state of knowledge on treatment options for maintenance therapy.