Cesario Bellantuono

Psychiatric screening in general practice in Italy

SummaryNinety consecutive patients aged 14 and above attending a general practice in Verona completed the 30-item General Health Questionnaire (GHQ), were assessed by the general practitioner for the presence of psychiatric disturbances on a 5 point scale, and interviewed by a psychiatrist using the Clinical Interview Schedule (CIS). The Italian versions of both the GHQ and the CIS were confirmed as feasible instruments for general practice studies in Italy. Taking the Overall Severity Rating made by the psychiatrist (Psy-OSR) at the end of the CIS as the criterion, the best CIS threshold in discriminating between “cases” and “non cases” was 12/13, while the GHQ cut off point of 5/6 gave the best results in terms of balance between sensitivity (81%) and specificity (71%). According to this cutting score, 47.8% of patients were high scorers. The corresponding figures of sensitivity and specificity for a GHQ cut off 4/5 were 89% and 65%. A comparison of the performance of the GHQ-30, GHQ-12 and C-GHQ (Goodchild and Duncan-Jones method of scoring), obtained in the usual way, as well as using ROC analysis showed that the C-GHQ gave the best overall results, but the difference was not significant. Using the Psy-OSR ≥2 or the CIS Total Weighted Score ≥13 as indicators, the prevalence of “true” cases in this sample was 35.5% and 38.8% respectively, a rate lower than that reported by Fontanesi et al. (1985) in another general practice study in Italy.

Recognition of depression and appropriateness of antidepressant treatment in Italian primary care.

Abstract.Background:A significant proportion of primary care patients are affected by a depressive disorder and about half of these patients are undetected and undertreated.Methods:Twenty-five primary care physicians (PCPs) were recruited in five Italian centres. All consecutive patients who attended the PCPs’ clinics in a 2-week period completed the Personal Health Questionnaire (PHQ), and those scoring more than nine on the PHQ were interviewed with the Hamilton Rating Scale for Depression—17 items (HDRS-17). The appropriateness of antidepressant drug treatment was assessed according to the decision to treat, the coverage, the type of drug and the dosage prescribed.Results:The adjusted prevalence for ICD-10 depression in 2093 patients was 18.7%, while the conspicuous morbidity was 10.7%. The ability of PCPs to detect a depression increased proportionally with HDRS scores. The coverage, i. e. the proportion of patients who would benefit from an antidepressant (AD) and who actually received such drugs, was 20.9%. The drugs most frequently prescribed were SSRI (36 %), followed by TCA (21%) and by other AD. Most SSRI were prescribed at therapeutic dosage, while two-thirds of TCA were at sub-therapeutic dosage. About 37% of patients started a non-pharmacological treatment. The severity of depression at the first consultation predicted the persistence of a depressive state in the longer term.Conclusions:The ability of Italian PCPs to detect depression is satisfactory when the patient’s depressive state is moderate or severe. The appropriateness of antidepressant drug treatment still needs to be improved.

SSRIs during breastfeeding: spotlight on milk-to-plasma ratio

SummaryObjective: To investigate the usefulness of the milk-to-plasma (M/P) ratio for assessing the risks for the breastfed infant associated with the maternal use of SSRIs.Data sources: Medline, Toxnet, Embase, Current Contents, and PsycInfo indexed articles from 1980 to September 2006.Study selection and data extraction: All studies reporting the M/P ratio in mothers taking SSRIs while breastfeeding or studies which such an information could be calculated from data reported in the article.Data synthesis: Higher M/P ratios were rarely associated with a clinically significant impact on the babies during the early phases of breastfeeding.Conclusions: So far no evidence-based information seems to support the hypothesis that SSRIs characterized by a M/P ratio <1.0 should be preferred. Hence, physicians should consider different parameters when attempting to choose the safest SSRI for the breastfeeding woman. These parameters might be represented by the number of well-documented published adverse event reports and the tendency of each SSRI of inducing in the infants serum concentrations that are elevated above 10% of average maternal serum levels. In any case, if the mother wishes to breastfeed her infant while taking a SSRI, the baby should be closely monitored in order to promptly detect any iatrogenic event.

Psychiatric morbidity in an Italian general practice.

A two-stage screening strategy was applied in a single-handed general practice in northern Italy. The study was designed so that all the second-stage psychiatric interviews were conducted during the first phase of the study (group A patients), while self-report questionnaire (GHQ) and GP assessments only were collected during the second phase (group B patients). The estimated true case rate of psychiatric disorder (36%) did not differ between the two phases of the study, but there were marked differences in the general practitioners diagnostic behaviour. During the first phase (when psychiatric interviews were being conducted in the practice), her behaviour was heavily biased towards diagnosing psychiatric disorder; 61% of the patients were regarded by her as psychiatric cases and the hidden psychiatric morbidity rate was only 9%. During the second phase of the study (no psychiatric interviews in the practice), only 37% of the patients were regarded as psychiatric cases by the GP, and the hidden morbidity rate was 59%. The results are interpreted as demonstrating that the presence of a psychiatrist conducting a two-stage screening survey in the practice had a profound effect on the diagnostic threshold. They also provide support for the use of the GHQ as a case-finding instrument in general practice.

Self-reported use of psychotropic drugs and alcohol abuse in South-Verona

The data for this cross-sectional survey were obtained from a stratified probability sample of 510 residents in South-Verona during the period May-June 1980. The two-week prevalence of psychotropic drug consumption was found to be 13%. The prevalence was higher in women (18%) than in men (9%). The most commonly consumed category of psychotropic drugs were the benzodiazepines, which accounted for 70% of all the psychotropic drugs consumed by women and 85% of those consumed by men. Using a logistic analysis, a strong association between drug consumption and minor psychiatric morbidity, as indicated by the GHQ scores, was found for both sexes, a finding not significantly different from that found in the West London study by Murray et al. (1981). Alcohol abuse in men was less prevalent in the youngest age-group. Thirty-three (19%) of the male GHQ low scorers were alcohol abusers, compared with 12 (40%) of the high scorers. No significant association was found between psychotropic drug consumption and alcohol abuse in men.

Converging evidence for the association of functional genetic variation in the serotonin receptor 2a gene with prefrontal function and olanzapine treatment.

IMPORTANCE Serotonin (5-hydroxytryptamine) receptor 2a (5-HT2AR) signaling is important for modulation of corticostriatal pathways and prefrontal activity during cognition. Furthermore, newer antipsychotic drugs target 5-HT2AR. A single-nucleotide polymorphism in the 5-HT2AR gene (HTR2A rs6314, C>T; OMIM 182135) has been weakly associated with differential 5-HT2AR signaling and with physiologic as well as behavioral effects. OBJECTIVE To use a hierarchical approach to determine the functional effects of this single-nucleotide polymorphism on 5-HT2AR messenger RNA and protein expression, on prefrontal phenotypes linked with genetic risk for schizophrenia, and on treatment with olanzapine. DESIGN In silico predictions, in vitro, and case-control investigations. SETTING Academic and clinical facilities. PARTICIPANTS The postmortem study included 112 brains from healthy individuals; the in vivo investigation included a total sample of 371 healthy individuals and patients with schizophrenia. EXPOSURES Patients received olanzapine monotherapy for 8 weeks. MAIN OUTCOMES AND MEASURES In silico predictions, messenger RNA, and protein expression in postmortem human prefrontal cortex and HeLa cells, functional magnetic resonance imaging prefrontal activity and behavior during working memory and attention in healthy individuals, and response to an 8-week trial of olanzapine treatment in patients with schizophrenia. RESULTS Bioinformatic analysis predicted that rs6314 alters patterns of splicing, with possible effects on HTR2A expression. Moreover, the T allele was associated with reduced prefrontal messenger RNA expression in postmortem prefrontal cortex, with reduced protein expression in vitro, inefficient prefrontal blood oxygen level-dependent functional magnetic resonance imaging response during working memory and attentional control processing, and impaired working memory and attention behavior, as well as with attenuated improvement in negative symptoms after olanzapine treatment. CONCLUSIONS AND RELEVANCE Our results suggest that HTR2A rs6314 affects 5-HT2AR expression and functionally contributes to genetic modulation of known endophenotypes of schizophrenia-like higher-level cognitive behaviors and related prefrontal activity, as well as response to treatment with olanzapine.

Efficacy and safety of novel antipsychotics: a critical review.

Efficacy and safety of novel antipsychotic (AP) drugs (amisulpride, olanzapine, quetiapine, ziprasidone and zotepine) have been reviewed. Data on their antipsychotic efficacy and side effects profile have been evaluated only on the basis of controlled trials so far published. Overall, all these drugs have shown an antipsychotic efficacy on positive symptoms of schizophrenia similar to that of the conventional AP drugs. On negative symptoms, all novel AP drugs, except quetiapine and ziprasidone, demonstrated a better efficacy than haloperidol. Long‐term efficacy of these AP drugs in the maintenance treatment of schizophrenia needs to be explored by further, better‐designed, epidemiological studies. The safety profile shows that the novel AP drugs are generally well‐tolerated and induce significantly less acute extrapyramidal side effects in comparison with haloperidol. Some methodological flaws in the experimental design of the clinical trials analysed are discussed. Although these novel AP drugs have potential clinical advantages, a number of relevant questions still remain to be addressed, in order to establish the impact of these drugs in the overall treatment of schizophrenia. Copyright

Urban-rural differences in psychotropic drug prescribing in Northern Italy

SummaryUrban-rural differences in psychotropic drug prescribing were examined by comparing data from general practices in two contrasting areas of northern Italy. Patients attending the urban doctors were 1.5 times more likely to be prescribed a psychotropic drug than their rural counterparts. We also explored urban-rural differences in factors influencing psychotropic prescribing. Such influences were more numerous and complex in the urban than the rural setting.

Psychotropic drug use in Italy: national trends and regional differences

Psychotropic drug sales data for Italy were examined for the years 1975-84. The principal findings were of more-or-less consistent annual increases in sales of antidepressants, minor tranquillizers and, to a lesser extent, of neuroleptics. These trends are interpreted in the context of the characteristics of the Italian National Health Service (NHS), and in relation to findings from psychotropic drug utilization studies in other Western countries. Regional differences in psychotropic drug sales for 1983/4 were also examined. Marked differences were found and, in general, levels of use were higher in North/Central Italy than in the South. Factors influencing regional differences were explored using regression analysis. Regional NHS expenditure (excluding that on drugs) was found to influence strongly the sales of all categories of psychotropic drug, whereas there was also a marked urban greater than rural difference in the sales of tranquillizers.

The management of affective disorders in the community

Using two systems which routinely record information about the management of psychiatric disorders in the community (a drug prescription monitoring system and a psychiatric case register), a parallel study was conducted in South Verona on antidepressant prescriptions written by general practitioners (GPs) and on contacts for affective disorders with specialized psychiatric services, in 1983 and 1984. The extent of patient contact for affective disorders was approximately ten times greater at the GP level (in one year about 150 antidepressant prescriptions per 1000 adult inhabitants) than at the out-patient/community psychiatric service level. Similarly, the extent of patient contact at the latter level was approximately ten times greater than at the in-patient level. Patients with a diagnosis of affective disorder accounted for about 20% of the total number of patients contacting the specialized services in one year. The proportions of patients admitted to hospital, among those in contact with these services and assigned a diagnosis of depressive neurosis or a diagnosis of affective psychosis, were 34 and 33% (in 1983 and 1984) and 49 and 50% (in 1983 and 1984), respectively. There was a clear correspondence between monthly fluctuations in the extent of care for affective disorders provided at the two levels in 1984, but not in 1983.