Anatomical substrates of cognitive and clinical dimensions in first episode schizophrenia

OBJECTIVE

To explore gray (GM) and white matter (WM) abnormalities and the relationships with neuropsychopathology in first-episode schizophrenia (FES).

METHOD

Nineteen patients with first episode of non-affective psychosis and 18 controls underwent a magnetic resonance voxel-based morphometry. Additionally, WM fractional anisotropy (FA) was calculated. For correlative analysis, symptoms and neuropsychological performances were scored by PANSS and by a comprehensive neuropsychological assessment respectively.

RESULTS

Patients showed significantly decreased volume of left temporal lobe and disarray of all major WM tracts. Disorganized PANSS factor was inversely related to left cerebellar GM volume (corrected P = 0.03) and to WM FA of the left cerebellum, inferior fronto-occipital fasciculi (IFOF), and inferior longitudinal fasciculi (corrected P < 0.05). PANSS negative factor was inversely related to FA in the IFOF and superior longitudinal fasciculi (corrected P < 0.05). Impairment in facial emotion identification showed associations with temporo-occipital GM volume decrease (corrected P = 0.003) and WM disarray of superior and middle temporal gyri, anterior thalamic radiation, and superior longitudinal fasciculi (corrected P < 0.05). Speed of processing and visual memory correlated with WM abnormalities in fronto-temporal tracts.

CONCLUSION

These results confirm how the structural development of key brain regions is related to neuropsychopathological dysfunction in FES, consistently with a neurodevelopmentally derived misconnection syndrome.

Functional neuroimaging in obsessive-compulsive disorder

BACKGROUND AND AIM

Obsessive-compulsive disorder (OCD) is a severe, highly prevalent and chronically disabling psychiatric disorder that usually emerges during childhood or adolescence. This paper aims to review the literature on functional neuroimaging in OCD, analysing the reported dysfunctional connectivity in the corticostriatothalamocortical circuitry.

METHOD

This study included papers published in peer-reviewed journals dealing with functional imaging in OCD.

RESULTS

Striatal dysfunction, mainly of the caudate nucleus, leads to inefficient thalamic gating, resulting in hyperactivity within the orbitofrontal cortex (intrusive thoughts) and the anterior cingulate cortex (non-specific anxiety). Compulsions consist of ritualistic behaviours performed to recruit the inefficient striatum and neutralise unwanted thoughts and anxiety. Functional neuroimaging findings are discussed against the background of specific cognitive impairments, mainly regarding visuospatial processing, executive functioning and motor speed. Cognitive deficits are partial and specific, matching imaging data.

CONCLUSIONS

Several studies have targeted brain regions hypothesised to be involved in the pathogenesis of OCD, showing the existence of dysfunctional connectivity in the corticostriatothalamocortical circuitry. Improvements in spatial resolution of neuroimaging techniques may contribute to a better understanding of the neurocircuitry of OCD and other anxiety disorders.

Affective temperaments are associated with higher hopelessness and perceived disability in patients with open-angle glaucoma

AIM

The aims of the study were to study: (i) affective temperaments in open-angle glaucoma (OAG) patients with some degree of functional visual impairment; (ii) psychological well-being and perceived disability, and their associations with affective temperaments; and (iii) associations between visual impairment, affective temperaments and psychological well-being.

METHOD

Participants were 91 outpatients (39 women, and 52 men) with open-angle glaucoma (OAG) who were assessed for Visual Field Index, Mean Defect and Pattern Standard Deviation. Patients were also administered the Beck Hopelessness Scale, the TEMPS-A (Rome), the Gotland Male Depression Scale, the Emotional Well-being Scale, the Perceived Disability Questionnaire and the Suicidal History Self-Rating Screening Scale.

RESULTS

Open-angle glaucoma patients (compared with a non-clinical sample of university students) had higher scores on the TEMP-A dysthimic and hyperthimic traits and lower scores on cyclothimic, irritability and anxiety traits. Such temperament variability was not linked to differences in severity of glaucoma. We did not find strong evidence supporting the fact that measures of visual impairment were linked to emotional well-being and depression. However, logistic regression analysis revealed that patients may have different patterns related to their illness according to specific temperaments.

CONCLUSION

Patients with OAG may have different temperament profiles than non-clinical individuals. Such categorisation may be useful for predicting how they face the illness, for providing better care as well as for early recognition of mood disorders symptoms.

Stigmatization of schizophrenia as perceived by nurses, medical doctors, medical students and patients

Stigmatization of schizophrenia is widespread and its genetic explanation may potentially increase the stigma. The present study investigated whether seeing schizophrenia as a genetic or environmental disorder might influence perceived beliefs towards people with schizophrenia and whether social stigmatizing attitudes were differently perceived the 202 subjects who were recruited. Perceived social stigmatizing attitudes were compared among participants who read two vignettes depicting a person with schizophrenia. Then, the Standardized Stigmatization Questionnaire (SSQ) was administered. A genetic explanation of schizophrenia was more frequently associated with stigmatizing attitudes. Also, there were higher levels of perceived stigmatization in medical students and medical doctors than in other groups based on their social experience or background. However, the sample size was small and this was a non-experimental design; also the SSQ would benefit from more cross-validation. About half of the participants perceived stigmatizing social attitudes. Finally, considering schizophrenia as a genetic disorder influenced participants perception of other people's beliefs about dangerousness and unpredictability and people's desire for social distance.

The impact of the Val158Met catechol-O-methyltransferase genotype on neural correlates of sad facial affect processing in patients with bipolar disorder and their relatives

BACKGROUND

The Met allele of the catechol-O-methyltransferase (COMT) valine-to-methionine (Val158Met) polymorphism is known to affect dopamine-dependent affective regulation within amygdala-prefrontal cortical (PFC) networks. It is also thought to increase the risk of a number of disorders characterized by affective morbidity including bipolar disorder (BD), major depressive disorder (MDD) and anxiety disorders. The disease risk conferred is small, suggesting that this polymorphism represents a modifier locus. Therefore our aim was to investigate how the COMT Val158Met may contribute to phenotypic variation in clinical diagnosis using sad facial affect processing as a probe for its neural action.

METHOD

We employed functional magnetic resonance imaging to measure activation in the amygdala, ventromedial PFC (vmPFC) and ventrolateral PFC (vlPFC) during sad facial affect processing in family members with BD (n=40), MDD and anxiety disorders (n=22) or no psychiatric diagnosis (n=25) and 50 healthy controls.

RESULTS

Irrespective of clinical phenotype, the Val158 allele was associated with greater amygdala activation and the Met158 allele with greater signal change in the vmPFC and vlPFC. Signal changes in the amygdala and vmPFC were not associated with disease expression. However, in the right vlPFC the Met158 allele was associated with greater activation in all family members with affective morbidity compared with relatives without a psychiatric diagnosis and healthy controls.

CONCLUSIONS

Our results suggest that the COMT Val158Met polymorphism has a pleiotropic effect within the neural networks subserving emotional processing. Furthermore the Met158 allele further reduces cortical efficiency in the vlPFC in individuals with affective morbidity.

Brain structural abnormalities in first episode psychosis: A multimodal analysis

Introduction

White matter abnormalities play a prominent role in the pathogenesis of schizophrenia. Diffusion tensor imaging (DTI) studies showed a widespread decrease in fractional anisotropy (FA) in psychotic disorders.

Aims

To examine white and grey matter abnormalities in first episode psychosis (FEP).

Methods

We obtained T1-weighted and DTI magnetic resonance images (1.5 T) from 8 right-handed drug-naïve FEP patients and 8 healthy controls. The DTI data set was used to calculate FA maps; we carried-out optimized voxel-based morphometry (VBM) analysis of grey matter (GM) and FA maps using SPM2.

Patients were assessed with a neuropsychological battery comprising the Trail Making Test, the Stroop Colour Word Test, the Wisconsin Card Sorting Test and a test of Facial Affect recognition.

Results

The voxelwise analysis showed decreased FA in the superior longitudinal and inferior fronto-occipital fasciculi, bilaterally, and in the left uncinate fasciculus. We observed reduced GM volume in the left frontal cortex (Brodmann areas [BA] 47, 13, 11, 10, and 9) and in right frontal (BA6), temporal (BA34) and occipital (BA 18, 19, and 30) cortex.

Neuropsychological assessment showed impaired executive function and deficit in facial affect recognition.

Conclusion

Our findings showed fronto-temporal disconnectivity in FEP and structural alterations in both cortical and subcortical regions.

Neuroanatomical findings are consistent with patients’ neuropsychological performance.

Further studies to establish a relationship between white and grey matter disarray on one hand and neuropsychological testing are needed.

FC14-04 - Tobacco smoking and suicidal ideation and planning in schoolchildren 12–15 years old from ten low- and middle-income countries: impact of cultural differences

Objective

The authors examined the association between tobacco smoking and suicidal ideation and planning in schoolchildren from 10 countries in Africa, the Americas, and the Western Pacific region.

Method

Data were collected through the Global school-based Student Health Survey (GSHS), a collaborative surveillance project between the World Health Organization (WHO), the United Nations, UNICEF, UNESCO, UNAIDS, and the US Centers for Disease Control and Prevention (CDC). Suicidal ideation and planning, tobacco smoking, and drug and alcohol use were included in loglinear models to analyze, separately for each sex, higher order interactions among suicidality and regional and country differences.

Results

Schoolchildren who reported suicidal ideation and/or suicidal planning had a higher risk of smoking cigarettes even after controlling for drug and alcohol misuse. Furthermore, analyses indicated higher order interactions between suicidal ideation and planning and countries belonging to different regions with different exposure to tobacco smoking among schoolchildren.

Conclusion

Future studies analyzing the mechanism and sequencing of the relationship among suicidal ideation and tobacco smoking should explore cultural factors.

The functional neuro-anatomy of the human response to fear: A brief review

The perception of fear and subsequent appropriate behavioral responding are crucial for the adaptation of species to their living environment. Functional neuroimaging studies of the neural basis of fear during the last few decades in humans contributed to significant advancement in the understanding of its mechanisms. Imaging studies help us delineating the role of amygdala-based neurocircuitry in fear activation and attention capture. The aim of this paper was to briefly review the most recent functional neuroimaging studies of fear perception, modulation and learning. Important knowledge was acquired about the factors that set fear in motion, including the role of nonconscious processes and the character of fear in guiding attention. A subcortical network interacts with the prefrontal cortex to modulate emotional response that allows better coping with environmental and social circumstances. Fear learning reduces the need to relearn about danger, and flexibility processes readjust fear behavior when external circumstances change. Future improvement of functional and other neuroimaging techniques may promote better clarification of the neurocircuitry involved in fear perception, learning and modulation.

Folie à deux: double case-report of shared delusions with a fatal outcome

BACKGROUND

Treatment of shared delusional disorder (folie à deux) often involves separation and use of antipsychotic medication, with uncertain outcomes and potential risks.

METHODS

We report on two highly interdependent and chronically psychotic sisters with shared systematic delusion, followed by psychiatrists over several years.

RESULTS

The dominant patient was diagnosed with schizoaffective disorder and her non-dominant sister with paranoid schizophrenia. Both received antipsychotics and supportive therapy as outpatients and allowed to continue conjoint therapy with individual psychiatrists-therapists. They returned for follow-up visits for 20 months, when the dominant decided to continue treatment alone, as her sister gradually improved symptomatically and functionally. After separation, the dominant became increasingly anxious. She impulsively ingested an overdose of the non-dominant sister's medicines and died of cardiac arrest, despite her sister's efforts to seek medical assistance. The surviving non-dominant sister developed anxiety and increasing agitation requiring psychiatric hospitalization and increased pharmacotherapy. She improved gradually, but continued to be dysfunctional and required placement in a psychiatric inpatient unit for several months, eventually doing better in a community-based rehabilitative program with regular psychiatric follow-up.

CONCLUSIONS

Combined treatment of patients with folie à deux may encourage continuous pathological interactions, but separation may increase risk of adverse outcomes.

The effects of lithium and anticonvulsants on brain structure in bipolar disorder

OBJECTIVE

To investigate the effect of lithium, anticonvulsants and antipsychotics on brain structure in bipolar disorder (BD).

METHOD

A cross-sectional structural brain magnetic resonance imaging study of 74 remitted patients with BD, aged 18-65, who were receiving long-term prophylactic treatment with lithium or anticonvulsants or antipsychotics. Global and regional grey matter, white matter, and cerebrospinal fluid volumes were compared between treatment groups.

RESULTS

Grey matter in the subgenual anterior cingulate gyrus on the right (extending into the hypothalamus) and in the postcentral gyrus, the hippocampus/amygdale complex and the insula on the left was greater in BD patients on lithium treatment compared to all other treatment groups.

CONCLUSION

Lithium treatment in BD has a significant effect on brain structure particularly in limbic/paralimbic regions associated with emotional processing.

Suicide prevention among youths. Systematic review of available evidence-based interventions and implications for Italy

Suicide completion is a leading cause of death for children, adolescents, and young adults. There is evidence that the suicide rate for those aged 15 to 24 years has tripled since 1950, and suicide is now the second or third leading cause of death in this age group. Recent studies indicate that the incidence of suicide attempts among adolescents may exceed 10% annually. The role of caregivers and schools (as well as colleges and universities) is important in the assessment, management, and prevention of suicidal behaviour in children and youth. Recognition of risk factors for suicide is of paramount importance for prevention. Furthermore, a number of educational programs have demonstrated possible key roles in implementing suicide prevention strategies. As suicide is a problem of concern among Italian youths, this paper overviews current official statistical evidence of the phenomenon and suggests a national suicide prevention strategy based on a number of tools already involved in this field, especially in the USA.

A woman lost in the cemetery: A case of time-limited amnesia

A 43-year-old woman one day experienced a dissociative fugue which she could not recall. She was married, nulliparous, with no history of dissociative disorder or other psychiatric disorders. She had been sexually abused during late childhood-early adolescence. She was examined thoroughly from both psychiatric and medical standpoints to exclude organic causes for her condition. Magnetic Resonance Imaging showed only some non-specific abnormalities. On personality tests, a histrionic structure of personality emerged, with obsessive and narcissistic traits accompanied by rigidity and anxiety, dysphoria and high risk for depression; some impairment was found in executive function tests. Final diagnosis was one of dissociative fugue. In fact, organic traits were not sufficient to establish a diagnosis of Transient Global Amnesia.

Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients

INTRODUCTION

A long-acting, injected, carbohydrate-microsphere preparation of risperidone (RLAI; Risperdal Consta ((R))) is reported to be safe and effective in chronic psychotic illnesses but, as its long-term and comparative efficacy remain unclear, this study compared clinical status during oral antipsychotic treatment versus conversion to RLAI.

METHODS

Psychotic patients (n=88; initial BPRS=93+/-5) were treated for 6 months with clinically chosen oral medication and then converted to biweekly RLAI for the first 6 months (6-6 months matched mirror comparison) and then for another 18 months. Clinical status in the two treatment periods and in the 18 months of follow-up was compared with measures including BPRS improvement (primary outcome), CGI variants and SF-36 ratings.

RESULTS

RLAI (at a mean dose of 47 mg/2 weeks at six and up to 23.1+/-3.3 months) was associated with major improvements in all outcome measures (p<0.001). Initial BPRS scores fell by an average of 50% within six months; hospitalizations declined from 19.8% to 0%, and rates of adverse events were reduced by 2.5- to 7.4-fold. Such benefits were sustained during 18 months of follow-up with RLAI-treatment.

CONCLUSIONS

The findings are limited by the lack of a parallel control treatment, such as with oral risperidone or another antipsychotic, lack of blinded assessments, and a moderate number of subjects. Nevertheless, the findings add to indications that RLAI can be an effective and well-tolerated treatment-option for chronically psychotic patients.

Burnout, hopelessness and suicide risk in medical doctors

OBJECTIVES

The aim of the present study was to investigate the association between burnout and hopelessness in medical doctors.

MATERIALS AND METHODS

We conducted an investigation of 133 medical doctors working either in a hospital setting or in general practice to explore the relationship between the level of burnout and hopelessness, a psychometric marker for suicide risk. The participants were administered the Oldenburg Burnout Inventory (OBI) and Beck's Hopelessness Scale (BHS).

RESULTS

Burnout is an important issue in mediating the level of hopelessness. Doctors with high hopelessness had higher scores on the disengagement factor (2.61±0.47 vs 2.14±0.41; t131=-4.37; p<0.001; Cohen D=1.07), and on the exhaustion factor (2.68±0.65 vs 2.19±0.54; t131=-3.39; p<0.001; Cohen D=0.82) than doctors with low hopelessness. A multivariate regression analysis confirmed that disengagement and exhaustion are significant predictors of the BHS scores.

CONCLUSIONS

People in charge of workers' health should pay particular attention to the level of burnout in doctors, intervene with changes in the work environment and evaluate the impact of such procedures.

White matter hyperintensities, suicide risk and late-onset affective disorders: an overview of the current literature

White matter hyperintensities (WMHs) refer to areas of hyperintense signal on T2- or proton density-weighted brain magnetic resonance imaging. Although WMHs are a common finding in patients with bipolar disorder (BD), particularly with a later disease onset, some studies report a higher frequency of WMHs only in unipolar affective disorders. We reviewed the literature examining examining both the severity and presence of WMHs in late life and particularly in individuals with late-onset BD (LOBD). Studies investigating white matter lesions in LOBD were systematically retrieved and the reference lists of these studies were scanned for additional relevant studies of neuroimaging in LOBD. The majority of neuroimaging studies reported an association between older age and LOBD and the presence of WMHs in LOBD. Also, we found in a small sample of patients preliminary evidence of a significant relationship between older age with late-onset BD and WMHs having a higher prevalence of cardiovascular and cerebrovascular risk factors. In conclusion over 60 years older individuals with LOBD and WMHs might have a type of illness characterized by more neuropathological changes and biologically different compared to non LOBD. This is consistent with the hypothesis of vascular mania. WMHs could be a reliable biological risk marker for late onset mood disorders.

Duloxetine versus venlafaxine in the treatment of unipolar and bipolar depression

OBJECTIVES

Both duloxetine and venlafaxine are efficacious in treating patients with Major Depressive Disorder (MDD), even though the advantages in treatment patients with bipolar disorder is unclear. This study aimed to evaluate the efficacy of duloxetine vs venlafaxine in the acute treatment of unipolar and bipolar depression.

MATERIALS AND METHODS

The study was a non randomized controlled trial. The participants were 62 consecutive outpatients (41 men; 21 women) affected by unipolar and bipolar depression treated either with duloxetine and venlafaxine.

RESULTS

More patients treated with duloxetine had a positive response to treatment and remission both for depression (HAMD17 response: 90.3% vs 0.0%; p < .001; HAM-D17 remission: 48.4% vs 0.0%; p < .001), and anxiety (HAM-A response: 90.3% vs 6.5%; p < .001; HAM-A remission: 71.0% vs 6.5%; p < .001) than controls. Patients treated with duloxetine were also more likely to show a decrease in HAM-D17 suicidality (100% vs 45.2%; p less than .001) and an increase in the quality of life (SF-36 percentage of improvement: 6.35 [SD=9.66 vs -2.58 [9.98]; p less than .001) than controls.

CONCLUSIONS

Duloxetine is more effective in reducing anxiety and suicidal ideation. Both treatments were safe and tolerated, and both may be successfully used in unipolar and bipolar depression.

Neural Activation During the STROOP Task in Bipolar Disorder Patients and Their Unaffected Relatives

Aims:

To examine potential similarities in neural activation during the STROOP colour word test (SCWT) in patients with Bipolar Disorder (BD) and their unaffected first degree relatives of BD patients as an expression of genetic predisposition.

Methods:

39 remitted BD patients were compared to 46 of their healthy relatives and to 42 controls. fMRI data were collected on a 1.5 T GE Signa MR system using a blocked periodic design and analysed in SPM5.

Results:

There was no statistically significant group difference in the behavioural performance. At the corrected cluster level threshold of p< 0.001 controls showed more activation than:

a.

Conclusion:

These findings suggest that changes in neural activation during response inhibition may reflect genetic predisposition to BD.

Activation of Serotonin Metabolism and BDNF Changes in Depressed Patients with Multiple Sclerosis During Interferon-Beta Therapy

Background:

Indoleamine-2, 3-dioxygenase is responsible for tryptophan catabolism; IFN-β is a treatment for multiple sclerosis (MS) and it has been associated with depression. IDO activation might play a role in IFN-β induction of depressive symptoms. Depressive symptoms associated with MS illness and IFN-β treatment have been treated with pharmacological and non-pharmacological intervention.

Aims:

Evaluation of the kynurenine pathway, IDO activation and neurotoxic agents, serum BDNF in MS patients during IFN-β intervention.

Methods:

14 study subjects, aged 18-64 years with major depressive disorder and MS treated with IFN-β, before and after pharmacologic and non-pharmacologic intervention, and 34 age matched healthy controls were enrolled at the University of Rome "La Sapienza" and at the at the University of Antwerp. Depressed participants were randomized to sertraline-treatment or interpersonal psychodynamic psychotherapy.

Results:

There were significant improvements in both depression and anxiety symptoms with medication and psychotherapy groups, although the effect with sertraline was more robust. Sertraline treatment was associated with a decline in serotonin. In the psychotherapy group, a significant increase in 3-hydroxyanthranilic acid (HAA) was observed after 4 months treatment (p= .04) with a significant decrease in tryptophan levels at 6 weeks (p= .02) and a trend towards a significant decrease in BDNF after 6 wks (p=0.06), neither of which were seen in the medication condition.

Discussion:

The increase in HAA among the psychotherapy-treated patients raises the possibility of a neurodegenerative challenge for patients with multiple sclerosis during treatment with IFN-β which appeared to be prevented with pharmacological treatment.

Defective group-II metaboropic glutamate receptors in the hippocampus of spontaneously depressed rats

Spontaneously depressed flinders sensitive line (FSL) rats showed a reduced expression of mGlu2/3 metabotropic glutamate receptors in the hippocampus, as compared to "non-depressed" flinders resistant line (FRL) rats. No changes in mGlu2/3 receptor protein levels were found in other brain regions, including the amygdala, hypothalamus, and cerebral cortex. Biochemical analysis of receptor signalling supported the reduction of mGlu2/3 receptors in the hippocampus of FSL rats. Accordingly, the selective mGlu2/3 receptor agonist, LY379268 (1microM) reduced forskolin-stimulated cAMP formation by 56% and 32% in hippocampal slices from FRL and FSL rats, respectively. In addition, LY379268 enhanced 3,5-dihydroxyphenylglycine-stimulated inositol phospholipid hydrolysis from 65% to 215% in hippocampal slices from FRL rats, whereas it was inactive in slices from FRL rats. We also examined the behavioural response of FSL rats to systemic injection of LY379268 (0.5mg/kg, i.p., once a day for 1-21 days) by measuring the immobility time in the forced swim test, which is known to be increased in these rats. LY379268 was administered alone or combined with the classical antidepressant, chlorimipramine (10mg/kg, i.p.). LY379268 alone had no effect at any of the selected time-points, whereas chlorimipramine alone reduced the immobility time only after 21 days of treatment. In contrast, when combined with LY379268, chlorimipramine reduced the immobility time during the first 14 days of treatment. These data support the view that mGlu2/3 receptors might be involved in the pathophysiology of depressive disorders, and that pharmacological activation of these receptors may shorten the latency of antidepressant medication.

Postpartum depression without delivering a child?

OBJECTIVE

Depression in people related to delivering women is documented in their mates, but only anecdotal in other family members. We describe a case of depression in a woman who had previously experienced postpartum depression after the birth of her nephew.

METHOD

A clinical description of the case.

RESULTS

A 53-year-old woman, hysterectomized at age 47 years, was admitted for attempted suicide. She developed major depressive episode 1 month after her daughter had delivered a son. She had a past history of two postpartum depressive episodes clinically identical to the current episode. The episode resolved after 5 weeks. At 1-year follow-up, the patient is still asymptomatic.

CONCLUSION

Psychological and cultural factors were at play in this case more than hormonal and biopsychosocial ones.

Metabotropic glutamate receptors and neuroadaptation to antidepressants: imipramine-induced down-regulation of beta-adrenergic receptors in mice treated with metabotropic glutamate 2/3 receptor ligands

Antidepressant drugs have a clinical latency that correlates with the development of neuroadaptive changes, including down-regulation of beta-adrenergic receptors in different brain regions. The identification of drugs that shorten this latency will have a great impact on the treatment of major depressive disorders. We report that the time required for the antidepressant imipramine to reduce the expression of beta-adrenergic receptors in the hippocampus is reduced by a co-administration with centrally active ligands of type 2/3 metabotropic glutamate (mGlu2/3) receptors. Daily treatment of mice with imipramine alone (10 mg/kg, i.p.) reduced the expression of beta-adrenergic receptors in the hippocampus after 21 days, but not at shorter times, as assessed by western blot analysis of beta1-adrenergic receptors and by the amount of specifically bound [3H]CGP-12177, a selective beta-adrenergic receptor ligand. Down-regulation of beta-adrenergic receptors occurred at shorter times (i.e. after 14 days) when imipramine was combined with low doses (0.5 mg/kg, i.p.) of the selective mGlu2/3 receptor agonist LY379268, or with the preferential mGlu2/3 receptor antagonist LY341495 (1 mg/kg, i.p.). Higher doses of LY379268 (2 mg/kg, i.p.) were inactive. This intriguing finding suggests that neuroadaptation to imipramine--at least as assessed by changes in the expression of beta1-adrenergic receptors--is influenced by drugs that interact with mGlu2/3 receptors and stimulates further research aimed at establishing whether any of these drugs can shorten the clinical latency of classical antidepressants.

Remission of mood disorder with psychotic features after treatment with mirtazapine

The antidepressant mirtazapine enhances both noradrenergic and serotonergic transmission by blocking α2-adrenergic presynaptic auto- and heteroreceptors, respectively. We here report on three patients with mood disorders with psychotic features (two cases with depressive and one with bipolar disorder). Treatment with mirtazapine significantly improved not only their depression, but also their delusions. Depressive symptoms were only partially responsive and delusions unresponsive in all three patients to previous antidepressive and/or antipsychotic treatment, and only mirtazapine induced persistent improvement. These clinical cases suggest that mirtazapine can be a valid alternative for patients with depression with psychotic features and partial treatment-resistance.

[Psychiatric approach to the clinical aspects of drug dependence: psychiatric comorbidity in drug addicts]

The authors analyze the most important theoretical models in the field of drug addiction: the moral, the medical, the psychodynamic and the psychiatric model, with particular reference to the concepts of comorbidity and dual diagnosis. It is pointed out as these approaches invariably lead to a dichotomy between the "defect/process" model and the "conflict/development" model. The proposed hypothesis is an attempt to reconcile the opposite points of view in an unitary vision: on the basis of the fundamental psychopathological elements (drive dyscontrol and dependence), the addicts are so distributed into three areas, different for nosography and treatment.

Suicide among the elderly in Italy: a descriptive epidemiological study (1969 to 1994)

Data regarding the elderly suicide trend in Italy between 1969 and 1994 were analyzed from an epidemiological point of view in order to verify hypotheses on suicide risk factors in old age. The data were obtained from the National Register of the Institute of Health (Italy) and were standardized at 1971 for age and sex. For the purposes of the study, only data for people aged 70 years and over were considered. The elderly suicide rate increased from 274 per 1,000,000 in 1969 to 354.7 per 1,000,000 in 1994 in males and from 59.7 per 1,000,000 in 1969 to 82.1 per 1,000,000 in 1994 in females. In the three macroareas (northern, central, and southern regions, indicated as N, C, and S), it is possible to observe different trends. In both genders, N and C rates are the highest in Italy (tending to be similar), while S rates are lower and distinct from the others. The most marked increase was observed in the S male rate, whereas N and C rates show a remission after the rate increase in 1980. The most important finding to emerge from this study is the interruption in the tendency for suicide rates to increase in recent years (dating back to the mid-1980s) and the nonuniformity of the nationwide distribution of suicides.

Peduncular hallucinosis following a transoral odontoidectomy for cranio-vertebral junction malformation. A case report

This is a case report of a sixty-two years old man suffering from a cranio-vertebral malformation whose dens epistrophei was removed through a transoral approach. During the postoperative course, he experienced a transient peduncular hallucinosis probably caused by surgical trauma on his brainstem. The possible physiopathological, etiopathological, clinical, and therapeutic aspects of this rare phenomenon are discussed.

Intracranial meningiomas in the 9th decade of life: a retrospective study of 17 surgical cases

The general availability of cerebral computed tomographic and magnetic resonance imaging scans makes the observation of symptomatic intracranial meningiomas in very elderly patients (aged 80 yr or more) relatively frequent. A few authors have reported on patients who have undergone surgery for intracranial meningiomas in their 9th decade of life, without providing indications regarding the surgical criteria and the prognostic factors. We report on a series of 17 patients who have received surgery for intracranial meningiomas in their 9th decade of life, with the goal of determining some surgical criteria for general physicians and neurosurgeons. Patients with severe systemic disease and definite functional limitations (American Society of Anesthesiology Class III) had a major postoperative morbidity (P = 0.020) and mortality (P = 0.005), especially if they scored low (< 70) on the preoperative Karnofsky Rating Scale (P = 0.010). The risk of postoperative morbidity was higher when the maximum diameter of the tumor was > 5 cm (P = 0.031).

[Temporary aspects of aging: a new approach to the problem]

Medical, psychologic and social problems are typical of the old age. Usually growing old means organic impair, loneliness and a lower social role; moreover, spatial behavior is completely reduced. The period could be lived and be considered in a different way, although aging is unavoidable. This work suggests that we should consider the passing of time a most comprehensive way. The cyclic, biological time can be replaced by a time which considers and gives expression to everybody's needs and activities. The first aim is to give the elderly a new social role, necessary to avoid a "ecosystemic destabilization". Therefore social workers should supply the aged with a new education at "lived time", as a new therapy form.

[Considerations on the concept of suggestion in relation to pharmacology]

After some brief considerations on the history of the concept of suggestion, the authors evaluate the importance of this concept in the doctor-patient relationship in which the pharmacological variable is present. They report their personal experience through a case report and hope for an integrated approach in which the drug could be seen as a biological and relational agent.

[Nosographic problems and clinico-phenomenal characteristics of psychoses in epilepsy]

A critical analysis is made of the published reports on the epidemiologico-clinical and etiopathogenetic aspects of psychoses in epilepsy. Having underlined the principal characteristics of this pathology together with the main methodological and descriptive problems which emerge from the studies examined, the paper concludes by stressing the need for an approach based on a multifactorial understanding of the causes of these psychoses. In operative terms it is also necessary to evaluate the role of the predominant risk factors in each individual case.