Psychotherapy employed additionally to Psychopharmacotherapy is not related to Better Treatment Outcome in Major Depressive Disorder

Introduction

Although numerous effective antidepressant (AD) strategies are available for the treatment of major depressive disorder (MDD), many patients do not achieve satisfactory treatment response.

Objectives

The aims of the present European, cross-sectional, multicenter, naturalistic study were (1) to determine the proportion of patients suffering from primary MDD who received additional psychotherapy to their ongoing psychopharmacotherapy and (2) to identify the associated socio-demographic and clinical patterns.

Methods

Patients receiving both treatments were compared to those lacking concomitant additional psychotherapy that was manual-driven psychotherapy (MDP) in all cases.

Results

While 68.8% of a total of 1279 MDD patients received exclusively psychopharmacotherapy, 31.2% underwent a psychopharmacotherapy-MDP combination. The latter patient population was rather younger, higher educated, employed, exhibited an earlier mean age of MDD onset, lower severity of current depressive symptoms with lower odds of suicidality and higher rates of melancholic features, and comorbid asthma and migraine, and was generally treated with lower daily doses of their first-line ADs. Whereas agomelatine was more commonly dispensed in these patients, selective serotonin reuptake inhibitors were more often prescribed in MDD patients lacking additional MDP. No significant between-group differences were detected in terms of treatment outcome.

Conclusions

The fact that the employment of additional MDP was not related to better treatment outcome in MDD represents our major and clinically most relevant finding. Generally, MDP was employed in a minority of our patients who experienced rather beneficial socio-demographic and clinical characteristics. This might reflect an inferior accessibility of these psychotherapeutic techniques for patients who are more severely ill and less socio-economically privileged.

Disclosure

References Bartova L, Fugger G, Dold M, Swoboda MMM, Zohar J, Mendlewicz J, Souery D, Montgomery S, Fabbri C, Serretti A, Kasper S. Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disor

Development of a maleic acid-based material to selectively solid-phase extract basic compounds from environmental samples

This study presents a novel mixed-mode weak cation-exchange (WCX) material. This material was prepared by means of the functionalization of a mesoporous divinylbenzene (DVB) resin with maleic acid (maleic acid-DVB), which yielded a high carboxylic moiety content resulting in WCX interactions as well as suitable specific surface area for reversed-phase interactions. After the optimization of the solid-phase extraction (SPE) protocol to enhance the selectivity of the sorbent, this material was evaluated as a novel WCX sorbent in the SPE of a group of drugs from environmental water samples. The method is based on SPE followed by liquid chromatography (LC) coupled to high resolution mass spectrometry (HRMS) with an Orbitrap analyzer, and was validated and applied for the determination of basic drugs in river, effluent and influent wastewater samples. Maleic acid-DVB sorbent yielded suitable recovery rates (57% to 89%) and an acceptable matrix effect (<32%) thanks to the effective washing step included when these environmental waters were loaded through the novel resin. The method was applied to different environmental water samples and some basic drugs were suitably quantified in these environmental samples.

Clinical factors predicting treatment resistant depression: affirmative results from the European multicenter study

OBJECTIVES

Clinical variables were investigated in the 'treatment resistant depression (TRD)- III' sample to replicate earlier findings by the European research consortium 'Group for the Study of Resistant Depression' (GSRD) and enable cross-sample prediction of treatment outcome in TRD.

EXPERIMENTAL PROCEDURES

TRD was defined by a Montgomery and Åsberg Depression Rating Scale (MADRS) score ≥22 after at least two antidepressive trials. Response was defined by a decline in MADRS score by ≥50% and below a threshold of 22. Logistic regression was applied to replicate predictors for TRD among 16 clinical variables in 916 patients. Elastic net regression was applied for prediction of treatment outcome.

RESULTS

Symptom severity (odds ratio (OR) = 3.31), psychotic symptoms (OR = 2.52), suicidal risk (OR = 1.74), generalized anxiety disorder (OR = 1.68), inpatient status (OR = 1.65), higher number of antidepressants administered previously (OR = 1.23), and lifetime depressive episodes (OR = 1.15) as well as longer duration of the current episode (OR = 1.022) increased the risk of TRD. Prediction of TRD reached an accuracy of 0.86 in the independent validation set, TRD-I.

CONCLUSION

Symptom severity, suicidal risk, higher number of lifetime depressive episodes, and comorbid anxiety disorder were replicated as the most prominent risk factors for TRD. Significant predictors in TRD-III enabled robust prediction of treatment outcome in TRD-I.

Manifesto for a European research network into Problematic Usage of the Internet

The Internet is now all-pervasive across much of the globe. While it has positive uses (e.g. prompt access to information, rapid news dissemination), many individuals develop Problematic Use of the Internet (PUI), an umbrella term incorporating a range of repetitive impairing behaviours. The Internet can act as a conduit for, and may contribute to, functionally impairing behaviours including excessive and compulsive video gaming, compulsive sexual behaviour, buying, gambling, streaming or social networks use. There is growing public and National health authority concern about the health and societal costs of PUI across the lifespan. Gaming Disorder is being considered for inclusion as a mental disorder in diagnostic classification systems, and was listed in the ICD-11 version released for consideration by Member States (http://www.who.int/classifications/icd/revision/timeline/en/). More research is needed into disorder definitions, validation of clinical tools, prevalence, clinical parameters, brain-based biology, socio-health-economic impact, and empirically validated intervention and policy approaches. Potential cultural differences in the magnitudes and natures of types and patterns of PUI need to be better understood, to inform optimal health policy and service development. To this end, the EU under Horizon 2020 has launched a new four-year European Cooperation in Science and Technology (COST) Action Programme (CA 16207), bringing together scientists and clinicians from across the fields of impulsive, compulsive, and addictive disorders, to advance networked interdisciplinary research into PUI across Europe and beyond, ultimately seeking to inform regulatory policies and clinical practice. This paper describes nine critical and achievable research priorities identified by the Network, needed in order to advance understanding of PUI, with a view towards identifying vulnerable individuals for early intervention. The network shall enable collaborative research networks, shared multinational databases, multicentre studies and joint publications.

Clinical correlates of augmentation/combination treatment strategies in major depressive disorder

OBJECTIVE

This multicenter, multinational, cross-sectional study aimed to investigate clinical characteristics and treatment outcomes associated with augmentation/combination treatment strategies in major depressive disorder (MDD).

METHOD

Sociodemographic, clinical, and treatment features of 1410 adult MDD patients were compared between MDD patients treated with monotherapy and augmentation/combination medication using descriptive statistics, analyses of covariance (ancova), and Spearman's correlation analyses.

RESULTS

60.64% of all participants received augmentation and/or combination strategies with a mean number of 2.18 ± 1.22 simultaneously prescribed psychiatric drugs. We found male gender, older age, Caucasian descent, higher weight, low educational status, absence of occupation, psychotic symptoms, melancholic and atypical features, suicide risk, in-patient treatment, longer duration of hospitalization, some psychiatric comorbidities (panic disorder, agoraphobia, obsessive-compulsive disorder, and bulimia nervosa), comorbid somatic comorbidity in general and concurrent hypertension, thyroid dysfunction, diabetes, and heart disease in particular, higher current and retrospective Montgomery and Åsberg Depression Rating Scale total scores, treatment resistance, and higher antidepressant dosing to be significantly associated with augmentation/combination treatment. These findings were corroborated when examining the number of concurrently administered psychiatric drugs in the statistical analyses.

CONCLUSION

Our findings suggest a clear association between augmentation/combination strategies and treatment-resistant/difficult-to-treat MDD conditions characterized by severe symptomatology and high amount of psychiatric and somatic comorbidities.

Obsessive-compulsive disorder in the elderly: A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a highly disabling condition, with frequent early onset. Adult/adolescent OCD has been extensively investigated, but little is known about prevalence and clinical characterization of geriatric patients with OCD (G-OCD≥65years). The present study aimed to assess prevalence of G-OCD and associated socio-demographic and clinical correlates in a large international sample.

METHODS

Data from 416 outpatients, participating in the ICOCS network, were assessed and categorized into 2 groups, age<vs≥65years, and then divided on the basis of the median age of the sample (age<vs≥42years). Socio-demographic and clinical variables were compared between groups (Pearson Chi-squared and t tests).

RESULTS

G-OCD compared with younger patients represented a significant minority of the sample (6% vs 94%, P<.001), showing a significantly later age at onset (29.4±15.1 vs 18.7±9.2years, P<.001), a more frequent adult onset (75% vs 41.1%, P<.001) and a less frequent use of cognitive-behavioural therapy (CBT) (20.8% vs 41.8%, P<.05). Female gender was more represented in G-OCD patients, though not at a statistically significant level (75% vs 56.4%, P=.07). When the whole sample was divided on the basis of the median age, previous results were confirmed for older patients, including a significantly higher presence of women (52.1% vs 63.1%, P<.05).

CONCLUSIONS

G-OCD compared with younger patients represented a small minority of the sample and showed later age at onset, more frequent adult onset and lower CBT use. Age at onset may influence course and overall management of OCD, with additional investigation needed.

Prescribing patterns of psychiatric drugs in major depressive disorder – Findings from a large European multicenter, cross-sectional study

Introduction

The multicenter, cross-sectional survey summarizes the current prescription patterns of psychopharmacological medications in patients with major depressive disorder (MDD) treated in European university psychiatric centers.

Methods

The study included a total of 1181 MDD patients who were recruited in 9 academic sites across 8 European countries. Socio-demographic, clinical, and psychopharmacological characteristics were collected within a detailed clinical interview and the current depressive symptom severity was measured by the Montgomery and Åsberg Depression Rating Scale (MADRS). Symptom reduction during the present MDD episode was analyzed by calculating retrospective MADRS scores. Descriptive statistics, analyses of variance (ANOVAs), and Spearman correlation analyses were performed to examine the impact of various features on the applied pharmacological strategies.

Results

Regarding first-line antidepressant medication, the most frequently prescribed drug classes were selective serotonin reuptake inhibitors (SSRIs) (53.4%), serotonin-norepinephrine reuptake inhibitors (SNRIs) (23.6%), noradrenergic and specific serotonergic antidepressants (NaSSAs) (8.2%), tricyclic antidepressants (TCA) (5.1%), and the melatonergic antidepressant agomelatine (5.0%). The most commonly used individual antidepressants were escitalopram (18.4%), venlafaxine (15.2%), sertraline (12.9%), paroxetine (9.1%), mirtazapine (8.2%), duloxetine (7.0%), and fluoxetine (6.5%). Among the patients, 59.4% were treated with polypsychopharmaceutical medications (mean: 2 drugs) and for the number of individual drugs, we found a significant correlation with the present MADRS total score and the MADRS total score change during the current depressive episode.

Conclusion

Consistent with surveys investigating primarily municipal psychiatric treatment centers, we could replicate the observation that SSRIs are the most commonly used antidepressants in MDD for the first time for European university centers.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The wake-promoting drug modafinil stimulates specific hypothalamic circuits to promote adaptive stress responses in an animal model of PTSD

Pharmacotherapeutic intervention during traumatic memory consolidation has been suggested to alleviate or even prevent the development of posttraumatic stress disorder (PTSD). We recently reported that, in a controlled, prospective animal model, depriving rats of sleep following stress exposure prevents the development of a PTSD-like phenotype. Here, we report that administering the wake-promoting drug modafinil to rats in the aftermath of a stressogenic experience has a similar prophylactic effect, as it significantly reduces the prevalence of PTSD-like phenotype. Moreover, we show that the therapeutic value of modafinil appears to stem from its ability to stimulate a specific circuit within the hypothalamus, which ties together the neuropeptide Y, the orexin system and the HPA axis, to promote adaptive stress responses. The study not only confirms the value of sleep prevention and identifies the mechanism of action of a potential prophylactic treatment after traumatic exposure, but also contributes to understanding mechanisms underlying the shift towards adaptive behavioral response.

Neuronal cell adhesion genes and antidepressant response in three independent samples

Drug-effect phenotypes in human lymphoblastoid cell lines recently allowed to identify CHL1 (cell adhesion molecule with homology to L1CAM), GAP43 (growth-associated protein 43) and ITGB3 (integrin beta 3) as new candidates for involvement in the antidepressant effect. CHL1 and ITGB3 code for adhesion molecules, while GAP43 codes for a neuron-specific cytosolic protein expressed in neuronal growth cones; all the three gene products are involved in synaptic plasticity. Sixteen polymorphisms in these genes were genotyped in two samples (n=369 and 90) with diagnosis of major depressive episode who were treated with antidepressants in a naturalistic setting. Phenotypes were response, remission and treatment-resistant depression. Logistic regression including appropriate covariates was performed. Genes associated with outcomes were investigated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) genome-wide study (n=1861) as both individual genes and through a pathway analysis (Reactome and String databases). Gene-based analysis suggested CHL1 rs4003413, GAP43 rs283393 and rs9860828, ITGB3 rs3809865 as the top candidates due to their replication across the largest original sample and the STAR*D cohort. GAP43 molecular pathway was associated with both response and remission in the STAR*D, with ELAVL4 representing the gene with the highest percentage of single nucleotide polymorphisms (SNPs) associated with outcomes. Other promising genes emerging from the pathway analysis were ITGB1 and NRP1. The present study was the first to analyze cell adhesion genes and their molecular pathways in antidepressant response. Genes and biomarkers involved in neuronal adhesion should be considered by further studies aimed to identify predictors of antidepressant response.

SASOP Biological Psychiatry Congress 2013 Abstracts

<p><strong>List of abstracts and authors:</strong></p><p><strong>1. Bipolar disorder not otherwise specified -overdiagnosed or underdiagnosed?</strong></p><p>E Allers</p><p><strong>2. The prognosis of major depression untreated and treated: Does the data reflect the true picture of the prognosis of this very common disorder?</strong></p><p>E Allers</p><p><strong>3. Can we prolong our patients' life expectancy? Providing a better quality of life for patients with severe mental illness</strong></p><p>O A Betencourt</p><p><strong>4. The scope of ECT practice in South Africa</strong></p><p>J Benson-Martin, P Milligan</p><p><strong>5. Biomarkers for schizophrenia: Can we evolve like cancer therapeutics?</strong></p><p>P Buckley<strong></strong></p><p><strong>6. Relapse in schizophrenis: Major challenges in prediction and prevention</strong></p><p>P Buckley</p><p><strong>7. Informed consent in biological treatments: The right to know the duty to inform</strong></p><p><strong></strong>I Chetty</p><p><strong>8. Effectiveness of a long-acting injectable antipsychotic plus an assertive monitoring programme in first-episode schizophrenia</strong></p><p><strong></strong>B Chiliza, L Asmal, O Esan, A Ojagbemi, O Gureje, R Emsley</p><p><strong>9. Name, shame, fame</strong></p><p>P Cilliers</p><p><strong>10. Can we manage the increasing incidence of violent raging children? We have to!</strong></p><p>H Clark</p><p><strong>11. Serotonin, depression and antidepressant action</strong></p><p>P Cowen</p><p><strong>12. Prevalence and correlates of comorbid psychiatris illness in patients with heroin use disorder admitted to Stikland Opioid Detoxification Unit</strong></p><p>L Dannatt, K J Cloete, M Kidd, L Weich</p><p><strong>13. Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers</strong></p><p>A K Domingo, S Seedat, T M Esterhuizen, C Laurence, J Volmink, L Asmal</p><p><strong>14. Neuropeptide S -emerging evidence for a role in anxiety</strong></p><p>K Domschke</p><p><strong>15. Pathogenetics of anxiety</strong></p><p>K Domschke</p><p><strong>16. The effects of HIV on the fronto-striatal system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>17. Effects of acute antipsychotic treatment on brain morphology in schizophrenia</strong></p><p>R Emsley, L Asmal, B Chiliza, S du Plessis, J Carr, A Goosen, M Kidd, M Vink, R Kahn</p><p><strong>18. Development of a genetic database resource for monitoring of breast cancer patients at risk of physical and psychological complications</strong></p><p>K Grant, F J Cronje, K Botha, J P Apffelstaedt, M J Kotze</p><p><strong>19. Unipolar mania reconsidered: Evidence from a South African study</strong></p><p><strong></strong>C Grobler</p><p><strong>20. Antipsychotic-induced movement disorders: Occurence and management</strong></p><p>P Haddad</p><p><strong>21. The place of observational studies in assessing the effectiveness of long-acting injectable antipsychotics</strong></p><p>P Haddad</p><p><strong>22. Molecular mechanisms of d-cycloserine in fear extinction: Insights from RNS sequencing</strong></p><p>S Hemmings, S Malan-Muller, L Fairbairn, M Jalali, E J Oakeley, J Gamieldien, M Kidd, S Seedat</p><p><strong>23. Schizophrenia: The role of inflammation</strong></p><p>DC Henderson</p><p><strong>24. Addictions: Emergent trends and innovations</strong></p><p>V Hitzeroth</p><p><strong>25. The socio-cultural-religious context of biological psychiatric practice</strong></p><p>B Janse van Rensburg</p><p><strong>26. Biochemical markers for identifying risk factors for disability progression in multiple sclerosis</strong></p><p><strong></strong>S Janse van Rensburg, M J Kotze, F J Cronje, W Davis, K Moremi, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>27. Alcohol-induced psychotic disorder: Brain perfusion and psychopathology - before and after antipsychotic treatment</strong></p><p>G Jordaan, J M Warwick, D G Nel, R Hewlett, R Emsley</p><p><strong>28.'Pump and dump': Harm reduction strategies for breastfeeding while using substances</strong></p><p>L Kramer</p><p><strong>29. Adolescent neuropsychiatry - an emerging field in South African adolescent psychiatric services</strong></p><p>A Lachman</p><p><strong>30. Recovery versus remission, or what it means to be healthy for a psychiatric patient?</strong></p><p>B Latecki</p><p><strong>31. Holistic methods utilised to normalise behaviours in youth diagnosed with neuro-biochemical disorders</strong></p><p>P Macqueen</p><p><strong>32. Candidate genes and novel polymorphisms for anxiety disorder in a South African cohort</strong></p><p>N McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D Stein, V Russel, C Lochner</p><p><strong>33. Higher visual functioning</strong></p><p>A Moodley</p><p><strong>34. The effects of prenatal methylmercury exposure on trace element and antioxidant levels in rat offspring following 6-hydroxydopamine-induced neuronal insult</strong></p><p>Z M Moosa, W M U Daniels, M V Mabandla</p><p><strong>35. Paediatric neuropsychiatric movement disorders</strong></p><p>L Mubaiwa</p><p><strong>36. The South African national female offenders study</strong></p><p>M Nagdee, L Artz, C de Clercq, P de Wet, H Erlacher, S Kaliski, C Kotze, L Kowalski, J Naidoo, S Naidoo, J Pretorius, M Roffey, F Sokudela, U Subramaney</p><p><strong>37. Neurobiological consequences of child abuse</strong></p><p>C Nemeroff</p><p><strong>38. What do Stellenbosch Unviversity medical students think about psychiatry - and why should we care?</strong></p><p>G Nortje, S Suliman, K Seed, G Lydall, S Seedat</p><p><strong>39. Neurological soft skins in Nigerian Africans with first episode schizophrenia: Factor structure and clinical correlates</strong></p><p><strong></strong>A Ojagbemi, O Esan, O Gureje, R Emsley</p><p><strong>40. Should psychiatric patients know their MTHFR status?</strong></p><p>E Peter</p><p><strong>41. Clinical and functional outcome of treatment refractory first-episode schizophrenia</strong></p><p>L Phahladira, R Emsley, L Asmal, B Chiliza</p><p><strong>42. Bioethics by case discussion</strong></p><p>W Pienaar</p><p><strong>43. Reviewing our social contract pertaining to psychiatric research in children, research in developing countries and distributive justice in pharmacy</strong></p><p>W Pienaar</p><p><strong>44. The performance of the MMSE in a heterogenous elderly South African population</strong></p><p>S Ramlall, J Chipps, A I Bhigjee, B J Pillay</p><p><strong>45. Biological basis addiction (alocohol and drug addiction)</strong></p><p>S Rataemane</p><p><strong>46. Volumetric brain changes in prenatal methamphetamine-exposed children compared with healthy unexposed controls</strong></p><p><strong></strong>A Roos, K Donald, G Jones, D J Stein</p><p><strong>47. Single voxel proton magnetic resonance spectroscopy of the amygdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A Hess, S Seedat, E Meintjies</p><p><strong>48. Discussion of HDAC inhibitors, with specific reference to supliride and its use during breastfeeding</strong></p><p>J Roux</p><p><strong>49. Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia</strong></p><p>C Schumann, L Asmal, K Cloete, B Chiliza, R Emsley</p><p><strong>50. Are dreams meaningless?</strong></p><p>M Solms</p><p><strong>51. The conscious id</strong></p><p>M Solms<strong></strong></p><p><strong>52. Depression and resilience in HIV-infected women with early life stress: Does trauma play a mediating role?</strong></p><p>G Spies, S Seedat</p><p><strong>53. State of affairs analysis for forensic psychiatry in SA</strong></p><p>U Subramaney</p><p><strong>54. Escitalopram in the prevention of post-traumatic stress disorder: A pilot randomised controlled trial</strong></p><p>S Suliman, S Seedat, J Pingo, T Sutherland, J Zohar, D J Stein</p><p><strong>55. Epigenetic consequences of adverse early social experiences in primates</strong></p><p>S Suomi</p><p><strong>56. Risk, resilience, and gene x environment interactions in primates</strong></p><p>S Suomi</p><p><strong>57. Biological aspects of anorexia nervosa</strong></p><p>C Szabo</p><p><strong>58. Agents used and profiles of non-fatal suicidal behaviour in East London</strong></p><p>H Uys</p><p><strong>59. The contributions of G-protein coupled receptor signalling to opioid dependence</strong></p><p>J van Tonder</p><p><strong>60. Emerging trend and innovation in PTSD and OCD</strong></p><p>J Zohar</p><p><strong>61. Making the SASOP treatment guidelines operational</strong></p><p>E Allers</p><p><strong>Poster Presentations</strong></p><p><strong>62. Neuropsychological deficits in social anxiety disorder in the context of early developmental trauma</strong></p><p><strong></strong>S Bakelaar, D Rosenstein, S Seedat</p><p><strong>63.Social anxiety disorder in patients with or without early childhood trauma: Relationship to behavioral inhibition and activation and quality of life</strong></p><p><strong></strong>S Bakelaar, C Bruijnen, A Sambeth, S Seedat</p><p><strong>64. Exploring altered affective processing in obssessive compulsive disorder symptom subtypes</strong></p><p>E Breet, J Ipser, D Stein, C Lochner<strong><br /></strong></p><p><strong>65. To investigate the bias toward recognising the facial expression of disgust in obsessive compulsive disorder as well as the effect of escitalopram</strong></p><p>E Breet, J Ipser, D Stein, C Lochner</p><p><strong>66. A fatal-case of nevirapine-induced Stevens-Johnson's syndrome in HIV mania</strong></p><p>A Bronkhorst, Z Zingela, W M Qwesha, B P Magigaba<strong></strong></p><p><strong>67. Association of the COMT G472A (met/met) genotype with lower disability in people diagnosed with multiple sclerosis</strong></p><p>W Davis, S J van Rensburg, L Fisher, F J Cronje, D Geiger, M J Kotze</p><p><strong>68. Homocycsteine levels are associated with the fat mass and obesity associated gene FTO(intron 1 T&gt;A) polymorphism in MS patients</strong></p><p>W Davis, S J Van Rensburg, M J Kotze, L Fisher, M Jalali, F J Cronje, K Moremi, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>69. Analysis of the COMT 472 G&gt;A (rs4680) polymorphism in relation to environmental influences as contributing factors in patients with schizophrenia</strong></p><p>D de Klerk, S J van Rensburg, R A Emsley, D Geiger, M Rensburg, R T Erasmus, M J Kotze</p><p><strong>70. Dietary folate intake, homocysteine levels and MTHFR mutation detection in South African patients with depression: Test development for clinical application </strong></p><p>D Delport, N vand der Merwe, R Schoeman, M J Kotze</p><p><strong>71. The use ofexome sequencing for antipsychotic pharmacogenomic applications in South African schizophrenia patients</strong></p><p>B Drogmoller, D Niehaus, G Wright, B Chiliza, L Asmal, R Emsley, L Warnich</p><p><strong>72. The effects of HIV on the ventral-striatal reward system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>73. Xenomelia relates to asymmetrical insular activity: A case study of fMRI</strong></p><p>S du Plessis, M Vink, L Asmal</p><p><strong>74. Maternal mental helath: A prospective naturalistic study of the outcome of pregancy in women with major psychiatric disorders in an African country</strong></p><p>E du Toit, L Koen, D Niehaus, B Vythilingum, E Jordaan, J Leppanen</p><p><strong>75. Prefrontal cortical thinning and subcortical volume decrease in HIV-positive children with encephalopathy</strong></p><p>J P Fouche, B Spottiswoode, K Donald, D Stein, J Hoare</p><p><strong>76. H-magnetic resonance spectroscopy metabolites in schizophrenia</strong></p><p>F Howells, J Hsieh, H Temmingh, D J Stein</p><p><strong>77. Hypothesis for the development of persistent methamphetamine-induced psychosis</strong></p><p><strong></strong> J Hsieh, D J Stein, F M Howells</p><p><strong>78. Culture, religion, spirituality and psychiatric practice: The SASOP Spirituality and Psychiatry Special Interest Group Action Plan for 2012-2014</strong></p><p>B Janse van Rensburg</p><p><strong>79. Cocaine reduces the efficiency of dopamine uptake in a rodent model of attention-deficit/hyperactivity disorder: An <em>in vivo</em> electrochemical study</strong></p><p><strong></strong>L Kellaway, J S Womersley, D J Stein, G A Gerhardt, V A Russell</p><p><strong>80. Kleine-Levin syndrome: Case in an adolescent psychiatric unit</strong></p><p>A Lachman</p><p><strong>81. Increased inflammatory stress specific clinical, lifestyle and therapeutic variables in patients receiving treatment for stress, anxiety or depressive symptoms</strong></p><p>H Luckhoff, M Kotze, S Janse van Rensburg, D Geiger</p><p><strong>82. Catatonia: An eight-case series report</strong></p><p>M Mabenge, Z Zingela, S van Wyk</p><p><strong>83. Relationship between anxiety sensitivity and childhood trauma in a random sample of adolescents from secondary schools in Cape Town</strong></p><p>L Martin, M Viljoen, S Seedat</p><p><strong>84. 'Making ethics real'. An overview of an ethics course presented by Fraser Health Ethics Services, BC, Canada</strong></p><p>JJ McCallaghan</p><p><strong>85. Clozapine discontinuation rates in a public healthcare setting</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>86. Retrospective review of clozapine monitoring in a publica sector psychiatric hospital and associated clinics</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>87. Association of an iron-related TMPRSS6 genetic variant c.2007 C&gt;7 (rs855791) with functional iron deficiency and its effect on multiple sclerosis risk in the South African population</strong></p><p>K Moremi, S J van Rensburg, L R Fisher, W Davis, F J Cronje, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus, M Kidd, M J Kotze</p><p><strong>88. Identifying molecular mechanisms of apormophine-induced addictive behaviours</strong></p><p>Z Ndlazi, W Daniels, M Mabandla</p><p><strong>89. Effects of lifestyle factors and biochemistry on the major neck blood vessels in patients with mutiple sclerosis</strong></p><p>M Nelson, S J van Rensburg, M J Kotze, F Isaacs, S Hassan</p><p><strong>90. Nicotine protects against dopamine neurodegenration and improves motor deficits in a Parkinsonian rat model</strong></p><p>N Ngema, P Ngema, M Mabandla, W Daniels</p><p><strong>91. Cognition: Probing anatomical substrates</strong></p><p>H Nowbath</p><p><strong>92. Chronic exposure to light reverses the effects of maternal separation on the rat prefrontal cortex</strong></p><p>V Russel, J Dimatelis</p><p><strong>93. Evaluating a new drug to combat Alzheimer's disease</strong></p><p>S Sibiya, W M U Daniels, M V Mabandla</p><p><strong>94. Structural brain changes in HIV-infected women with and without childhood trauma</strong></p><p>G Spies, F Ahmed, C Fennema-Notestine, S Archibald, S Seedat</p><p><strong>95. Nicotine-stimulated release of hippocampal norepinephrine is reduced in an animal model of attention-deficit/ hyperactivity disorder: the spontaneously hypertensive rat</strong></p><p>T Sterley</p><p><strong>96. Brain-derive neurotrophic factor (BDNF) protein levels in anxiety disorders: Systematic review and meta-regression analysis</strong></p><p>S Suliman, S M J Hemmings, S Seedat</p><p><strong>97. A 12-month retrospective audit of the demographic and clinical profile of mental healthcare users admitted to a district level hospital in the Western Cape, South Africa</strong></p><p>E Thomas, K J Cloete, M Kidd, H Lategan</p><p><strong>98. Magnesium recurarization: A comparison between reversal of neuromuscular block with sugammadex v. neostigmine/ glycopyrrolate in an <em>in vivo</em> rat model</strong></p><p><strong></strong>M van den Berg, M F M James, L A Kellaway</p><p><strong>99. Identification of breast cancer patients at increased risk of 'chemobrain': Case study and review of the literature</strong></p><p>N van der Merwe, R Pienaar, S J van Rensburg, J Bezuidenhout, M J Kotze</p><p><strong>100. The protective role of HAART and NAZA in HIV Tat protein-induced hippocampal cell death</strong></p><p>S Zulu, W M U Daniels, M V Mabandla</p>

Manifesto for a European research network into obsessive-compulsive and related disorders

Obsessive-compulsive and related disorders (O-CRDs) are highly disabling psychiatric illnesses of early-onset. They are responsible for considerable morbidity and socioeconomic burden. Existing treatments are usually only partially successful and there is an urgent need to understand the aetiological factors and neurobiological bases of the disorders in order to develop new and more effective strategies for prevention, early detection and effective treatment. Emerging data from the neurosciences supports the reconceptualisation of obsessive-compulsive disorder as a spectrum disorder, related to but different from the anxiety disorders and closely aligned with other less well understood psychiatric disorders characterised by compulsive acts such as body dysmorphic disorder, trichotillomania, skin-picking disorder, hoarding disorder; and possibly extending to tic disorders and other neurodevelopmental disorders such as autism. A new, O-CRDs research network, supported by the Networks Initiative of the European College of Neuropsychopharmacology and comprising leading figures in preclinical and clinical research, has been established. It aims to provide a European perspective on the current debate around internationally-accepted diagnostic criteria and treatment strategies for O-CRDs. Its objectives include; (1) identifying the key outstanding research questions that depend upon cross-centre collaborative investigation, (2) setting a research agenda that is likely to produce an impact on health-outcomes, and (3) strengthening existing projects and collaborative enterprises with these objectives in mind. This paper reviews some of these critical research priorities. By establishing shared multinational databases, collaborative research networks, multicentre studies and joint publications, it is hoped that progress will be achieved.

The impact of COMT gene polymorphisms on suicidality in treatment resistant major depressive disorder--a European multicenter study

Many association studies have reported associations between the catechol-O-methyltransferase (COMT) gene and psychiatric disorders including major depression (MDD). The COMT gene has further been associated with suicidal behaviour, as well as with treatment response, although with conflicting results. In the present study, we further elucidate the impact of COMT in treatment response in MDD patients with suicide risk and/or a personal history of suicide attempts. Two hundred fifty MDD patients were collected in the context of a European multicentre resistant depression study and treated with antidepressants at adequate doses for at least 4 weeks. Suicidality was assessed using Mini International Neuropsychiatric Interview (MINI) and the Hamilton Rating Scale for Depression (HAM-D). Treatment response was defined as HAM-D ≤ 17 and remission as HAM-D ≤ 7 after 4 weeks of treatment with antidepressants at adequate dose. Genotyping was performed for seven SNPs (rs4680, rs2075507, rs737865, rs6269, rs4633, rs4818 and rs165599) within the COMT gene. With regard to suicide risk and personal history of suicide attempts, neither single marker nor haplotypic association was found with any SNP after multiple testing correction. In non-responders, we found significant single marker and haplotypic association with suicide risk, but not in responders. The same holds true for both remitters and non-remitters, and when testing for association with a personal history of suicide attempts and treatment response phenotypes. In conclusion, we found significant association of COMT SNPs with suicide risk in MDD patients not responding to antidepressant treatment. Larger well-defined cohorts will be required to dissect this further.

Microinfusion of a corticotrophin-releasing hormone receptor 1 antisense oligodeoxynucleotide into the dorsal hippocampus attenuates stress responses at specific times after stress exposure

Corticotrophin-releasing hormone (CRH) plays a key role in the adjustment of neuroendocrine and behavioural adaptations to stress. Dysregulation in CRH systems has been implicated in a variety of stress-related psychiatric disorders such as post-traumatic stress disorder (PTSD). The present study examined the relationship between stress-induced PTSD-like behavioural response patterns and levels of CRH, CRH receptor (CHR-R)1 and phosphorylated extracellular signal-regulated kinase (pERK1/2) in the rat hippocampus subregions. The effects of pharmacological manipulations on behavioural, physiological and response patterns of brain-derived neurotrophic factor (BDNF) and pERK1/2 expression using a CRH receptor (CRH-R)1-antisense oligodeoxynucleotide (CRH-R1-ASODN) were evaluated. CRH and CRH-R1 mRNA and pERK1/2 protein levels were assessed in the hippocampus subregions 7 days after exposure to predator scent stress (PSS). The effects of CRH-ASODN versus CRH-Scrambled-ODN microinfusion to the dorsal hippocampus either 1 h or 48 h post-exposure on behavioural tests (elevated plus maze and acoustic startle response) were evaluated 7 days later, 14 days after PSS exposure. Localised brain expression of BDNF and ERK1/2 was subsequently assessed. All data were analysed in relation to individual behaviour patterns. A distinct pattern associated with extreme behavioural response (EBR) was revealed in the bioassay of behavioural study subjects, classified according to their individual patterns of behavioural response at 7 days. These EBR individuals displayed significantly higher CRH and CRH-R1 mRNA levels in the CA1 and CA3 areas, mediating down-regulation of pERK1/2 protein levels. Microinfusion of a CRH-R1-ASODN into the dorsal hippocampus 48 h after stress exposure, although not immediately after exposure (1 h), significantly reduced behavioural disruption and was associated with concomitant up-regulation of BDNF and pERK1/2 protein levels compared to CRH-R1-Scrambled -ODN controls. CRH/CRH-R1 is actively involved in the neurobiological response to predator scent stress processes and thus warrants further study as a potential therapeutic avenue for the treatment of anxiety-related disorders.

A pilot study of the "Continuation of Care" model in "revolving-door" patients

PURPOSE

The efficiency of continuation of care (COC) treatment by inpatient caregivers as compared to treatment administered by outpatient services for "revolving door" psychiatric patients was tested in this study. Number and days of hospitalization were examined.

METHOD

All patients who were hospitalized three times or more during the past 12 months were offered continuing follow-up in the ward, by the same staff, instead of being referred to the outpatient department. Information on number and length of hospitalizations before and after initiation of this care model was retrieved from the hospital computerized database.

RESULTS

Of the 36 patients meeting the criteria, 35 patients agreed to participate. The number of hospitalizations in the 18 months following the index hospitalization was 1.79±3.51 as compared to 4.67±1.79 before the index hospitalization (p=0.0002), and the number of days of hospitalization 18 months after was 24±41.65 as compared to 119.71±69.31 before (p<0.0001).

CONCLUSION

COC via inpatient follow-up significantly reduces the number and length of hospitalizations in "revolving door" psychiatric patients as compared to the traditional system of follow-up in an outpatient clinic.

Animal models of depression and anxiety: What do they tell us about human condition?

While modern neurobiology methods are necessary they are not sufficient to elucidate etiology and pathophysiology of affective disorders and develop new treatments. Achievement of these goals is contingent on applying cutting edge methods on appropriate disease models. In this review, the authors present four rodent models with good face-, construct-, and predictive-validity: the Flinders Sensitive rat line (FSL); the genetically "anxious" High Anxiety-like Behavior (HAB) line; the serotonin transporter knockout 5-HTT(-/-) rat and mouse lines; and the post-traumatic stress disorder (PTSD) model induced by exposure to predator scent, that they have employed to investigate the nature of depression and anxiety.

Hippocampal microinfusion of oxytocin attenuates the behavioural response to stress by means of dynamic interplay with the glucocorticoid-catecholamine responses

The neurohypophysial hormone oxytocin acts as a central nervous system neurotransmitter/neuromodulator. We evaluated the effects of oxytocin on behavioural responses to stress, as well as associated biophysiological responses, in a controlled, prospective animal model. The long-term effects of exogenous oxytocin microinjected to the hippocampus of male rats were assessed. Animals were exposed to predator scent stress and treated 1 h or 7 days later with oxytocin or vehicle. Behaviours were assessed with the elevated plus-maze and acoustic startle response tests, 7 days after microinjection and freezing behaviour upon exposure to a trauma-related cue on day 8. These data served for classification into behavioural response groups. Trauma cue response, circulating corticosterone and oxytocin, hippocampal expression of glucocorticoid and mineralocorticoid receptors, and oxytocin receptor mRNA levels were assessed. The interplay between oxytocin, corticosterone and norepinephrine was assessed. Microinfusion of oxytocin both immediately after predator scent stress exposure or 7 days later, after exposure to trauma cue significantly reduced the prevalence rates of extreme responders and reduced trauma cue freezing responses. Post-exposure treatment with oxytocin significantly corrected the corticosterone stress response, decreased glucocorticoid receptor expression and increased mineralocorticoid receptor expression in the hippocampus compared to vehicle treatment. High-dose corticosterone administration together with norepinephrine caused release of plasma oxytocin and hippocampal oxytocin receptor. Oxytocin is actively involved in the neurobiological response to predator scent stress processes and thus warrants further study as a potential therapeutic avenue for the treatment of anxiety-related disorders.

An association between stress-induced disruption of the hypothalamic-pituitary-adrenal axis and disordered glucose metabolism in an animal model of post-traumatic stress disorder

Retrospective clinical reports suggesting that traumatic stress populations display an increased propensity for glucose metabolism disorders were examined in a controlled prospective animal model. Stress-induced behavioural and hypothalamic-pituitary-adrenal (HPA) axis response patterns were correlated to central and peripheral parameters of glucose metabolism and signalling, and to body measurements in Sprague-Dawley rats exposed to predator scent stress. Forty days post-exposure, fasting blood glucose and insulin levels, oral glucose tolerance test, body weight and white adipose tissue mass, systemic corticosterone levels and brain expression of insulin receptor (IR) and insulin-sensitive glucose transporter 4 (GLUT4) protein levels were evaluated. In a second experiment inbred strains with hyper- (Fischer) and hypo- (Lewis) reactive HPA axes were employed to assess the association of metabolic data with behavioural phenomenology versus HPA axis response profile. For data analysis, animals were classified according to their individual behavioural response patterns (assessed at day 7) into extreme, partial and minimal response groups. The exposed Sprague-Dawley rats fulfilling criteria for extreme behavioural response (EBR) (20.55%) also exhibited significant increases in body weight, abdominal circumference and abdominal white adipose tissue mass; a hyperglycaemic oral glucose tolerance test; and fasting hyperglycaemia, hyperinsulinaemia and hypercorticosteronemia, whereas minimal responders (MBR) and control animals displayed no such disturbances. Hippocampal and hypothalamic expression of IR and GLUT4 protein were significantly lower in EBR than in MBR and control rats. The inbred strains showed no metabolic differences at baseline. Exposed Fischer rats displayed hyperglycaemia and hyperinsulinaemia, whereas Lewis rats did not. A significant protracted disorder of glucose metabolism was induced by exposure to a stress paradigm. This metabolic response was associated with the characteristic pattern of HPA axis (corticosterone) response, which underlies the behavioural response to stress.

Is there a Role for Antipsychotics in OCD?

There are actually four types of situations where intervention with antipsychotics might be considered for the treatment of Obsessive compulsive disorder. Obsessive compulsive patients with poor insight (what was previously called ‘psychotic obsession’), schizophrenic patients with OCD, obsessive compulsive patients with tic disorder, and obsessive compulsive patients who did not respond to intervention with an adequate treatment of antiobsessive medication.

The data supporting the role of antipsychotic medication in obsessive compulsives with poor insight are not convincing. However, at times the treatment dilemma (antipsychotic or antiobsessive) actually derives from diagnostic ambiguity; many of the very severe ego-syntonic obsessive compulsive patients may be erroneously diagnosed as schizophrenic, while they are actually severe OCD that should be treated with antiobsessive medication and not antipsychotic.

The prevalence of OCD amongst schizophrenic patients ranges from 10-25% and has a negative effect on the prognosis for those substantial proportion of schizophrenic patients. Preliminary data implies that for this subset of patient (the schizo-obsessive patients) a combination of antipsychotic and antiobsessive medication might be useful.

It is crucial to screen for tic disorder in patients with, OCD as this subset of patients responds (both in terms of obsession and tics) to a combination of typical antipsychotic and antiobsessive medication.

Data in regard to augmentation of OCD patients who did not respond to treatment with SSRI suggest that risperidone might have a specific therapeutic potential in this subset of patients. The role of antipsychotics with 5HT1D properties like ziprasidone need to be studied.

Physical activity protects male patients with post-traumatic stress disorder from developing severe fibromyalgia

OBJECTIVES

Fibromyalgia syndrome (FMS) has been associated with various psychiatric and other, ill-defined disorders. We recently showed that fibromyalgia is more prevalent in men suffering from combat-related Post Traumatic Stress Disorder (PTSD). In this paper we analyze the relationship between engagement in physical activity, the psycho-metric traits of PTSD and the future development of FMS.

METHODS

Fifty-five male patients, all known to have combat-related PTSD, were investigated for the presence of fibro-myalgia according to the American College of Rheumatology (ACR) criteria. Each patient completed questionnaires characterizing his quality of sleep, and the Sheehan Disability Scale measuring performance in the familial, social and vocational spheres. Additionally, each of the enrollees was interviewed by an experienced psychiatrist, who then completed a Clinician Administered PTSD Scale, a Clinical Global Impression Scale, and calculated an SF-36 score. Each patient was asked whether he exercised often, occasionally or not at all. The data was analyzed by the chi2 test and by ANOVA.

RESULTS

PTSD patients who also suffered from FMS had a more severe form of disease as measured by the Clinician Administered PTSD Scale (CAPS) score, 88.2 +/- 14.0 (n = 28) compared to 97.6 +/- 13.2 of patients with PTSD and FMS (n = 27) (p = 0.013, F(d.f 2)-6.61, ANOVA test). Interestingly, engaging in physical exercise was also associated with less severe disease. When the patients were analyzed based on their tender point count (0-5, 6-10, or > 11), the number of tender points decreased with increasing physical activity (p = 0.02, chi2(d.f.-4) = 11.3).

CONCLUSION

Physical exercise in male patients with combat-related PTSD provides protection from the future development of fibromyalgia. Furthermore, physical activity is related in this group of patients to a better perception of their quality of life.

Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

Anxiety disorders: a review of tricyclic antidepressants and selective serotonin reuptake inhibitors

OBJECTIVE

Anxiety disorders are the most common mental health disorders. While the older tricylic antidepressants (TCAs) are efficacious in the treatment of many anxiety disorders, recent studies with fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have emphasized the role of serotonin in the aetiology of these conditions.

METHOD

We reviewed the efficacy, safety and tolerability of TCAs and SSRIs in the treatment of the most common anxiety disorders, specifically, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder.

RESULTS

Both the TCA and SSRI antidepressants are effective in treating a wide variety of anxiety disorders. SSRIs, due to their greater safety and tolerability, should be the preferred choices in treating anxiety disorders in those instances where TCAs and SSRIs are considered equally effective. In the cases of OCD and social phobia, SSRIs are almost always preferable given that the TCAs do not appear effective in these disorders.

CONCLUSION

Further research is needed on the naturalistic long-term use of the TCAs and SSRIs in the treatment of anxiety disorders.

Pindolol augmentation in patients with treatment-resistant panic disorder: A double-blind, placebo-controlled trial

The objective of this study was to determine the efficacy of pindolol as an augmentor of fluoxetine in treatment-resistant panic disorder (PD). Twenty-five outpatients having PD with or without agoraphobia were included. These patients had not responded to two different trials with antidepressants and an 8-week trial of fluoxetine 20 mg/day. Treatment-resistant PD was defined as a less than 20% reduction in score on the Panic Self-Questionnaire (number of attacks per week) (PSQ) and the Clinical Anxiety Scale With Panic Attacks (CAS+PA). These patients continued to receive fluoxetine 20 mg/day and were randomly assigned to additionally receive either pindolol (2.5 mg three times daily) or placebo for the following 4 weeks. Evaluations were performed weekly using the Hamilton Rating Scale for Anxiety, the Hamilton Rating Scale for Depression (HAM-D), the CAS+PA, the NIMH Anxiety Scale, the PSQ, and the Clinical Global Impression Scale. The data were analyzed using a repeated-measures analysis of variance (ANOVA) and a t-test for independent samples. Patients treated with the combination of pindolol and fluoxetine (N = 13) demonstrated a significant improvement over the patients treated with fluoxetine and placebo on all rating scales, with the exception of HAM-D. The statistical differences were shown using the repeated-measures ANOVA (baseline, week 2, week 4) and also with t-tests from the second week of the trial. These preliminary results demonstrate that pindolol has an augmenting effect on fluoxetine in patients with treatment-resistant PD.

Pindolol augmentation in treatment-resistant obsessive compulsive disorder: a double-blind placebo controlled trial

OBJECTIVE

To evaluate the efficacy of pindolol augmentation in treatment-resistant obsessive compulsive disorder (OCD) patients who were unsuccessfully treated with serotonin reuptake inhibitors.

METHOD

Fourteen treatment-resistant OCD patients were treated with paroxetine for 17.4+/-2.1 weeks up to 60 mg/d after they failed at least two other serotonin reuptake inhibitor trials. The patients, who did not respond to open-label paroxetine treatment, were assigned to a double-blind, placebo-controlled pindolol (2.5 mgx3/d) augmentation. All the subjects were evaluated biweekly for a six-week period with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Anxiety Scale (HAM-Anx), and Montgomery Asberg Depression Rating Scale (MADRS). Data was analyzed by paired t-test, and ANOVA with repeated measures.

RESULTS

Pindolol augmentation to paroxetine (n=8) as compared to placebo augmentation (n=6), was associated with a significant (P<0.01) improvement in Y-BOCS as measured by paired t-test after the fourth week of the treatment and by ANOVA with repeated measures (df: 4.9, f: 3,3, P<0.006). Although no significant differences were found between placebo and pindolol groups on HAM-Anx and MADRS, a trend for improvement in the pindolol group was noted.

CONCLUSIONS

The results of our study demonstrated that pindolol may augment the therapeutic effect of paroxetine in treatment-resistant OCD patients.

Association between obsessive-compulsive disorder and polymorphisms of genes encoding components of the serotonergic and dopaminergic pathways

Obsessive-compulsive disorder (OCD) is a severe and disabling anxiety disorder with a marked genetic contribution. Pharmacological data indicated involvement of the serotonergic and dopaminergic systems. We studied the association between OCD and six candidate genes encoding important components of the serotonergic and dopaminergic pathways in 75 biologically unrelated patients and 172 ethnically matched controls (Ashkenazi and non-Ashkenazi Jews). Polymorphisms in the following genes were studied: tryptophan hydroxylase (TPH), serotonin 2A receptor (HTR2A), serotonin 2C receptor (HTR2C), serotonin transporter (5-HTT), dopamine receptor D4 (DRD4), and dopamine transporter (DAT1). The genotypic and allelic distribution of all polymorphisms tested did not show statistically significant differences between patients and controls. Our results suggest that these polymorphisms do not play a major role in the genetic predisposition to OCD, although a minor contribution cannot be ruled out.

Obsessive compulsive disorder: serotonin and beyond

OCD was considered a rare, treatment refractory disorder of psychological origin, up until 20 years ago. Research in the last two decades has altered the perspectives regarding OCD. It is now clear that OCD is a prevalent disorder--about 2% of the population suffer from OCD--and that it is amenable both to psychological (cognitive-behavioural approach) and pharmacological intervention (with serotonergic medication). The biochemical and neuroanatomical (the frontal basal-thalamo cortical circuit) pathophysiology of OCD is also beginning to emerge. OCD is unique with regards to its specific response to serotonergic medication that blocks reuptake. Clomiprimine, fluoxetine, fluvoxemine, paroxetine, sertraline and citalopram were all found to be effective treatments for OCD based on large, multicentre, double-blind, placebo-controlled studies. As only serotonergic medications appear to be effective in OCD, the serotonergic hypothesis has been formulated and tested. Indeed, pharmacological challenges with specific serotonin agonists such as mCPP and sumatriptan, which were associated with transient exacerbation of OCD symptoms, are in line with the specific role of 5HT in the pathogenesis of OCD. However, this serotonergic hypothesis, while necessary, is not sufficient. It is clear that the dopaminergic and autoimmune mechanism are also implicated in the pathogenesis of OCD. Further studies are required to understand the relevance of the serotonergic and non-serotonergic systems in OCD, and to highlight the various possible subtypes of this intriguing disorder.

Is there sexual dimorphism in obsessive-compulsive disorder?

The present review addresses the question of sexual dimorphism in obsessive-compulsive disorder. It enumerates examples that could be interpreted to suggest the existence of such dimorphism from the fields of epidemiology, phenomenology, pharmacology, neuropsychology, neuroimaging and genetics. We conclude that data, at this point, are too scarce to warrant a firm conclusion. On the contrary it seems that there are enough indications in the literature that hint at the possibility of sexual dimorphism to stimulate further research in the field.

Orbitofrontal cortex dysfunction in obsessive-compulsive disorder? I. Alternation learning in obsessive-compulsive disorder: male-female comparisons

BACKGROUND

We have previously reported a significant negative correlation between severity of symptoms and performance of an alternation learning task in female obsessive-compulsive disorder (OCD) patients. The present study was aimed at exploring this relationship between alternation learning and OCD symptom severity in male OCD patients.

METHODS AND RESULTS

Eighteen female obsessive-compulsive disorder patients and 14 male non-depressed, drug free, OCD patients participated in the study. Measures of dorsolateral prefrontal function (Wisconsin Card Sorting Test) and orbitofrontal cortex function (object alternation learning) showed no significant differences between the sexes. The relationship between orbitofrontal cortex function and severity of OC symptoms was significantly different between the sexes (z=2.44. P=0.007). While this correlation was negative in the females it was positive in the males.

CONCLUSIONS

These results may indicate sexual dimorphism in OCD.

Orbitofrontal cortex dysfunction in obsessive-compulsive disorder? II. Olfactory quality discrimination in obsessive-compulsive disorder

BACKGROUND

Olfactory quality discrimination is a putative marker of orbitofrontal cortex function in mammals. As this portion of the cerebral cortex was repeatedly implicated in the pathophysiology of obsessive-compulsive disorder (OCD) this study was designed in an attempt to quantify this behavioural function in OCD patients.

METHODS AND RESULTS

Olfactory quality discrimination was compared in OCD patients and healthy controls. Thirty two subjects participated in the study: 16 (13 women and 3 men) medication free OCD outpatients and 16 sex and age matched healthy controls. Olfactory tests consisted of determination of detection thresholds to isoamyl acetate, and a three way forced choice quality discrimination task, using isoamyl acetate, citral and eugenol as stimuli. No significant differences in sensitivity and performance of the quality discrimination task between the two groups were found. Within the OCD group the more severely affected patients (Y-BOCS>29) performed significantly better than the less severely affected (Y-BOCS<30) patients on the more difficult part of the quality discrimination task. Within this subgroup of patients the correlation between performance on the olfactory task and a previously reported alternation task tended to be negative as compared to a significantly positive correlation in the control group.

CONCLUSIONS

It seems that olfactory quality discrimination may prove to be a useful noninvasive marker of prefrontal cortex function in OCD. Furthermore, the organization of functional modules within the orbitofrontal cortex, rather than a simple dysfunction, may prove to characterize OCD.

Evidence for striatal modulation in the presence of fixed cortical injury in obsessive-compulsive disorder (OCD)

A patient with obsessive-compulsive disorder (OCD) onset resulting from a traumatic head injury underwent longitudinal brain imaging evaluation. Structural and functional brain imaging studies were repeatedly performed before and after treatment. Computerized tomography (CT) demonstrated bilateral prefrontal contusions immediately following the trauma and prior to the onset of OCD. Magnetic resonance imaging (MRI) demonstrated bilateral cortical abnormalities in the prefrontal and anterior-temporal regions a few months following the onset of OCD. Almost concurrently, single photon emission computerised tomography (SPECT) demonstrated bilateral perfusion deficits in fronto-temporal regions, and asymmetric increased perfusion in the anterior striatum. Six months later, after clinical improvement, a second SPECT study demonstrated improvement of brain perfusion, mostly in the striatum. The reflection of these results on a possible model of brain pathogenesis in OCD, and the role of brain imaging in neuropsychiatric evaluation, are demonstrated.

Response to missile attacks on civilian targets in patients with panic disorder

BACKGROUND

The complex interaction that exists between biological and cognitive factors determines the reaction of panic-disorder patients to stressors. The current study was conducted to systematically assess the behavioral effects of a real, life-threatening event on panic-disorder patients.

METHOD

Sixty-five panic-disorder patients completed structured telephone interviews during the first 4 weeks of the Persian Gulf War. Evaluation included frequency of panic attacks, anxiety levels, and function levels both during and between air raid alarms.

RESULTS

The findings indicate that panic-disorder patients, despite high levels of anxiety, did not demonstrate an increased frequency of panic attacks during the Persian Gulf War. In addition, the majority of patients reported good-to-high levels of functioning during the crisis in both everyday and alarm-related functioning. Grouping of subjects according to proximity to risk or current antipanic treatment did not produce significant differences in the frequency of panic attacks or levels of anxiety.

CONCLUSION

The findings suggest that vulnerability of patients with panic disorder to a "panic-stricken" response does not increase during real-life stressors. The lack of increased frequency of panic attacks observed under these circumstances provides additional support for the opinion that panic and fear are two distinct entities.

Increased olfactory sensitivity in first episode psychosis and the effect of neuroleptic treatment on olfactory sensitivity in schizophrenia

Olfactory sensitivity to two odorants, isoamyl acetate and androstenone, was assessed in 19 male schizophrenic patients and 10 control subjects. Tests were performed during a drug-free period and 2-3 weeks after initiation of neuroleptic drug therapy. Olfactory sensitivity in schizophrenic patients was significantly impaired during the drug-free period and neuroleptic treatment further reduced olfactory sensitivity in these patients. The same olfactory tests were administered to 22 first-episode-psychosis patients, 12 first-episode-schizophrenia and 10 brief-psychotic-disorder patients, as well as to 20 age-matched control subjects. The first-episode-psychosis patients had significantly higher sensitivity to isoamyl acetate and to androstenone, but the incidence of anosmia to androstenone was not higher in the first episode patient group as compared to the control group. We conclude that olfactory dysfunction in schizophrenic patients, and possibly other forms of psychosis, is mainly due to long-term effects of commonly used neuroleptic drugs.

A double-blind crossover comparison of clomipramine and desipramine in the treatment of panic disorder

OBJECTIVE

To compare the efficacy of clomipramine hydrochloride (CMI), a serotonin reuptake inhibitor with the noradrenergic tricyclic antidepressant agent, and desipramine hydrochloride (DMI) for patients with panic disorder (PD).

METHOD

Following a 2-week, single-blind placebo washout phase, 17 PD outpatients completed a 16-week, double-blind, crossover comparison of CMI and DMI. Key outcome measures included panic attacks frequency, the NIMH Global Scales for Anxiety, Depression and Impairment, Hamilton Anxiety Scale (Psychic and Somatic Subscales), Zung Anxiety Inventory (Raw and Index Subscales) and the Spielberger State Anxiety Scale.

RESULTS

Both CMI and DMI led to significant improvement from baseline placebo state in panic attacks frequency and behavioral ratings (p<0.001). CMI led to a greater reduction in the frequency of panic attacks (p=0.028) and was superior to DMI on ratings of anxiety: NIMH Global Anxiety, Zung Anxiety Scale (Raw and Index) and the Spielberger Anxiety Scale. No difference was found between the drugs on the NIMH Global Impairment Scale and the Hamilton Somatic and Psychic Scales.

CONCLUSION

Both drugs appeared to have significant therapeutic effects in patients with PD, but CMI appeared to be more effective. The effectiveness of the serotonergic drug suggests that the role of the serotonergic system in the pathogenesis of PD should be further explored.

Treatment resistant depression: methodological overview and operational criteria

A wide variety of definitions are used for Treatment Resistant Depression (TRD), considering various criteria and different concepts. Some of the key issues are: the diagnosis, the treatment adequacy in terms of dose and duration, the treatment response assessment and the number of failed therapeutic trials required. Systematic research has been characterizing the concept and criteria to define the different variables involved. Lack of consensus on these issues limits comparison across clinical trials and interpretation of treatment efficacy in the management of treatment resistant patients. Through reanalyzes of available data, we point out the limits of TRD definitions and propose conceptual and operational criteria for a collaborative research project on TRD. It appears that a number of variables commonly associated to treatment resistance are independent of patients characteristics and mainly refer to misdiagnosis and inadequate treatment. The proposed criteria are intended for therapeutic trials in TRD, combining the evaluation of treatment efficiency and the validation of the concept of TRD itself. Major depression with poor response to two adequate trials of different classes of antidepressants is proposed for an operational definition of TRD. Rationale for this definition is discussed in contrast to alternative definitions.

Treatment of severe, drug resistant obsessive compulsive disorder with the 5HT1D agonist sumatriptan

The serotonergic system has been implicated in both the aetiology and pharmacological treatment of obsessive compulsive disorder. In pharmacological challenge tests, mCPP, a 5-HT agonist, with an affinity for 5HT2C as well as 5HT1A and 5HT1D receptors, was associated with a transient exacerbation of obsessive compulsive symptoms. Chronic administration of mCPP was found to bring about some relief of these symptoms. Sumatriptan is an antimigraine agent, which interacts most potently with 5HT1D receptors. In the cases to be presented, we report the effects of chronic administration of Sumatriptan to three severe, treatment resistant, OCD patients. Following chronic administration of sumatriptan, these patients, who have been resistant to any former pharmacological treatment, responded with an improvement in their depression and a modest reduction in their obsessive compulsive symptoms.

Healing environment in psychiatric hospital design

Mental health professionals have long speculated that the physical environment in which treatment occurs has an impact on both the treatment process and its outcome. The few empirical studies that evaluated the effects of psychoenvironmental design have shown encouraging results and demonstrated clinically desirable behavioral changes and even reduced psychopathology. In view of the concept that architecture is a tool in the therapeutic process, the design and execution of the psychiatric hospital in the Chaim Sheba Medical Center at Tel-Hashomer, Israel, were conducted by a multidisciplinary team of architects, mental health professionals, and administrators. The hospital contains three acute inpatient wards and a day care and large outpatient clinic. Its operation began in 1991. This paper deals with the merging of "user-friendly" architectural and environmental design components that create an integral healing environment. The paper discusses the positive effects of specific components on patients and staff, and suggests that our model of psychoenvironmental approach to psychiatric hospital design can provide an important and effective tool in the pursuit of a humane, efficient containment and reduction of severe psychopathology.

Epidemiology of obsessive-compulsive disorder: a world view

The worldwide prevalence of obsessive-compulsive disorder (OCD) is approximately 2% of the general population. Symptoms of OCD include fear of contamination by dirt or germs; constant checking; repetitive, intrusive thoughts of a somatic, aggressive, or sexual nature; extreme slowness; and an inordinate concern with orderliness and symmetry. Differential diagnosis is sometimes complicated by the overlap between OCD and obsessive-compulsive personality disorder (OCPD). The most common complication of OCD is depression. However, while both serotonergic and nonserotonergic antidepressants are effective in treating patients with depression, only serotonergic medications are effective in treating OCD patients. Because OCD patients often attempt to conceal their symptoms, it is incumbent on clinicians to screen for OCD in every mental status examination, since appropriate treatment can often result in improved quality of life.

[Brain imaging and its clinical application in psychiatry]

The common structural and functional brain imaging techniques are described from a practical, clinical point of view. The clinical indications for brain imaging in psychiatry are reviewed in relation to the specific limitations and advantages of each technique. The clinical applications of computerized tomography (CT), magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT) are discussed in relation to the differential diagnosis between organic and functional psychiatric disorders. In a 55-year-old man with late onset of behavioral changes but without neurological signs the application of structural brain imaging (CT and MRI) in case management was demonstrated. The imaging findings involved the differential diagnosis between depression and focal brain lesions. In a 38-year-old man with personality changes and depression following a traumatic brain injury, time interval repeated functional brain imaging (SPECT) was used. Brain imaging reflected improvement in clinical status following treatment and was able to differentiate between reversible and permanent traumatic brain injuries. The superior yield of time interval repeated functional imaging in diagnosis and management of postconcussion syndrome is discussed.

A general hospital study of attempted suicide in adolescence: age and method of attempt

Attempted suicide in adolescence is a major health problem and recent reports indicate a dramatic increase in the frequency of attempted and completed suicide among adolescents. The aim of this study was to evaluate the characteristics of adolescent admissions with attempted suicide in a large general hospital. The files of all children and adolescents admitted due to a suicide attempt between the years 1984 and 1994 were examined retrospectively, with regard to age, sex, method of attempt, season, year and length of hospitalization. Four hundred and four admissions with attempted suicide were recorded. The majority (83.7%) were females and drug overdose was the most common (92.8%) method used. Thirty patients (7.5%) repeated the attempt during the study period. No specific time of the year was associated with an increase in adolescent suicide attempt admissions. The most remarkable finding was that younger adolescents had a higher probability of performing a violent suicide attempt. Hypotheses for these trends are examined together with possible ramifications for treatment provision.

Emergence of kleptomania during treatment for depression with serotonin selective reuptake inhibitors

Kleptomania, one of the rare impulse-control disorders, is characterized by an irresistible impulse to steal objects not needed for personal use or monetary value. There is a comorbidity between mood disorders, eating disorders, anxiety disorders, personality disorders, and kleptomania. Several recent case reports have suggested that serotonin reuptake inhibitors could be effective in the treatment of obsessive-compulsive spectrum disorders and specifically in kleptomania. We describe three depressed patients who paradoxically experienced kleptomanic behavior during treatment with serotonin selective reuptake inhibitors.