Hemodynamic and white blood cells parameters in patients with first-episode psychosis: a pilot longitudinal study

OBJECTIVE

Patients with schizophrenia are at higher risk of cardiovascular (CVS) related mortality. Close attention is being paid to the clinical utility of readily available CVS markers.

METHODS

A pilot one-year longitudinal study in inpatients with first-episode psychosis (FEP) was carried out to determine markers of inflammation and endothelial dysfunction (monocyte- and neutrophil-to-lymphocyte ratios) and basal blood pressure, pulse, and derived hemodynamic parameters (PP: pulse pressure; RPP: rate pressure product; and MAP: mean arterial pressure).

RESULTS

After one year, PP and RPP increased, as did systolic blood pressure and heart rate. Systolic blood pressure, PP, total white blood cells, and neutrophils correlated with weight gain. After one year, correlations between monocyte-to-lymphocyte ratio and RPP and MAP were observed.

CONCLUSION

Our study indicates worsening CVS health over the first year of treatment and emphasises the importance of early monitoring of CVS status using easily accessible parameters to prevent CVS-related mortality.Key pointsPatients with schizophrenia are at higher risk of cardiovascular mortality.The CVS risk could be evaluated using affordable, routinely available CVS markers such as monocyte- and neutrophil-to-lymphocyte ratios, blood pressure, and pulse together with the derived parameters.Our pilot study in first-episode psychosis patients indicates worsening of CVS health based on these parameters during the first year of treatment, the early monitoring of CVS status is highly relevant in clinical practice.

Neurological soft signs and their relationship to 1-year outcome in first-episode schizophrenia

Objectives

To examine the relationship between the severity of neurological soft signs at onset and at the 1-year follow-up of patients with schizophrenia, and to investigate temporal stability of neurological soft signs within 1 year from the onset of the first episode schizophrenia.

Methods

The study included 92 first-episode male schizophrenic patients. Neurological soft signs were assessed on the Neurological Evaluation Scale (NES) during index hospitalization and at a 1-year follow-up. The patients were divided into remitters and non-remitters according to their psychiatric status assessed at the 1-year follow-up, using the Positive and Negative Syndrome Scale (PANSS).

Results

A trend for a lower score for the NES item “others” in late remitters versus non-remitters at baseline was found during index hospitalization. At the 1-year follow-up, the overall severity of the neurological soft signs was statistically significantly higher in non-remitters than in remitters. Within 1 year after index hospitalization, a significant reduction of neurological soft signs, with the exception of sensory integration, occurred in remitters. Within 1 year after index hospitalization, the non-remitters reported a significant reduction of the overall NES score.

Conclusion

These findings in a population of patients with first episode schizophrenia are in accord with the findings of previous studies which found an association between neurological soft signs, treatment response and outcome. This association may characterize a subgroup of patients with a poor course of illness and outcome. Neurological soft signs might be regarded as one of the indicators of treatment outcome in patients suffering from their first episode of schizophrenia.

Aldosterone and aldosterone/cortisol ratio is higher in serum of long-term compared to first episode schizophrenia patients: A pilot study

We have previously shown that patients with severe depressive episode exhibit higher aldosterone concentrations compared to those with moderate depressive episode. The present study was undertaken to test the hypothesis that circulating concentration of aldosterone reflect the clinical state in patients with schizophrenia. The sample consisted of 36 hospitalized patients (25 men, 11 women) with the first episode or long-term course of schizophrenia. The severity of psychopathology was evaluated using the Positive and Negative Syndrome Scale (PANSS). Samples for measurement of serum aldosterone were obtained immediately after awakening. The results showed that serum aldosterone concentrations were lower in patients with the first episode compared to those in patients with long-term course of schizophrenia. Importantly, lower aldosterone concentrations observed in patients with the first episode were associated with more severe clinical symptoms as indicated by all subscales of PANSS. Serum cortisol concentrations did not differ between the groups, while the aldosterone/cortisol ratio showed similar pattern as aldosterone concentrations. The present pilot study suggests that circulating aldosterone in patients with schizophrenia may reflect the severity of clinical symptoms but in an opposite direction than in patients with major depressive disorder.

What Does Antidepressant Drug level Monitoring Reveal About Outpatient Treatment and Patient Adherence?

Introduction The evaluation of plasma levels of antidepressants may improve the treatment outcome. The aim was to verify adherence and adequacy of administered doses of antidepressants among patients hospitalized for inadequate outpatient therapeutic response.

Methods Selective serotonin reuptake inhibitors or venlafaxine plasma levels were assessed on the first day of hospitalization and after 3 days of controlled administration. The patients were considered adherent if the plasma level on admission was within the interval of the minimum and maximum plasma level on the fourth day, expanded by 30%. The adequacy of antidepressant doses used during the outpatient treatment was assessed by comparing the plasma level on the fourth day with the therapeutic reference range.

Results Out of 83 patients, 52 (62.7%) were adherent. The plasma levels of antidepressants on the fourth day were found to be within the therapeutic reference range in 35 (43.2%) patients. The same number manifested levels below the therapeutic reference range. In 11 (13.6%) patients, the levels were higher than recommended. No significant difference in rate of adherence was found among individual antidepressants.

Conclusion The results show that antidepressant nonresponders are frequently under-dosed or nonadherent.

Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations

INTRODUCTION

Therapeutic drug monitoring (TDM) of clozapine is a very useful method for verifying both the correct intake and the interindividual variability of its metabolism, thereby avoiding the risk of toxicity. The purposes of this paper were to discover how many patients using clozapine in common clinical practice have clozapine plasma concentration (PC) levels in the proposed reference range and to identify factors that influence clozapine PC levels.

METHODS

Our study included 100 inpatients (diagnosed with schizophrenia or schizoaffective disorder) taking standard doses of clozapine (100-700 mg/day). Clozapine concentration was measured by high-performance liquid chromatography. Correlations between doses and PC levels and the influence of smoking and gender on clozapine PC levels were calculated.

RESULTS

A large number of the patients (67%) had PC levels outside the proposed reference range. The clozapine PC levels were influenced by dose, gender, and cigarette smoking.

CONCLUSION

The correlations between dose, gender, and cigarette smoking and clozapine PC levels highlighted by our study overlap other research. It was surprising to find such a large number of patients with clozapine PC levels outside the therapeutic range. This result suggests the importance of clozapine TDM due to misunderstood inter- and/or intraindividual variability or misestimated partial therapeutic compliance.

Novel treatment options in depression and psychosis

In spite of tremendous development in central nervous system research, current treatment is suboptimal, especially in severe mental disorders. In medicine, there are two main methods of improving the health care provided: seeking new treatment procedures and perfecting (optimizing) the existing ones. Optimization of treatment includes not only practical tools such as therapeutic drug monitoring but also implementation of general trends in the clinical practice. New pharmacological options include new more sophisticated forms of monoaminergic drugs, old drugs rediscovered on the base of a better understanding of pathophysiology of mental illnesses, and drugs aimed at new treatment targets. In depression, treatment resistance to antidepressive pharmacotherapy represents one of the most important clinical challenges. Switching to monotherapy with new multimodal/multifunctional antidepressants and augmentation with new atypical antipsychotics (aripiprazole and brexpiprazole) may be promising options. Further, current evidence supports utility and safety of adjunctive treatment of nutraceuticals. Novel approaches being studied include ketamine and opioids. Recent advances in technology and emerging knowledge about dysfunctional brain circuits and neuroplasticity have led to the development of different new neuromodulation techniques usually used as add-on therapy. Antipsychotics are still the cornerstone of the current treatment of schizophrenia. Two new partial dopamine agonists, brexpiprazole and cariprazine, are now available in addition to aripiprazole. Although the mechanisms of action are similar, the two agents differ in terms of their pharmacodynamic profiles. Further, two new formulations of long-acting injections of second-generation antipsychotics (aripiprazole lauroxil and 3-month paliperidone palmitate) were introduced into clinical practice. New treatment options not yet available include cannabidiol, glutamate modulators, and nicotine receptors agonists.

Risperidone increases the cortical silent period in drug-naive patients with first-episode schizophrenia: A transcranial magnetic stimulation study

OBJECTIVES

Schizophrenia is accompanied by impaired cortical inhibition, as measured by several markers including the cortical silent period (CSP). It is thought that CSP measures gamma-aminobutyric acid receptors B (GABA_B) mediated inhibitory activity. But the mutual roles of schizophrenia as a disease and the drugs used for the treatment of psychosis on GABA mediated neurotransmission are not clear.

METHODS

We recruited 13 drug-naive patients with first-episode schizophrenia. We used transcranial magnetic stimulation to assess CSP prior to initiating risperidone monotherapy and again four weeks later. At the same time, we rated the severity of psychopathology using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

We obtained data from 12 patients who showed a significant increase in CSP, from 134.20±41.81 ms to 162.95±61.98 ms ( p=0.041; Cohen's d=0.544). After the treatment, the PANSS total score was significantly lower, as were the individual subscores ( p<0.05). However, no correlation was found between ΔCSP and ΔPANSS.

CONCLUSION

Our study in patients with first-episode schizophrenia demonstrated an association between risperidone monotherapy and an increase in GABA_B mediated inhibitory neurotransmission.

Cognitive impairment and cortisol levels in first-episode schizophrenia patients

Many modalities of cognition are affected in schizophrenia. The most common findings include dysfunctions of episodic and working memory and of executive functions. Although an inverse correlation between cortisol level and memory function has been proven, few studies have focused on the relationship between cortisol level and cognitive impairment in patients with schizophrenia. In an open, naturalistic, prospective study, consecutively hospitalized males diagnosed with first-episode schizophrenia, hypothalamic-pituitary-adrenal axis activity (afternoon cortisol levels, post-dexamethasone cortisol levels) was evaluated before and at the end of acute treatment. Psychopathology was assessed using the positive and negative syndrome scale (PANSS). Cognitive functions (memory, attention, psychomotor, verbal fluency, and executive functions) were tested after symptom alleviation using a neurocognitive test battery. In the total sample (n = 23), significant decreases in total PANSS score (including all subscales), afternoon cortisol levels, and post-dexamethasone cortisol levels occurred during the course of treatment. It was found that higher afternoon cortisol levels at the beginning of treatment were significantly related to impaired performance in memory functions. Afternoon cortisol levels were not significantly associated with other measured cognitive functions. No correlation was discovered between cognitive functions and post-dexamethasone cortisol levels. The determination of afternoon cortisol levels may serve to detect potential candidates for specific cognitive intervention immediately after the first psychotic breakthrough.

Repetitive transcranial magnetic stimulation reduces cigarette consumption in schizophrenia patients

INTRODUCTION

High-frequency repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex (DLPFC) seemed to decrease tobacco consumption and craving in nicotine-dependent people without psychiatric disorder or otherwise healthy people. Even if the prevalence of cigarette smoking in schizophrenia patients is high and estimated to be between 45% and 88%, this technique has not been systematically studied in this indication in schizophrenia yet.

THE AIM OF THE STUDY

The aim of this study was to test the ability of high-frequency (10Hz) rTMS over the left DLPFC to decrease cigarette consumption in schizophrenia patients.

METHODS

The study included 35 male schizophrenia patients on stable antipsychotic medication. The patients were divided into two groups: the first (18 patients) were actively stimulated and the second (17 patients) underwent sham (placebo) stimulation. The sham rTMS was administered using a purpose-built sham coil that was identical in appearance to the real coil and made the same noise but did not deliver a substantial stimulus. The rTMS was administered at the stimulation parameters: location (left dorsolateral prefrontal cortex: DLPFC), intensity of magnetic stimulation in % of motor threshold (110%), stimulation frequency (10Hz), number of trains (20), single train duration (10s), inter-train interval (30s), and total number of stimulation sessions (21). In each stimulation session, 2000TMSpulses were given, with a total of 42,000pulses per treatment course. Patients noted the number of cigarettes smoked in the 7days before treatment, during the whole stimulation treatment (21days), and again for a 7-day period after treatment.

RESULTS

Cigarette consumption was statistically significantly lower in the actively stimulated patients than in the sham rTMS group as early as the first week of stimulation. No statistically relevant correlations were found in the changes of ongoing negative or depressive schizophrenia symptoms and the number of cigarettes smoked.

CONCLUSION

High-frequency rTMS over the left DLPFC has the ability to decrease the number of cigarettes smoked in schizophrenia patients.

Prevalence of remission and recovery in schizophrenia in the Czech Republic

OBJECTIVE

The aim of the study was to map the point prevalence of remission and recovery in patients with schizophrenia in the Czech Republic.

METHOD

The point-symptomatic remission criteria were based on the definition of remission in schizophrenia according to Andreasen, without the time criterion. The definition of complete remission contained, in addition to the point-symptomatic remission criteria, a time aspect which was determined by the absence of psychiatric hospitalisation or a change in antipsychotic medications due to inefficiency in the preceding six months. Functional remission was defined by a total score on the PSP scale in the range between 71 and 100 points. Recovery was defined by the simultaneous fulfilment of the criteria for complete and functional remission.

RESULTS

A total of 481 patients with schizophrenia were included in the study. The point-symptomatic remission criteria were fulfilled in a total of 258 patients (54%); complete remission occurred in a total of 214 patients (44%). Functional remission was reached by 124 patients (26%) in total. Recovery was proven in a total of 91 patients (19%).

CONCLUSION

The ascertained data are in accordance with the results of methodologically similar studies and confirm the known trajectories of the course of schizophrenia.

A detailed analysis of the effect of repetitive transcranial magnetic stimulation on negative symptoms of schizophrenia: a double-blind trial

OBJECTIVE

The aim of the study was to assess the effect of rTMS not only on the general severity of negative schizophrenia symptoms, but also particularly on their individual domains, such as affective flattening or blunting, alogia, avolition or apathy, anhedonia, and impaired attention.

METHODS

Forty schizophrenic male patients on stable antipsychotic medication with prominent negative symptoms were included in the study. They were divided into two groups: 23 were treated with active and 17 with placebo rTMS. Both treatments were similar, but placebo rTMS was administered using a purpose-built sham coil. Stimulation was applied to the left dorsolateral prefrontal cortex (DLPFC). The stimulation frequency was 10 Hz; stimulation intensity was 110% of the individual motor threshold intensity. Each patient received 15 rTMS sessions on 15 consecutive working days (five working days "on" and two weekend days "off" design). Each daily session consisted of 20 applications of 10-second duration with 30-second intervals between sequences. The patients and raters were blind to condition of stimulation treatment.

RESULTS

The active rTMS led to a statistically significantly higher reduction of the Scale for the Assessment of Negative Symptoms (SANS) total score and of all domains of negative symptoms of schizophrenia. After Bonferroni adjustments for multiple testing, the statistical significance disappeared in alogia only.

CONCLUSION

High-frequency rTMS stimulation over the left DLPFC at a high stimulation intensity with a sufficient number of applied stimulating pulses may represent an efficient augmentation of antipsychotics in alleviating the negative symptoms of schizophrenia.

Brain functional connectivity of male patients in remission after the first episode of schizophrenia

OBJECTIVES

Abnormal task-related activation and connectivity is present in schizophrenia. The aim of this study was the analysis of functional networks in schizophrenia patients in remission after the first episode.

EXPERIMENTAL DESIGN

Twenty-nine male patients in remission after the first episode of schizophrenia and 22 healthy controls underwent examination by functional magnetic resonance during verbal fluency tasks (VFT). The functional connectivity of brain networks was analyzed using independent component analysis.

RESULTS

The patients showed lower activation of the salience network during VFT. They also showed lower deactivation of the default mode network (DMN) during VFT processing. Spectral analysis of the component time courses showed decreased power in slow frequencies of signal fluctuations in the salience and DMNs and increased power in higher frequencies in the left frontoparietal cortex reflecting higher fluctuations of the network activity. Moreover, there was decreased similarity of component time courses in schizophrenia—the patients had smaller negative correlation between VFT activated and deactivated networks, and smaller positive correlations between DMN subcomponents.

CONCLUSIONS

There is still an abnormal functional connectivity of several brain networks in remission after the first episode of schizophrenia. The effect of different treatment modalities on brain connectivity, together with temporal dynamics of this functional abnormality should be the objective of further studies to assess its potential as a marker of disease stabilization.

Dynamics of neurological soft signs and its relationship to clinical course in patients with first-episode schizophrenia

The aim of the study was to assess the dynamics of neurological soft signs (NSS) over four years from the clinical onset of schizophrenia, depending on the clinical course of the disease, and to evaluate the relationship of NSS to symptomatic dimensions in patients with first-episode schizophrenia. Sixty-eight patients with first-episode schizophrenia were included in the trial. The clinical status was assessed using Positive and Negative Syndrome Scale (PANSS) at the same time as the neurological examination, at admission to the hospital for first-episode schizophrenia and at a check-up examination four years later. The assessment of NSS using the Neurological Evaluation Scale (NES) coincided with the assessment of the clinical condition of the patients. According to the Andreasen remission criterion of schizophrenia, after four years we found that 57% of patients' were remitters and 43% were non-remitters. During the monitoring period, in remitters total NES score and sensory integration/sequencing of motor acts items of the NES decreased. In non-remitters, increase in the total NES score and the 'others' item of the NES was observed. A connection between the dynamics of NSS and the clinical course of schizophrenia, over the period of four years, and a relationship between NSS and negative schizophrenia symptoms was found.

Importance of gender in the treatment of schizophrenia

OBJECTIVE

To compare male and female patients participating in e-STAR (electronic Schizophrenia Treatment Adherence Registry), an international, prospective, observational study assessing use of risperidone long-acting injection in patients with schizophrenia or schizoaffective disorder in both the Czech and Slovak Republics.

METHOD

The demographic, clinical, and treatment-related data were collected at baseline and then prospectively for 24 months. We focused on gender differences in demographic and clinical data (hospitalizations, concomitant medication, and clinical improvement using Clinical Global Impressions-severity of illness [CGI-S], Global Assessment of Functioning [GAF], and Personal and Social Performance [PSP] scales). All psychiatric diagnoses were made according to International Classification of Diseases, Tenth Revision criteria. Data were collected from September 2006 through September 2009.

RESULTS

A total of 868 patients (488 men and 380 women) were included in the assessment. At baseline, the women were significantly older than the men (42.1 ± 12.8 vs 34.8 ± 11.1 years, respectively; P < .0001). The women were also significantly more frequently diagnosed with schizoaffective disorder (P = .0048). There was no difference between men and women in the proportion of patients hospitalized in the retrospective and prospective period (including length of stay). At 24 months, the men were taking fewer antidepressants and benzodiazepines than the women (controlled for baseline values). In men and women, a significant decrease in the CGI-S score (P < .001) and a significant increase in the GAF and PSP scores (P < .001) from baseline were observed. The improvements in CGI-S and PSP scores were similar in both groups (no significant difference between male and female patients). The improvement (increase) in the mean GAF score was significantly higher in women than in men (P = .0317).

CONCLUSIONS

The treatment with risperidone long-acting injection was associated with clinically significant improvement in both male and female patients with schizophrenia with comparable severity of illness. There were no significant differences in most outcome measures. Gender differences, especially concerning treatment response to individual antipsychotics and their different forms, should be more intensively studied.

Does repetitive transcranial magnetic stimulation have a positive effect on working memory and neuronal activation in treatment of negative symptoms of schizophrenia?

OBJECTIVE

The objective of the study was to find out whether, under the conditions of a double-blind, placebo coil controlled study, high-frequency repetitive transcranial magnetic stimulation (TMS) over the left prefrontal cortex will show positive effects on working memory with simultaneous assessment of respective changes in neuronal activation.

RESULTS

Stimulation treatment led to a reduction of seriousness of negative schizophrenia symptoms in both comparative groups. However, mutual comparison of real (n=19) and sham (n=11) rTMS, respectively, has shown that the effect of real rTMS was statistically significantly higher compared with placebo stimulation. During stimulation treatment an improvement in working memory performance was also found. No statistically significant difference between the real and placebo sham rTMS, respectively, was established. The rate of neuronal activation did not change at all during rTMS treatment.

CONCLUSIONS

From clinical point of view rTMS seems to be a well-tolerated neurostimulation method for treatment of negative schizophrenia symptoms with favourable of impact on cognitive functions.

Safety of amisulpride in combination with antidepressants under common clinical practice conditions

AIM

The main objective was to identify the occurrence of adverse events associated with amisulpride when combined with antidepressants (ADs).

METHODS

A non-interventional questionnaire-based study focussed on identification of occurrence and tolerance of combinations of amisulpride with ADs under common clinical practice conditions.

RESULTS

Combinations of amisulpride with ADs were administered to 3178 patients suffering from depression. The average daily dose of amisulpride was 54.8 ± 17 mg (range 50-150 mg/day). The most frequently administered ADs were SSRIs. A total of 4463 adverse events were recorded in 1624 (51%) of all treated patients. The most frequent adverse event was weight gain, followed by headache, fatigue and sleepiness. Only 2% of all adverse events were evaluated as adverse events of medium or high intensity. Higher occurrences of some adverse events were noted for specific combinations.

CONCLUSION

The advantages of AD combinations undoubtedly include administration of lower doses and a reduction of adverse events associated with higher doses of individual ADs. On the other hand, adverse events can also sum. Nevertheless it is generally agreed that, in some patients, a combination of ADs, with different mechanisms of action, can be considered safe and effective polypharmacy.

Maximum-uncertainty linear discrimination analysis of first-episode schizophrenia subjects

Recent techniques of image analysis brought the possibility to recognize subjects based on discriminative image features. We performed a magnetic resonance imaging (MRI)-based classification study to assess its usefulness for outcome prediction of first-episode schizophrenia patients (FES). We included 39 FES patients and 39 healthy controls (HC) and performed the maximum-uncertainty linear discrimination analysis (MLDA) of MRI brain intensity images. The classification accuracy index (CA) was correlated with the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF) at 1-year follow-up. The rate of correct classifications of patients with poor and good outcomes was analyzed using chi-square tests. MLDA classification was significantly better than classification by chance. Leave-one-out accuracy was 72%. CA correlated significantly with PANSS and GAF scores at the 1-year follow-up. Moreover, significantly more patients with poor outcome than those with good outcome were classified correctly. MLDA of brain MR intensity features is, therefore, able to correctly classify a significant number of FES patients, and the discriminative features are clinically relevant for clinical presentation 1 year after the first episode of schizophrenia. The accuracy of the current approach is, however, insufficient to be used in clinical practice immediately. Several methodological issues need to be addressed to increase the usefulness of this classification approach.

Outcome in males with first-episode schizophrenia: 7-year follow-up

OBJECTIVES

The early course of schizophrenia is highly variable. We assessed outcomes of patients with first-episode schizophrenia at 7-year follow-up.

METHODS

Consecutively hospitalized male patients were included if they were experiencing their first admission for first-episode schizophrenia and were reassessed at 1-, 4- and 7-year follow-ups. The psychopathology was evaluated using the PANSS, relative decrease of PANSS and remission status based on severity of core symptoms.

RESULTS

Forty-four of 76 patients were reassessed three times. At the end of index hospitalization 73% of patients achieved remission; however, after 1, 4 and 7 years, the percentage had dropped to 50, 50 and 52%, respectively. When compared post-hoc there was no significant difference in PANSS and response to treatment between remitters and non-remitters during the index hospitalization; however, a significant difference in psychopathology emerged first after 1, 4 and 7 years. All patients who had not achieve remission after 1 year also failed to achieve remission after 4 and 7 years.

CONCLUSIONS

Response to treatment during the first psychotic break-through may not be a decisive indicator for the outlook of the disease. Our data suggest that when deterioration occurs, it does so early after the first episode.

Individualized treatment of eating disorders

OBJECTIVE

The goal of this study is to determine how a comprehensive approach comprising a combination of a particular psychotherapeutic programme and antidepressant treatment influences the signs and symptoms of eating disorders.

METHODS

Inpatients entering a particular 6-week programme were assessed using body mass index (BMI), Eating Disorder Inventory (EDI), Eating Attitudes Test (EAT-26) and psychological symptoms using Symptom Checklist (SCL-90).

RESULTS

In the whole group (n=84) the mean BMI remained stable (17.9, 17.8). There was a significant effect of TIME in the repeated measures ANOVA with most of dependent variables. The "TREATMENT" had no effect (antidepressants, no antidepressants) and there was no significant interaction between "TREATMENT" and "TIME". Post-hoc analysis revealed significant differences between baseline and end-point values of all but two EDI, all EAT items and some SCL dimensions in the antidepressant-treated group.

CONCLUSIONS

The comprehensive and individualized approach is able to achieve weight stabilization, and improvement in attitudes, pathological eating behaviour and psychopathology.

Gray matter morphology and the level of functioning in one-year follow-up of first-episode schizophrenia patients

Schizophrenia is a condition with a highly variable course that is hard to predict. The aim of the present study was to investigate if local gray matter volume (GMV) can differentiate poor (PF) and good (GF) functioning patients using voxel-wise analysis in a group of first-episode schizophrenia subjects (FES).

METHOD

32 FES male patients were assessed twice: at the time of the first episode of schizophrenia and one year later. 18 healthy controls matched for age, gender, and handedness were also included. Local gray matter volume was analyzed using voxel-wise full-factorial design with factors group (GF, PF) and time.

RESULTS

FES subjects had bilateral gray matter reduction in the lateral prefrontal cortex as compared with healthy controls. PF subjects had smaller GMV in the left orbitofrontal and frontopolar cortex.

CONCLUSION

GMV in the left prefrontal cortex differentiates later poor and good functioning schizophrenia patients. Morphological analysis might be considered a candidate for a biological marker in outcome prediction. However, the small sample size, and the lack of female subjects limit generalization of results. Moreover, studies analyzing the predictive value of brain morphology on a single-subject level should be performed to assess its real usefulness in outcome prediction.

Paliperidon mediated modification of cortical inhibition

Transcranial magnetic stimulation is a neurophysiological method which enables direct quantitative in vivo assessment of cortical excitability and inhibition. The aim of the study was to assess the impact of paliperidone on the motor threshold and cortical silent period, in a drug-naive patient, with first episode schizophrenia using this technique. Paliperidone monotherapy caused a significant reduction of severity of schizophrenic symptomatology in the patient. At the same time, a significant prolongation of the cortical silent period, from 118.68 ms before to 185.13 ms after therapy, occurred. Because the cortical silent period is a function of GABA(B) receptors, we can assume that paliperidone may have the ability to enhance GABA(B) receptor-mediated neurotransmission.

Treatment of negative symptoms of schizophrenia using repetitive transcranial magnetic stimulation in a double-blind, randomized controlled study

OBJECTIVE

To verify whether high-frequency rTMS applied above the area of the left prefrontal cortex in 15 stimulation sessions with maximum stimulation intensity is able to modify negative symptoms of schizophrenia in a double-blind, randomized controlled study.

METHODS

Twenty-two patients with schizophrenia stabilized on antipsychotic medication with prominent negative symptoms were included in the trial. They were divided into two groups: eleven were treated with effective rTMS and eleven with ineffective "sham" rTMS. The ineffectiveness of the sham rTMS was achieved through the stimulation coil position. Stimulation was applied to the left dorsolateral prefrontal cortex. The stimulation frequency was 10 Hz. Stimulation intensity was 110% of the motor threshold intensity. Each patient received 15 rTMS sessions on 15 consecutive working days. Each daily session consisted of 15 applications of 10-second duration and 30-second intervals between sequences. There were 1500 stimuli per session.

RESULTS

During real rTMS treatment a statistically significant decrease of negative symptoms was found (approximately 29% reduction in the PANSS negative symptom subscale and 50% reduction in the SANS). No adverse events occurred during therapy except for a mild headaches. In sham rTMS treatment a decrease of negative symptoms was also identified, but to a lesser extent than in real rTMS (about 7% in negative subscale PANSS and 13% in SANS). The change in SANS achieved statistical significance. Mutual comparison revealed a greater decrease of negative symptoms in favor of real rTMS in contrast to sham rTMS.

CONCLUSION

The augmentation of rTMS enabled patients to experience a significant decrease in the severity of the negative symptoms. Our results support the therapeutic potential of rTMS at higher frequency for negative symptoms of schizophrenia.

Monitoring of QT interval in patients treated with psychotropic drugs

BACKGROUND

Psychotropic drugs have the potential for QT interval prolongation, the frequency is not known. The aim of this study was to monitor the occurrence of QT interval prolongation in a non-selected population of patients treated with psychotropic drugs with proarrhythmic potential.

METHODS

In consecutive patients hospitalized at psychotic wards at the Department of Psychiatry treated with antipsychotic and antidepressant drugs with known or unexplored proarrhythmic potential a 12-lead ECG was recorded (50 mm/s, 20 mm/mV) on therapy; the QT interval was measured manually, corrected according to Bazett and Fridericia. QTc intervals of 470 ms (females) and 450 ms (males) were considered borderline, longer QTc intervals were considered pathologic.

RESULTS

ECGs were recorded in 452 patients (187 females, 265 males, aged 43+/-16 years). Using Bazett's correction, abnormal QTc values were observed only in 2% of the whole group and in 1.8% of the patients treated with drugs associated with QT prolongation (the greatest QTc value is 490 ms in female and 480 ms in male). With Fridericia's correction, there was only 1 case of borderline QTc in the whole group (the greatest QTc value is 450 ms in both sex groups).

CONCLUSIONS

Our 2-year real-life experience shows that occurrence of QTc prolongation in present psychiatric patients is low. Values associated with high risk of arrhythmias (QTc>500 ms) were not observed. This might be related to the recent changes of spectrum of antipsychotic therapy used, the general trend to use lower doses, and increasing awareness about the drug-induced long QT syndrome.

Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies

Premenstrual syndrome (PMS) encompasses a variety of symptoms appearing during the luteal phase of the menstrual cycle. Although PMS is widely recognized, the etiology remains unclear and it lacks definitive, universally accepted diagnostic criteria. To address these issues an international multidisciplinary group of experts evaluated the current definitions and diagnostic criteria of PMS and premenstrual dysphoric disorder (PMDD). Following extensive correspondence, a consensus meeting was held with the aim of producing updated diagnostic criteria for PMS and guidelines for clinical and research applications. This report presents the conclusions and recommendations of the group. It is hoped that the criteria proposed by the group will become widely accepted and eventually be incorporated into the next edition of the World Health Organization's International Classification of Diseases (ICD-11). It is also hoped that the proposed guidelines for quantification of criteria will be used by clinicians and investigators to facilitate diagnostic uniformity in the field as well as adequate treatment modalities when warranted.

Influencing negative symptoms of schizophrenia with repetitive transcranial magnetic stimulation: a case study

BACKGROUND

The present trial was designed to investigate the influence of repetitive transcranial magnetic stimulation (rTMS) on negative schizophrenic symptoms using high-frequency stimulation of the left dorsolateral prefrontal cortex in a simple blind randomized design.

METHODS

The study was carried out on a 42-year-old patient with schizophrenia (paranoid subtype) with prominent negative symptoms who was first treated with sham rTMS during the first 3 weeks and then with real high frequency during the following 3 weeks. He was rated before and after the sham and after the real rTMS therapy for positive, negative and depressive symptoms.

RESULTS

rTMS was superior to sham treatment in reduction of negative and depressive symptoms.

CONCLUSION

High-frequency rTMS applied over the left dorsolateral prefrontal cortex led to a reduction of severity of negative symptoms in a patient with chronic schizophrenia and may be beneficial as an augmentation option to antipsychotics in the treatment of negative symptoms of schizophrenia.

Neurological soft signs, clinical symptoms and treatment reactivity in patients suffering from first episode schizophrenia

OBJECTIVE

(a) To investigate the correlation between clinical symptoms and neurological soft signs in patients suffering from their first episode of schizophrenia and (b) to examine the relationship between soft signs and the reactivity of first episode treatment.

METHODS

The trial included 92 male patients undergoing a first episode of schizophrenia. The clinical symptoms of the patients were rated on the positive and negative syndrome scale (PANSS). The PANSS scale was used to provide a measure for three syndromes: psychomotor poverty, disorganisation, and reality distortion. Neurological soft signs were assessed with the help of the neurological evaluation scale.

RESULTS

The findings corroborated significant positive correlations between soft neurological signs on the one hand and negative symptoms and reduced treatment response on the other.

CONCLUSION

Our study of the population of patients with first episode schizophrenia has corroborated the findings of those trials that found a correlation between neurological soft signs and the negative symptomatic dimension of schizophrenia. Another finding of the trial is that neurological soft signs were associated with poorer response to treatment of the first episode of schizophrenia.