Is structured group psychoeducation for bipolar patients effective in ordinary mental health services? A controlled trial in Italy

BACKGROUND

Recent reviews of evidence-based guidelines for the clinical management of Bipolar Disorders (BD) have recommended that "all patients with BD be offered group or individual psychoeducation" to prevent relapse, improve treatment adherence, quality of life, and functioning. The present study evaluated the effectiveness of psychoeducation in routine mental health services in reducing number of hospitalisations and number of days spent in hospital, at a 1-year follow-up.

METHODS

A total of 102 outpatients were recruited from two Italian Departments of Mental Health. Inclusion criteria were a lifetime BD type I or II diagnosis, assessed with SCID, and ≥ 3 months of euthymia. Exclusion criteria were DSM-IV Axis I comorbidity, mental retardation (IQ<70), organic brain damage, or deafness. All participants received standard psychiatric care, including standard pharmacological treatment; the experimental group also received 21 group psychoeducation sessions, weekly held and conducted according to Colom and Vieta's model.

RESULTS

The number of patients hospitalised during the 1-year follow-up, the mean number of hospitalisations per patient, and the mean number of hospitalisation days were significantly lower for psychoeducated patients.

CONCLUSION

Our findings support the view that group psychoeducation is an effective way to prevent hospitalisation and decrease hospital days in pharmacologically treated patients with bipolar disorder also in routine clinical settings. The results confirm that psychoeducation promotes improvement in illness course by preventing acute phases and enhancing mood stability, and consequently, improvement in the quality of life for people with BD.

Schizophrenia susceptibility and NMDA-receptor mediated signalling: an association study involving 32 tagSNPs of DAO, DAOA, PPP3CC, and DTNBP1 genes

BACKGROUND

Recent studies supported associations between four NMDA-receptor-mediated signalling genes (D-amino acid oxidase, DAO; D-amino acid oxidase activator, DAOA; protein phosphatase 3 catalytic subunit gamma isoform, PPP3CC; dystrobrevin-binding protein 1, DTNBP1) and schizophrenia susceptibility, even though with contrasting results.

METHODS

In an attempt to replicate these findings for the first time in an Italian population, a panel of 32 tagSNPs was analysed in a representative case-control sample involving 879 subjects.

RESULTS

An association in the allele frequency was observed for the estimated PPP3CC CAG triplotype in the SNP window rs4872499 T/C-rs11780915 A/G-rs13271367 G/A (pcorrect = 0.001). Similarly, the clustered genotype frequencies of the estimated/phased CAG triplotype differed between cases and controls (p = 0.004), with the carriers having a higher frequency in the control population (p = 0.002, odd ratio OR = 0.59, 95% confident interval CI: 0.43-0.82).Following the phenotypic dissection strategy, the analysis of single SNPs evidenced a protective effect in males of rs11780915 and rs13271367 in PPP3CC gene (pcorrect = 0.02, pcorrect = 0.04 respectively). Moreover the estimated/phased GT diplotype (rs2070586A/G-rs3741775G/T) carriers of the DAO gene were more highly represented in female controls (p = 0.017, OR = 0.58, 95% CI: 0.37-0.90), as were the estimated/phased CAG triplotype carriers of the PPP3CC gene in females (p = 0.01, OR = 0.53, 95% CI: 0.32-0.87). In addition, we performed an interaction analysis, and a 66% (p = 0.003, OR = 0.34, 95% CI: 0.17-0.70) lower risk of developing schizophrenia for female (CAG + GT) carriers versus non-CAG or -GT carriers was observed. For DTNBP1, we found a protective effect in males for the rs6459409 (pcorrect = 0.02) and the estimated/phased CT diplotype (rs6459409-rs9476886) carriers (p = 3x10-4, OR = 0.46, 95% CI: 0.30-0.70).In relation to diagnostic subtypes, the estimated/phased DAO GT diplotype and PPP3CC CAG triplotype female carriers were found to show relative risk ratio (RRR) values of 0.52 and 0.54 lower risk for a paranoid phenotype respectively.

CONCLUSIONS

Although the results are preliminary and needed replication in a larger sample, this study suggests that NMDA receptor-mediated signalling genes (DAO, PPP3CC, DTNBP1) might be involved in schizophrenia pathogenic mechanisms related to gender.

Mental disorders and work integration: a retrospective study in a northern italian town

Objectives:

The present study was conducted in a vocational integration service of a northern Italian town with two major aims: to assess vocational integration programs undertaken from 1^st January 2004 to 1^st January 2007; and to identify job tenure-associated predictors.

Methods:

This is a retrospective study; we collected data such as gender, age, duration, type and outcome of the vocational integration program, and number of interventions performed by the vocational integration service. Self-report questionnaires were also used to assess the satisfaction of users, caregivers, practitioners, and of the company contacts involved in the study.

Results:

The service has enrolled 84 users during the observation period. Out of these users, 64.3% of them still had their jobs after three years. Users, caregivers and company contacts expressed high levels of satisfaction for the support received by the vocational integration service. The company expressed less satisfaction for the collaboration received by the Departments of Mental Health (DMHs) that coached the users. The only variable associated to the outcome was the number of interventions that the users received before their placement on the job.

Conclusions:

Despite all the limits of this study, its results show that the chance of taking advantage of a supported job placement service has likely proven itself effective in helping people with mental disorders to obtain and maintain a competitive employment. Our results, however, also point to the necessity of implementing newer strategies meant to develop a greater integration among all services dealing with mentally ill people.

Community attitudes towards mental illness and socio-demographic characteristics: an Italian study

Aim — To assess the association between socio-demographic characteristics and community attitudes towards mentally ill people. Method — We assessed a sample of 280 subjects, stratified for sex and age, which has identified using the electoral registers of Brescia. A letter was sent to everyone in order to introduce the future potential study participant to the topics of the public attitudes towards mental illness and it included an invitation to take part in the study. After, 280 subjects were contacted by telephone. Finally, 174 persons, who expressed their willingness to collaborate, were visited by a team of four trained interviewers. The instruments used were: a semi-structured interview; the Community Attitudes to the Mentally III (CAMI) inven-tory, which is composed by 40 statements, concerning the degree of acceptance of mental health services and mentally ill patients in the community; and the Fear and Behavioural Intentions (FABI) inventory, which is composed by 10 items, concerning fears and behavioural intentions towards mentally ill people. 106 subjects refused to participate. Results — Factor analysis of the CAMI revealed three components Physical distance and fear, Social isolation and Social responsibility and tolerance. Factor 1 is associated with: people >61 years old; people being divorced/widowed/living separated; people who haven't participated in social or volunteer activities. Factor 2 is associated with: people > 41 years old; people being schooled at a level that's higher than elementary level; unemployed people. Factor 3 doesn't present any associations. Conclusions — The results of this study outline the need to: a) promote interventions focused to improve the general attitude towards people with mental illness; b) to favour specific actions in order to prevent or eliminate prejudices in subgroups of the population.

Declaration of Interest: in the last two years the authors have been paid by the IRCCS Centra San Giovanni di Dio Fatebenefratelli in Brescia (Italy), as employees and free professionals.

Development and validation of a self-reported questionnaire on users' opinions about schizophrenia: a participatory research

BACKGROUND

Although users' involvement in mental health research has repeatedly been acknowledged as having a positive influence on research quality, this rarely happens.

AIMS

To develop and validate a Questionnaire on Users' Opinions (QOU) about schizophrenia, in close collaboration with 279 persons affected by this disorder.

METHODS

A preliminary list of items concerning the opinions of users with schizophrenia regarding causes, treatments and psychosocial consequences of the disorder was developed by 38 users with schizophrenia and 40 professionals who attended a workshop. Psychometric properties of the QOU were tested on 241 users with schizophrenia, 149 of whom were randomly assigned to a test-retest study and 92 to a face-validity study. Content and construct validity were explored in the whole sample.

RESULTS

The final version of the QOU contains: (1) 24 items on the psychosocial consequences of schizophrenia, grouped into six subscales, whose Cronbach's alpha ranged between 0.55 and 0.74; (2) five multiple choice items on the Italian psychiatric law; (3) 12 open questions; and (4) four yes/no skipping items. Items' reliability, measured by Cohen's kappa coefficient, ranged between 0.55 and 0.92.

CONCLUSION

This questionnaire may be useful to assess patients' beliefs about schizophrenia and to target psychosocial interventions for this mental disorder.

What people with schizophrenia think about the causes of their disorder

AIMS

To describe what users with schizophrenia think about the causes of their disorder.

METHODS

In each of the 10 participating Italian mental health centres, 25 users with schizophrenia were consecutively recruited and asked to complete the Users' Opinions Questionnaire (UOQ).

RESULTS

150 out of 198 respondents mentioned at least one social cause for their mental disorder, and 114 reported exclusively social causes. Family conflicts were the most frequently reported social cause (21%), followed by traumas (20%), work and study difficulties (17%), and psychological disturbances (17%). Ten percent of the respondents mentioned biological causes. Biological causes were more frequently reported by users who were aware of their diagnosis of schizophrenia, whereas social causes by those who just knew they suffered from a psychosis. Difficulties in social relationships were more frequently pointed out by respondents with an earlier onset of the illness and a higher number of compulsory admissions in the previous 12 months. These users expressed more scepticism about the usefulness of the treatments they received, and perceived a greater social distance.

CONCLUSIONS

Users' beliefs about the causes of their disorder should be taken into account by psychiatrists in order to improve their working alliance with them.

[The acceptability of the NICE recommendations for schizophrenia in the Italian Departments of Mental Health. The SIEP-DIRECT'S Project on the discrepancy between routine practice and evidence]

AIMS

This paper aims at presenting the most significant results emerging from the work carried out by the focus groups of the multi-centre Project SIEP-DIRECT'S. The Project is aimed at assessing the existing discrepancies between the evidence-based NICE guidelines for schizophrenia and the usual practices of care given by Italian mental health services. Each focus group was requested to give an evaluation on: (a) appropriateness of the English NICE guidelines in the context of the Italian mental health services; (b) clarity and usefulness of the 103 indicators developed on the basis of the NICE recommendations to measure their level of application within the services.

METHODS

In each of the 19 mental health departments or psychiatric services participating in the Project there were organized "multidisciplinary" focus groups and "specialistic" focus groups. The former included, amongst others, professional operators of the mental health services, patients, their relatives, representatives of patient organizations and general practitioners. They examined the recommendations and indicators upon which the participants could express their opinion or judgment based on their knowledge, experience or information in their possession. The latter group, composed only of psychiatrists, examined the recommendations and indicators relative to pharmacological treatments that regarded the specific competences of their professional category.

RESULTS

Most NICE recommendations seemed appropriate to the working context of the Italian services. However, some perplexity emerged as regards specific organizational models of the services, such as the specific services for psychotic onsets or the assertive outreach teams, which were believed not to be strictly pertinent to the traditional organization of mental health care in our Country. There were also some criticisms regarding the cognitive-behavioural treatments which the NICE Guidelines recommend as the principle psychotherapeutic option for patients with schizophrenia, since in many Italian services, when the use of psychological interventions are needed, the tendency is to prefer interventions based on psychodynamic theories. The SIEP indicators were generally held to be clear and acceptable.

CONCLUSIONS

In the view of the focus groups, the NICE guidelines are on the whole useful and suitable for orientating the services in the choice of more efficacious practices in the treatment of patients with schizophrenia. Moreover, the results obtained legitimate the use of the set of SIEP indicators for the evaluation of good practices and the quality of care offered by Italian services. Finally, the use of focus groups delines to a different context as well as the verification of the comprehensibility and applicability of SIEP indicators.

The stigma of schizophrenia from patients' and relatives' view: A pilot study in an Italian rehabilitation residential care unit

OBJECTIVE

To identify the constituent elements of the stigma from the perspective of those having first-hand experiences of it.

METHODS

Subjective experiences of stigma were explored in six focus groups: three with people suffering from schizophrenia and three with patients' relatives. Focus group sessions were tape-recorded, transcribed and analyzed by means of an inductive method, forming categories from the texts, as a basis for coding. Analysis aimed at establishing a typology of stigmatization experiences from the spoken words of the focus group participants.

RESULTS

Four dimensions of stigma were identified: access to social roles; internalization of stigma; quality of mental health services, public image of mental illness.

CONCLUSION

The most frequently found topics concerned experiences of marginalization and discrimination that people with schizophrenia experience in their daily life. These results mirror the findings of similar studies obtained in other cultural contexts.

The VADO approach in psychiatric rehabilitation: a randomized controlled trial

OBJECTIVE

This study investigated whether a specific structured planning and evaluation approach called VADO (in English, Skills Assessment and Definition of Goals) resulted in improved personal and social functioning among patients with chronic schizophrenia.

METHODS

A total of 85 patients with chronic schizophrenia who were under a stable medication regimen were randomly allocated to the VADO-based intervention or to routine care; 78 completed the program. Interventions were carried out in nine Italian day treatment or residential rehabilitation facilities. Assessment at the beginning of the study and at the one-year follow-up included the Personal and Social Performance scale (PSP) and Brief Psychiatric Rating Scale Version 4.0 (BPRS). Clinically significant improvement was defined as an increase of at least 10 points on the PSP or a decrease of at least 20 percent on the BPRS total score.

RESULTS

At baseline, average PSP scores in the experimental group and in the control group were 33.9+/-8.1 and 34.0+/-11.2, respectively (possible scores range from 1 to 100, with higher scores indicating better functioning). At six months, the score improved markedly in the experimental group (40.8+/-10.9) and minimal change was observed in the control group (35.3+/-11.6); the difference between groups was significant (difference of 6.9 points compared with 1.3 points; t=2.21, df=81, p<.05). At 12 months, the same trend was observed (difference of 12.0 points compared with 3.5 points), and the difference between groups was both statistically and clinically significant (t=2.99, df=75, p<.01).

CONCLUSIONS

A statistically and clinically significant improvement in functioning was observed among patients treated with the VADO approach.

Outcome assessment of the VADO approach in psychiatric rehabilitation: a partially randomised multicentric trial

Background

Recent studies on representative samples of psychiatric services have shown that low proportions of cases received effective rehabilitation interventions. The following are likely to be the most important causes: the scarcity of mental health workers trained in social and work skills strategies and the absence of a structured framework to formulate rehabilitation practices.

The aim of this study was to assess if a specific structured planning and evaluation manual, called VADO (Valutazione delle Abilità e Definizione degli Obiettivi – in english: Skills Assessment and Definition of Goals), is more effective than routine interventions in reducing disability in patients with schizophrenia.

Method

Each of 10 mental health services were invited to recruit 10 patients with a schizophrenic disorder. Altogether 98 patients were recruited. Of these, 62 patients were randomly allocated to the intervention/experimental or a control group. The remaining group of 36 patients was not randomised and it was considered as a parallel effectiveness study. Assessment measures at the beginning of the study and at the one-year follow-up included the FPS scale of social functioning and the BPRS 4.0. Between group (VADO vs. Routine) and time effects were examined with ANOVA, Chi-square or Fisher exact. Clinical "improvement" was defined as an increase of at least ten points on the FPS or a decrease of at least 20% on BPRS scores.

Results

31 of the 62 randomized patients received the experimental interventions, while 31 followed the routine ones. At follow-up, the experimental group showed statistically and clinically greater improvements in psychopathology and social functioning.

Better outcomes of both social functioning and symptom severity were observed in non randomised patients (parallel effectiveness study).

Conclusion

The results suggest that setting personalised and measurable objectives, as recommended by the manual, can improve the outcome of rehabilitation of severe mental disorders. Better outcomes in the parallel effectiveness study could be attributed to the greater confidence and enthusiasm of staff in centres where the VADO approach originated.

[Correlation between subjective well-being and pharmacological therapy in patients with psychotic disorders]

AIMS

The present study aims to investigate whether exists a meaningful relation between quality of life and subjective well being with regard to the pharmacological treatment (antipsychotic typical versus atypical) in a sample of people with psychotic disorders integrated in a Community Residential Rehabilitation Centre; to examine whether the different antipsychotic treatment is correlated to a different answer to the psychosocial rehabilitation intervention in terms of significant improvement in the positive and negative symptomatology, subjective well-being and quality of life.

METHOD

All patients, who suffer from schizophrenia and schizoaffective disorder according to DSM-IV criteria, treated with antipsychotic and stabilized from at least one month, were enrolled in the study.

RESULTS

32 patients have participated in the study: 22 patients treated with atypical drugs and 10 with typical. The analysis of the collected data didn't show any significant statistical difference at baseline with regard to symptomatology, subjective well-being and quality of life. From the statistical analysis of the data to the endpoint, after a month of psychosocial rehabilitation, we found a statistically meaningful improvement in all the areas inquired in the group of the patients dealt with antipsychotic atypical drugs.

CONCLUSION

The results confirm that the atypical antipsychotics are more effective, than the typical, to improve symptomatology, subjective well-being and quality of life of psychiatric patients.

Recent Outbreak of Soybean Sudden Death Syndrome Caused by Fusarium virguliforme and F. tucumaniae in Argentina

Sudden death syndrome (SDS) of soybean was detected initially in Argentina during 1991-1992 in the Pampas Region and 1992-1993 in the Northwest Region. The first report of the fulfillment of Koch's postulates of SDS caused by Fusarium solani f. sp. glycines in Argentina was published in 2003 (3). Subsequently, analyses have shown that F. solani f. sp. glycines represents several morphologically and phylogenetically distinct species, including F. tucumaniae in Argentina and F. virguliforme in the United States (1). Isolations were made from plants that exhibited typical SDS symptoms (interveinal foliar chlorosis and necrosis leading to defoliation of the leaflets but not the petioles) from fields in Santa Fe and Buenos Aires provinces in 2001, 2002, and 2003. To determine which species are responsible for SDS in Argentina, cultures of eight slow growing isolates that developed bluish pigmentation and produced abundant macroconidia in sporodochia on potato dextrose agar were subjected to morphological and molecular phylogenetic analyses and pathogenicity tests. Morphological analyses demonstrated that three of the isolates were F. virguliforme and five were F. tucumaniae. Isolates of F. tucumaniae produced long and narrow sporodochial conidia while F. virguliforme produced diagnostic comma-shaped conidia. Molecular phylogenetic analyses of DNA sequences from multiple loci confirmed morphology-based identifications and showed that the soybean SDS pathogen in the United States, F. virguliforme, was also present in Argentina. To our knowledge, this is the first report of F. virguliforme in Argentina and of this pathogen outside the United States. Five isolates of F. tucumaniae and three isolates of F. virguliforme were used for pathogenicity tests. F. virguliforme isolate 171 provided by J. Rupe (University of Arkansas, Fayetteville) was used as a positive control. Soybean cultivars Ripley, RA 702, Pioneer 9492RR, Spencer, and A-6445RG were inoculated with each of the isolates tested in a greenhouse assay using soil infestation and toothpick methods (2). All eight isolates produced typical foliar SDS symptoms 15 to 25 days after inoculation. Severity of foliar symptoms averaged 3.3 for F. virguliforme, 2.6 for F. tucumaniae, and 3.3 for the positive control using a disease severity scale in which 1 = no symptoms and 5 = severely infected or dead plants. Under these conditions, F. virguliforme appeared to be more virulent than F tucumaniae. Noninoculated plants remained symptomless. Koch's postulates were confirmed with soybean cultivars RA 702 and A6445RG. Isolates recovered from symptomatic plants inoculated by the soil infestation and toothpick methods were identical to those used to inoculate the plant. Strains were recovered at frequencies of 100 and 60% from plants inoculated by the toothpick and soil infestation methods, respectively. To our knowledge, this is the first report of the fulfillment of Koch's postulates for F. tucumaniae and F. virguliforme in Argentina. References: (1) T. Aoki et al. Mycologia 95:660, 2003. (2) K. W. Roy et al. Plant Dis. 81:1100, 1997 (3) M. Scandiani et al. Plant Dis. 87:447, 2003.

[Mental illness and media]

Many knowledges on the mental disease that the community possesses are turning out of information disclosed from the media. It's common in the press to connect actions of violence and murders to the mental diseases. For this reason, the reader is induced to infer that murders and other violent actions are more frequent in people who have suffered from mentally ill, than in the general population. The mystifying impression provided by media accrues from the fact that these reports are rarely compensated from positive reports. Objective of the present study is to characterize the type of information concerning mental illness diffused from the local daily paper "Giornale di Brescia" in the year 2001. The results show that many articles connote negatively the mental disease. The journalistic sensationalism, denounced facing the speech of the prejudgment in the comparisons of the mentally ill people, seems to still remain, in the considered year of publication, one unchanging tendency.

[Psychopharmacological treatment: patients' knowledge about their medication]

AIMS

To identify knowledge about medication in a sample of patients admitted in a residential psychiatric rehabilitation unit.

METHODS

All consecutive patients admitted in a psychiatric rehabilitation unit during January 2000-April 2001 were interviewed about the medications prescribed; in particular they were asked about names, daily dose, therapeutic and side effects of the psychotropic drugs they took.

RESULTS

74 patients were surveyed about their knowledge of the psychopharmacological treatment they took. Most patients demonstrated a good knowledge about drugs' name (77%) and daily dose (74.3%); one-quarter (25.7%) had some understanding about the reason why the medications were prescribed and theirs intended effects while only 5.4% was able to indicate the side effects of medications prescribed. Overall, 21.6% of patients could correctly indicate drugs' name, daily dose and therapeutic effects of all medications they took.

CONCLUSIONS

The results of our study indicate the importance in clinical practice to devote particular attention to the patients' understanding of provided information about treatment and the crucial role of strategies, aimed at improving compliance and maximize the effects of therapeutic interventions.

First Report of Koch's Postulates Completion of Sudden Death Syndrome of Soybean in Argentina

Foliage symptoms on soybean resembling those of sudden death syndrome were detected in Argentina during 1991 and 1992 in the Pampas Region and during 1992 and 1993 in the Northwest Region. Isolations were made in 1999, 2000, and 2001 from soybean plants (Glycine max (L.) Merr.) showing these symptoms. Five isolates of fungi obtained from taproot tissue and blue sporulation on taproot exteriors were selected for further evaluation. These isolates were plated on potato dextrose agar supplemented with streptomycin (PDAS). Based on the spore morphology, colony growth rate, morphology and pigmentation on PDAS, and lack of microconidia (1) five isolates were identified as Fusarium solani f. sp. glycines. Soybean cvs. Ripley, Spencer, Pioneer 9492RR, and A6445 RG were inoculated in greenhouse tests with each of the isolates using toothpick and soil infestation methods for a total of six experiments. Isolate 171 provided by J. Rupe (University of Arkansas, Fayetteville) was tested as a positive control. Foliar symptoms typical of sudden death syndrome and similar to those in the field were observed 14 and 25 days, respectively, after inoculations using the toothpick and soil infestation methods. Lesions produced on leaves averaged 3.6 for all five isolates and 4 for the reference strain using a disease severity scale where: 1 = no symptoms; 2 = slight symptom development with mottling and mosaic on leaves (1 to 20% foliage affected); 3 = moderate symptom development with interveinal chlorosis and necrosis on foliage (21 to 50% foliage affected); 4 = heavy symptom development with interveinal chlorosis and necrosis (51 to 80% foliage affected); and 5 = severe interveinal chlorosis and necrosis (81 to 100% foliage affected). Noninoculated controls were symptomless. Differences in virulence were observed among the isolates. Based on disease symptoms in the greenhouse and cultural morphology on PDAS, the isolates were classified as Fusarium solani f. sp. glycines. Isolates recovered from symptomatic plants resembled Fusarium solani f. sp. glycines on PDAS and peptone/p-chloro-nitrobenzene agar amended with streptomycin, confirming Koch's postulates. Fusarium solani f. sp. glycines was recovered from 60% of inoculated plants. Reference: (1) K. W. Roy et al. Plant Dis. 81:1100,1997.

Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study

In this study, we investigated the possible association between clinical or pharmacological variables and suicidal behavior in a sample of chronic schizophrenia or schizoaffective disorder patients. One hundred and three patients with a DSM-III-R diagnosis of chronic schizophrenia or schizoaffective disorder were studied. The sample was subdivided in two subsamples according to the presence/absence of suicidal attempts lifetime. The main demographic and clinical variables retrospectively collected were analyzed and compared between the two groups. Attempters had a significantly higher rate of nicotine abuse or dependence (chi-square=3.900, df=1, p<0.05, Odds Ratio (O.R.)=3.4), were more likely to have or have had lifetime major depressive episodes (chi-square=10.258, df=1, p<0.002, O.R.=6.5), were more likely to have a duration of untreated psychosis (DUP) > or =1 year (chi-square=6.228, df=1, p<0.02, O.R.=12.5), and were more frequently prescribed typical antipsychotics (chi-square=3.979, df=1, p<0.05, O.R.=6.5) than patients without suicidal attempts lifetime. Further investigations on larger samples and with prospective designs are warranted, particularly with respect to the role of early intervention and atypical antipsychotic treatment in reducing suicide risk in schizophrenic patients.

Levosulpiride in somatoform disorders: A double-blind, placebo-controlled cross-over study

Reliable data on the psychopharmacotherapy of somatoform disorders (SDs) are scanty because of patients' poor psychopathological awareness and compliance, the need for combination treatment, and the lack of suitable instruments for clinical diagnosis and assessment. The aim of the present study was to investigate the efficacy and tolerability of low doses of levosulpiride in the treatment of SDs. Seventy-four patients with SDs diagnosed according to ICD-10 and DSM-IIIR criteria by means of the Comprehensive International Schedule for Somatoform Disorders-Somatoform Disorders Schedule (CISSD-SDS) were treated for 4 weeks either with levosulpiride (50 mg b.i.d.) or placebo, under double-blind, cross-over conditions. The clinical evaluation was performed using CISSD-SDS. Side-effects were evaluated using the Simpson and Angus Extrapyramidal Side Effects Scale (EPSE) and specific check-lists for anticholinergic and endocrine side effects. Levosulpiride significantly reduced the number of SD symptoms compared to placebo ( P =0.007) after 4 weeks of treatment. Eighty per cent of positive responses were observed during treatment with levosulpiride in the placebo-levosulpiride sequence; on the other hand, only 44% of positive responses were found during treatment with active compound in the levosulpiride-placebo sequence ( P <0.002). Levosulpiride also determined a more evident reduction of the total number of SD symptoms compared to placebo ( P <0.001). There were no differences in endocrine and anticholinergic side effects between levosulpiride and placebo. In the levosulpiride group, a higher percentage of patients (13.4 vs. 2.8%; P =0.029) showed signs of extrapyramidal system involvement compared to placebo. Levosulpiride appears to be a well-tolerated and effective drug for the treatment for SDs.

[Efficacy of the "VADO" approach in psychiatric rehabilitation: a controlled study]

AIMS

Assessment of the efficacy of the rehabilitation approach that is recommended by the manual VADO (AAOS in English: Abilities Assessment and Objectives Setting) in schizophrenic syndromes.

METHODS

Controlled trial, partly with individual randomisation. Centres were invited to recruit 10 patients who in most centres were randomly allocated either to the VADO approach or to usual rehabilitation practice. At least two professionals for each centre attended a brief intensive training course. Patients were assessed at baseline and six months later with a) the FPS scale, which is an improvement on the DSM-IV SOFAS; b) the BPRS 4.0; c) AR, a clinical tool that is contained in VADO.

RESULTS

55 patients received the experimental interventions and 40 the control one. Six months later greater significant improvements were observed in the experimental group, both in social functioning and in psychopathology.

CONCLUSIONS

The dissemination of structured rehabilitation approaches that are based on personalized definition of objective, intensive progress monitoring, patient's therapeutic education and validated strategies and do not imply additional costs, may be warranted. A longer follow-up is under way.

[Clinical practice in mental health and educational needs in general practice]

AIM

To obtain information regarding general practitioners' perception of their practice in mental health care, opinions, difficulties and educational needs.

METHODS

All general practitioners attending the last annual session of continuing medical education (October-December 2000) were asked to complete the questionnaire regarding: 1) perception of current practice in mental health care and difficulties in managing mental health problems; 2) opinions regarding their practice; 3) educational needs and perception of benefit from strategies to improve mental health care.

RESULTS

254 general practitioners completed the questionnaire (response rate 70%). 81.4% recognize their role in mental health care and 89.9% report they should develop the necessary skills to deal with mental health problems, perceived as difficult to treat in general practice (77.3%). Educational priorities concern mainly anxiety, depression and somatization; further competences and skills are mainly necessary in doctor-patient communication and psychopharmacological treatment. Main difficulties concern the involvement degree with the specialists (44%) and the time patients need during the consultations (40.4%). Information about local mental health services, supervision and discussion with specialists and continuing medical education are considered useful to improve mental health care.

CONCLUSIONS

As regard their role in mental health care, general practitioners perceive a lack of knowledge and skills. Relationship with specialists and mental health services, daily practice characteristics and time necessary to deal with patients represent barriers detracting from optimal mental health care in general practice.

Increased serum interleukin-8 and interleukin-10 in schizophrenic patients resistant to treatment with neuroleptics and the stimulatory effects of clozapine on serum leukemia inhibitory factor receptor

There is now evidence that schizophrenia may be accompanied by an activation of the monocytic and T-helper-2 (Th-2) arms of cell-mediated immunity (CMI) and by various alterations in the Th-1 arm of CMI. There is also evidence that repeated administration of typical and atypical antipsychotics may result in negative immunomodulatory effects. This study was carried out to examine (1) the serum concentrations of interleukin-8 (IL-8), IL-10, the soluble CD8 (sCD8) and the leukemia inhibitory factor receptor (LIF-R) in nonresponders to treatment with typical neuroleptics as compared with normal volunteers and responders to treatment; and (2) the effects of atypical antipsychotics on the above immune variables. The latter were determined in 17 nonresponders to treatment with neuroleptics and in seven normal volunteers and 14 schizophrenic patients who had a good response to treatment with antipsychotic agents. The nonresponders had repeated measurements of the immune variables before, and 2 and 4 months after treatment with clozapine or risperidone. Serum IL-8 and IL-10 were significantly higher in schizophrenic patients than in normal controls. The serum concentrations of the sCD8 were significantly increased 2 months, but not 4 months, after starting treatment with atypical antipsychotics. Serum LIF-R concentrations were significantly increased 2 and 4 months after starting treatment with atypical antipsychotics. It is concluded that: (1) schizophrenia is characterized by an activation of both pro-inflammatory and anti-inflammatory aspects of cell-mediated immunity; (2) prolonged treatment with atypical antipsychotics may increase the anti-inflammatory capacity of the serum in schizophrenic patients by increasing serum LIF-R concentrations; and (3) short-term treatment with clozapine may induce signs of immune activation which disappear upon prolonged treatment.

Attitude towards psychiatric patients: a pilot study in a northern Italian town

The stigmatisation of the psychiatric patient is still a strong barrier to the integration process of these subjects in our society. Therefore, it is necessary to identify what types of prejudices exist and the types of variables with which they are linked, in order to plan strategies to reduce them. In this exploratory study we administered a semi-structured interview to 303 subjects in order to examine the relationships between social attitudes towards mental disorders and some social demographic variables, the information about mental disorders and the previous 'contacts' with psychiatric patients. The data analysis shows that there is a relationship between knowledge of psychiatric patients and a more positive attitude towards them (i.e., less fear, more integration and work opportunities). This study is to be considered preliminary as far as people's attitudes towards psychiatric patients are concerned. This result encourages the planning and implementation of sensitisation and information programs concerning mental disorders, in the sense that increasing the knowledge of mental disorders could lead to significant achievements in the important fight against the stigma surrounding psychiatric patients.

Haptoglobin polymorphism and schizophrenia: genetic variation on chromosome 16

Recently, it was shown that schizophrenia is accompanied by an activation of the inflammatory response system with signs of an acute phase response, such as increased plasma haptoglobin (Hp) concentrations. Hp is characterized by a molecular variation with three known phenotypes, i.e. Hp 1-1, Hp 2-1 and Hp 2-2. The aim of the present study was to examine Hp phenotypic and genotypic frequencies in schizophrenic patients. Hp phenotyping was carried out in 98 Northwestern Italian schizophrenic patients and the phenotypic and genotypic distributions were compared with the distributions established in the Northwestern Italian population. Plasma Hp concentrations were determined by means of a laser nephelometric method. The allele frequency of the Hp phenotypes in schizophrenia, i.e. Hp 1-1 (9.2%), Hp 2-1 (38.8%) and Hp 2-2 (52.0%), was significantly different from that in the Northwestern Italian population, i.e. Hp 1-1 (17.0%), Hp 2-1 (51.3%) and Hp 2-2 (38.5%). The frequency of the Hp-2 gene was significantly higher in schizophrenic patients (71.7%) as compared with the observed frequency in the Northwestern Italian population (62.5%). The alterations in Hp phenotypic and genotypic distribution were more pronounced in the schizo-affective, disorganized, undifferentiated and residual schizophrenic patients than in paranoid schizophrenic patients. More than a third (35.7%) of the schizophrenic patients showed plasma Hp concentrations which were higher than the upper limits of normality. Schizophrenia is accompanied by an altered distribution of the Hp phenotypes and genotypes, suggesting that genetic variation on chromosome 16 may be associated with schizophrenia.

The cAMP-dependent protein kinase substrate Rap1 in platelets from patients with obsessive compulsive disorder or schizophrenia

Previous studies have reported that the cAMP-dependent protein kinase and one of its substrates, namely Rap1, are altered in patients with affective disorders. Abnormalities in the cAMP-dependent protein kinase have also been reported in platelets of patients with obsessive compulsive disorder and schizophrenia. However, it remains to be determined whether abnormalities in Rap1 are specifically related to affective disorders or may also be present in schizophrenia and obsessive compulsive disorder. Thus, we investigated Rap1 in platelets from 12 drug-free patients with obsessive compulsive disorder, ten drug-free patients with schizophrenia, and 20 healthy subjects. While no difference was observed in the levels of Rap1 between groups, the phosphorylation state of Rap1 was significantly lower in patients with obsessive compulsive disorder than in schizophrenic patients and controls. These data further support the idea that abnormalities of cAMP signalling pathway could be associated, albeit in a somewhat different way, with several psychiatric disorders.

Association between -G308A tumor necrosis factor alpha gene polymorphism and schizophrenia

Dysregulation of the inflammatory response system has been linked to pathophysiology of schizophrenia. Evidence of immune activation has derived from the detection of abnormal levels of proinflammatory cytokines and their receptors in peripheral blood and cerebrospinal fluid from schizophrenic patients. Cytokines are involved in normal CNS development as well as in the pathogenesis of many neuro-psychiatric disorders, acting directly on neural cells or modulating neurotransmitter and neuropeptide systems. In particular tumor necrosis factor alpha (TNFalpha), depending on its concentration, can exert both neurotrophic and neurotoxic effects and influence neural cell growth and proliferation. Moreover, TNFalpha gene is located on the small arm of chromosome 6 (6p21.1-21.3), a locus associated with genetic susceptibility to schizophrenia. We studied the distribution of -G308A TNFalpha gene polymorphism in 84 schizophrenic patients and in 138 healthy volunteers. This biallelic base exchange polymorphism directly affects TNFalpha plasma levels. Frequency of the TNF2(A) allele is significantly increased in schizophrenic patients as compared to controls (P = 0.0042). Genotype distribution is also significantly different (P = 0.0024). TNF2 homozygotes are represented only in the patient group (P = 0.002). These data suggest a potential role of TNFalpha as a candidate gene for susceptibility to schizophrenia and suggest that immune dysregulation in schizophrenic patients could also have a genetic component.

Abnormal levels of cAMP-dependent protein kinase regulatory subunits in platelets from schizophrenic patients

Abnormalities in the cAMP-dependent protein kinase (PKA), a central component of cAMP signaling, have been reported in several psychiatric disorders. Previous studies showed cAMP signaling alterations in schizophrenic patients but less is known about the involvement of PKA in such disorder. Therefore, we investigated the PKA subunits by Western blot analysis in platelets from 12 patients with schizophrenia and 13 controls. The results showed that the immunolabeling of the PKA regulatory subunits type I (RI) and type II (RII) was significantly reduced in patients compared with controls whereas no differences were observed in the catalytic (C) subunit of the enzyme. These preliminary data suggest that schizophrenic patients have altered PKA levels, thus supporting that dysfunctions in the components of cAMP signaling may contribute to the pathophysiology of schizophrenia.

Lower serum vitamin E concentrations in major depression. Another marker of lowered antioxidant defenses in that illness

OBJECTIVE

Major depression is associated with defective antioxidant defenses. Vitamin E is the major fat soluble antioxidant in the body. The aim of the present study is to examine serum vitamin E concentrations in major depressed patients versus normal volunteers.

METHOD

Serum vitamin E concentrations were measured in 26 healthy volunteers and 42 major depressed patients by means of HPLC. Since vitamin E is a fat soluble vitamin, and serum vitamin E concentrations are strongly related to these of low-density-lipoprotein cholesterol (LDL-C) and triglycerides, we have adjusted the results for possible differences in these lipids. The numbers of peripheral blood leukocytes were measured.

RESULTS

Patients with major depression had significantly lower serum vitamin E concentrations than healthy controls. The area under the ROC (receiver operating characteristics) curve was 83%. There were significant and negative correlations between serum vitamin E and number of total leukocytes and neutrophils.

CONCLUSIONS

Major depression is accompanied by significantly lower serum vitamin E concentrations, suggesting lower antioxidant defenses against lipid peroxidation. The results could, in part, explain previous findings, which suggest increased lipid peroxidation in major depression.

Effects of atypical antipsychotics on the inflammatory response system in schizophrenic patients resistant to treatment with typical neuroleptics

There is now some evidence that schizophrenia may be accompanied by an activation of the inflammatory response system (IRS) and that typical antipsychotics may suppress some signs of IRS activation in that illness. This study was carried out to examine (i) the serum concentrations of interleukin-6 (IL-6), IL-6 receptor (IL-6R), IL-1R antagonist (IL-1RA) and Clara Cell protein (CC16), an endogenous anticytokine, in nonresponders to treatment with typical neuroleptics and (ii) the effects of atypical antipsychotics on the above IRS variables. The above parameters were determined in 17 patients with treatment-resistant schizophrenia (TRS) to treatment with neuroleptics and in seven normal volunteers and 14 schizophrenic patients who had a good response to treatment with antipsychotic agents. Patients with TRS had repeated measurements of the IRS variables before and 2 and 4 months after treatment with atypical antipsychotics. Serum IL-6 was significantly higher in schizophrenic patients, irrespective of their response to typical antipsychotics, than in normal controls. Serum IL-1RA was significantly higher in the TRS patients than in controls, whereas responders took up an intermediate position. The serum concentrations of CC16 were significantly lower after treatment with atypical antipsychotics during 4 months than before treatment. It is concluded that (i) schizophrenia and, in particular, TRS is characterized by an activation of the monocytic arm of cell-mediated immunity and (ii) atypical antipsychotics may decrease the anti-inflammatory capacity of the serum in TRS patients.

Venlafaxine in social phobia: a study in selective serotonin reuptake inhibitor non-responders

The study aimed to evaluate the clinical response to venlafaxine in social phobia in 12 patients who were non-responders to selective serotonin reuptake inhibitors, and to assess how the response could be influenced by the comorbidity in Axis II with avoidant personality disorder (APD). The duration of the study was of 15 weeks using open flexible doses regimen in individuals with or without concomitant APD. The venlafaxine dose ranged from 112.5 mg/day to 187.5 mg/day. Venlafaxine improves social phobia and/or APD symptomatology, as demonstrated by decreasing Liebowitz Social Anxiety Scale total scores (P < 0.05). In fact, venlafaxine significantly reduced the avoidant behaviour and specific sociophobic aspects, while notably improving the depression dimension and the basic anxiety symptoms. With regard to tolerability, the profile of venlafaxine was satisfactory with the main side-effects being nausea, headache and anxiety.

In vitro immunoregulatory effects of lithium in healthy volunteers

RATIONALE

There is now some evidence that major depression is associated with activation of the inflammatory response system (IRS). Lithium is effective in the treatment and prophylaxis of major depression and shows significant immunoregulatory functions.

OBJECTIVE

The aims of the present study were to examine the in vitro effects of lithium on the unstimulated and lipolysaccharide (LPS) + phytohemagglutinin (PHA)-induced production of proinflammatory cytokines, such as interleukin-6 (IL-6), IL-8, tumor necrosis factor-alpha (TNFalpha) and interferon-gamma (IFNgamma), and negative immunoregulatory cytokines or proteins, such as IL-10 and the IL-1 receptor antagonist (IL-1RA).

METHODS

The in vitro effects of lithium carbonate at low (10(-4) M and 10(-5) M) and therapeutic (10(-3) M) concentrations on the above cytokines and the IL-1RA were examined in nine healthy volunteers on whole blood supernatant cultured for 72 h.

RESULTS

Lithium (10(-3) M) in the presence of LPS+PHA significantly increased the stimulated production of IFNgamma, IL-8, TNFalpha, IL-1RA and IL-10. Lithium (10(-3) M) significantly increased the unstimulated production of IL-8 and IL-10.

CONCLUSIONS

The results suggest that lithium has significant immunoregulatory effects by increasing the production of both proinflammatory cytokines (IFNgamma, TNFalpha and IL-8) and negative immunoregulatory cytokines or proteins (IL-10 and the IL-1RA).

Seasonal and circadian rhythms in suicide in Cagliari, Italy

BACKGROUND

In previous studies of the seasonality of suicide, peaks have often been found in the number of suicides in the spring and early summer in both northern and southern hemispheres. The purpose of the present study was to investigate the distribution of suicide as to month, seasons, day of the week, and time of the day.

METHOD

Data on suicides in Cagliari (Italy) in the period 1990-1994 were analyzed by means of spectral analysis, cosinor and multiple regression analysis.

RESULTS

Two seasonal rhythms, i.e. an annual and a semiannual rhythm, accounted for 25% of the variation in the total number of suicides. The peak number of suicides occurred in February with a second less significant peak in June and July. Lows were found in November and December. There were no significant differences in number of suicides in relation to days of the week. Three rhythms, i.e. 24 hours (circadian), 8 hours and 1 hour, explained 63.9% of the variance in the number of suicides by time of the day. Peak numbers in number of suicides were found between 08:31 and 12:30h, while the number of suicides was also significantly higher between 12:31h and 20:30h than between 20.31h and 8.30h. Age and gender did not significantly affect the seasonal and circadian rhythms in suicide.

CONCLUSIONS

The results show that there is a significantly seasonal variation and a highly significant variation by time of the day in suicide in Cagliari, Italy.

Higher serum prolyl endopeptidase activity in patients with post-traumatic stress disorder

BACKGROUND

It is reported that psychiatric disorders, such as depression and schizophrenia, are associated with changes in serum activity of prolyl endopeptidase (EC 3.4.21.26), a cytosolic endopeptidase, which cleaves peptide bonds on the carboxylside of proline in proteins of relatively small molecular mass.

AIMS AND METHODS

The aims of the present study were to examine serum PEP activity in patients with post-traumatic stress disorder (PTSD) versus healthy volunteers. PEP activity has been determined by a fluorimetric assay.

RESULTS

Serum PEP activity was significantly higher in patients with PTSD than in normal volunteers. Serum PEP activity was significantly higher in patients with PTSD and concurrent major depression than in patients with PTSD without major depression. In PTSD patients, there were no significant correlations between serum PEP activity and severity of PTSD symptoms.

CONCLUSIONS

The results show that PTSD and, in particular, PTSD with concurrent major depression is associated with increased activity of PEP.

RELEVANCE

these results may be of importance for the (i) neuroendocrine pathophysiology of PTSD since PEP degrades neuropeptides, such as arginine vasopressin (AVP) and thyrotropin releasing hormone (TRH); and (ii) etiology of PTSD, since PEP degrades behaviorally active neuropeptides, such as AVP, TRH, oxytocin, neurotensin and substance P, which play a key role in positive reinforcement, social interactions, emotions and stress responsivity.

Depressive symptomatology during clozapine treatment: two case reports

We report the cases of two patients fulfilling DSM-IV criteria for schizophrenia, who developed a marked depressive symptomatology in the first period of a treatment with clozapine, and were treated successfully with serotonergic drugs (paroxetine, clomipramine). The AA. discuss the possible neurochemical determinants and implications of these clinical observations.

The inflammatory response system in treatment-resistant schizophrenia: increased serum interleukin-6

There is some evidence that the pathophysiology of schizophrenia is related to activation of the inflammatory response system (IRS), as indicated by increased serum concentrations of interleukin-6 (IL-6), IL-6 receptor (IL-6R), IL-1R antagonist (IL-1RA) and IL-2R and lower serum concentrations of CC16, an endogenous anti-inflammatory protein with immunosuppressive and anti-inflammatory effects. The aims of the present study were to examine serum CC16 in relation to IL-6, IL-6R and gp130, the IL-6 transducing signal protein, in schizophrenia and in treatment-resistant schizophrenia (TRS). Serum IL-6 and sIL-6R were significantly higher in medicated schizophrenic patients than in normal controls. Serum IL-6 was significantly higher in TRS than in normal volunteers, whereas schizophrenic patients without TRS showed intermediate values. Serum CC16 was significantly lower in schizophrenic patients with a positive family history for psychoses than in normal volunteers and patients without a positive family history. There was a significant inverse relationship between serum CC16 and serum IL-6 or sIL-6R in schizophrenic patients, but not in normal volunteers. The results suggest that the inflammatory response in schizophrenia, as indicated by increased serum IL-6 and sIL-6R, may be causally related to lower serum CC16 and that the latter might be a trait marker for schizophrenia.

Recent Outbreak of Stem Canker (Diaporthe phaseolorum var. meridionalis) of Soybean in Santa Fe, Argentina

This disease was first noted in the area in February 1993 (2), when a soybean (Glycine max (L.) Merr.) disease survey was conducted in several localities of southern Santa Fe province, the core soybean region of Argentina. At that time, its incidence ranged from 5 to 8% in isolated fields. However, in March 1997, stem canker reached a dramatic 70 to 100% incidence, probably helped by the extensive use of susceptible cultivars, favorable climatic conditions, and inoculum availability from no-till fields. Observed symptoms on stems consisted of V-shaped longitudinal lesions at petiole insertion, with reddish brown margins and discolored centers, where the pycnidia of the anamorph Phomopsis phaseoli (Desmaz.) Sacc. meridionalis Morgan-Jones were found. The lesions coalesced and consequently the main stem and branches died. Foliage symptoms started as yellow blotches, later developing into interveinal chlorosis and necrosis. Perithecia of the teleomorph Diaporthe phaseolorum (Cooke & Ellis) Sacc. var. meridionalis F. A. Fernandez (1) were obtained from infected stems in several crop seasons. Once ripe, the ascospores were cultured on potato dextrose agar (PDA) acidified with lactic acid (0.2%), amended with streptomycin (100 mg/liter), and maintained in darkness at 20 to 25°C. Yellowish white colonies were obtained, later becoming tan and developing perithecia. Perithecia had a beak length of 868 ± 183 μm, neck width of 126.2 ± 17 μm, the asci of 36.7 ± 4.7 μm length and bicellular biguttulate ascospores of 10.2 ± 1 μm length and 3 ± 0.13 μm width. All features match the available descriptions of the pathogen (1). Pathogenicity trials were performed on seedlings of resistant and susceptible cultivars up to second trifoliar leaf stage; these cultivars were classified according to inoculations and field behavior. Plants were wounded with a scalpel in the cotyledonary node and inoculated with a 3-mm-diameter PDA mycelial plug, covered with vaseline. Control seedlings were either not wounded or similarly wounded and covered with vaseline but no PDA plugs were applied. Symptom development was observed within 4 days from inoculation in the top leaf, and in 7 days most seedlings of susceptible cultivars were dead. Resistant cultivars survived and showed only reddish discoloration in wounds. The control seedlings were symptomless and the pathogen was not isolated from them. Conversely, inoculated seedlings with visible symptoms consistently yielded D. phaseolorum var. meridionalis from stem sections at different distances from the inoculation point.When cultured on water agar, alpha conidia from pycnidia and ascospores from the perithecia were obtained. References: (1) F. A. Fernandez and R. T. Hanlin. Mycologia 88:425, 1996. (2) R. N. Pioli et al. Comun. Biol. 11:156, 1993.