M Clerici

Depression after Stroke and Risk of Mortality: A Systematic Review and Meta-Analysis

Background. Depression after stroke may have great burden on the likelihood of functional recovery and long-term outcomes. Objective. To estimate the association between depression after stroke and subsequent mortality. Methods. A systematic search of articles using PubMed and Web of Science databases was performed. Odds ratios (ORs) and hazard ratios (HRs) were used as association measures for pooled analyses, based on random-effects models. Results. Thirteen studies, involving 59,598 subjects suffering from stroke (6,052 with and 53,546 without depression), had data suitable for meta-analysis. The pooled OR for mortality at followup in people suffering from depression after stroke was 1.22 (1.02–1.47). Subgroups analyses highlighted that only studies with medium-term followup (2–5 years) showed a statistically significant association between depression and risk of death. Four studies had data suitable for further analysis of pooled HR. The meta-analysis revealed a HR for mortality of 1.52 (1.02–2.26) among people with depression after stroke. Conclusions. Despite some limitations, this paper confirms the potential role of depression on post stroke mortality. The relationship between depression and mortality after stroke seems to be related to the followup duration. Further research is needed to clarify the nature of the association between depression after stroke and mortality.

Alexithymia and obesity. Study of the impaired symbolic function by the Rorschach test.

Many authors consider alexithymia a predisposing factor to psychosomatic and somatopsychic pathologies. In this study we investigated the presence of alexithymic characteristics in a group of 106 massive obese patients who requested a surgical intervention. 6 Rorschach alexithymia variables in the protocols of patients and a non-patient reference group (n = 600) were studied. Findings supported the presence of a striking alexithymic element among severely obese patients in comparison with their lean counterparts.

Pregabalin for alcohol dependence: a critical review of the literature

IntroductionAlcohol dependence represents a severe pathological disorder associated with a significant rate of morbidity and mortality. To date, limited pharmacological agents exist to treat this disorder, and there is a growing interest for new therapies. In this context, pregabalin represents a promising strategy. Pregabalin, like gabapentin, selectively binds to the α2δsubunit of voltage-gated calcium channels, inhibiting release of excessive levels of excitatory neurotransmitters. The main focus of this review is the clinical use of pregabalin in alcoholic patients, but the authors also reported some data about chemistry, pharmacology, and pharmacokinetics of this drug.MethodsThe authors conducted a PubMed search of clinical human studies published in English from January 2000 to August 2012 using the following search terms: pregabalin alcohol dependence, pregabalin alcohol withdrawal, pregabalin alcoholism.ResultsThe search revealed a total of five studies: two trials for the treatment of alcohol relapse and three articles for the management of alcohol withdrawal syndrome with pregabalin. The critical review of the literature suggests that pregabalin could be a novel and effective treatment option for the management of alcohol relapse in detoxified patients, whereas until now there have been mixed results for the treatment of alcohol withdrawal syndrome. In particular, pregabalin showed a greater beneficial effect on patients with comorbid conditions such as alcoholism and generalized anxiety disorders. The exact mechanism of action of pregabalin in the management of alcoholism is not well understood but it is thought to be due mainly to the modulation of neurotransmitters such as glutamate and norepinephrine by inhibiting activity-dependent calcium influx in nerve terminals.ConclusionPregabalin, within a dosage of 150–450 mg/day, showed beneficial effects for alcohol relapse prevention and contrasting results for the treatment of the withdrawal syndrome. Its use appears to be safe and well tolerated.

Body-image distortion in anorexia nervosa

In their recent Primer (Anorexia nervosa. Nat. Rev. Dis. Primers 1, 15074 (2015))1, Janet Treasure and colleagues give an impor‐ tant update on the advances made in the aetio logy, assessment, prevention and treat‐ ment of anorexia nervosa (AN). The authors also highlight the need for better, faster and lasting improvements in the management of this ‘enigmatic’ disorder, which crucially depends on improved understanding of speci fic disease mechanisms. However, in their description, they do not include the consistent evidence that disturbed body image does not only motivate severe dietary restriction and other weight loss behaviours but also plays a central part in the initiation, persistence and relapse of AN2–8. The Primer1 states that the under lying mechanism of the so‐called body‐image distortion (BID), in which emaciated individ uals perceive them‐ selves as fat9, remains obscure. Yet, there is widespread agreement that this evidence — at both the conceptual and the empirical levels — is imperative for elucidating what is behind severe and intense BID2–10. Findings from an increasing number of functional MRI (fMRI) studies, conducted (based on the symptom provocation para‐ digm) over the past 15 years and recently reviewed by one of us7, provide valuable insights into the neural basis of BID in AN. Unfortunately, we felt that these issues were not entirely addressed by the Primer1, making it difficult to understand the ‘reasonably consistent’ (REF. 7) evidence produced by this research3. The review7 summarized that the ‘affective’ component of BID in AN is related to alterations of the prefrontal cortex, the insula and the amygdala and that the ‘per‐ ceptive’ component of BID is related to alter‐ ations of the parietal lobes (which have roles in spatial and body representations4–7,10, body ownership9–12 and other features requiring multisensory integration4–7,11–14) or, more accu‐ rately, the posterior parietal regions (which are involved in visuospatial processing4–7,10,15). A deficit in parietal cortex‐mediated func‐ tions in AN is also underscored by findings from neurocognitive studies4–6. Although both extant neuroimaging and behavioural data2,4,7,8 suggest that two components of body image (the estimation of one’s own body size and the attitude towards one’s own body in terms of an emotional evaluation) are disturbed in individ uals with AN, these aspects might have been described in more detail in the Primer1. In fact, although two (widely accepted) body‐ image components can be distinguished, this does not imply that they are independent4,5,15. Indeed, experimental evidence supports a direct (unidirectional) link between how we perceive and how we feel about our body12. The aforementioned specific neural bases of the affective component of BID in AN also sup‐ port an altered emotional response to unpleas‐ ant (for example, self‐distorted fat image) stimuli7. Furthermore, in the few available fMRI studies based on a word paradigm (that is, tasks using ‘fat’, ‘thin’ and ‘neutral’ words), a variation in amygdala response was absent — making the involvement of this brain region less clear but suggesting the greater rele vance of self‐perception and the mechanism of body‐ image construction5,6,9 (see below). There is the need to take into account these (and other convergent4,5,12,13) clues and the considerable room for improvement that remains from the first‐line prevention and psychotherapeutic interventions2,3,5,8,10,12,13, currently described in the Primer1 (for example, the Body Project and enhanced cognitive–behavioural ther‐ apy), and targeting the ‘affective’ body‐image component2,5,10,12,13. Thus, we would suggest that it is now time to consider the develop‐ ment of intervention strategies that target the perceptive component. Cognitive neuroscientific strides in the field of body self‐consciousness (that is, the experience of being in a body process5, with body ownership being its fundamental con‐ stituent5,11) offer a novel perspective for, if not a paradigm shift in, understanding the mech‐ anism of body‐image construction5,6,10,11,13,15 — only inferred by the already mentioned experimental paradigms used to explore the neural basis of BID in AN4,7. Fundamentally, our spatial experience, including the bodily one, is organized around two different refer‐ ence frames: egocentric, which has its primary source in ‘online’ representations (referring to the temporal flow of information that constructs how our body is right now), and allocentric, which has its primary source in ‘offline’ representations (referring to what our body is normally like)5,6,10,13,15. That is, people use both the memory of how the body, includ‐ ing its shape and size, is believed (or remem‐ bered) to be (offline) and the perception of the body ‘here and now’ (online) to construct their body image5,6. The conceptual distinction between online and offline representations should not imply that these representations of the body are unconnected, as they can and do interact, with the online information about the body being continuously integrating with and compared to the offline model of the body in the brain5,6,10,13,15. Neuroscientifically informed models highlight how a similar process of amending and updating offline representa‐ tions based on new online representations might underline the complex relationship between body image, dietary restriction and weight loss5. From this perspective, individuals who lose large amounts of weight might adapt their offline model of the body accordingly, as the new online information is received and updates the oldest stored model of the body5. Accordingly, an impediment in the transaction between online and offline information might be at play in patients with AN who have a per‐ sistent experience of being fat, even when they are objectively emaciated5. In support, sophis‐ ticated contemporary research10 has shown that individuals with AN in the earliest stages are ‘locked’ in a virtual ‘wrong’ body that they detest, which differs from the real one. Despite the importance of these10 (and additional5,13,14) findings and the known role of brain abnormalities in the (posterior pari‐ etal) areas involved in the block of the online– offline transformation process5,6,11,15, further research is needed to investigate additional factors (for example, stress) involved in the impaired ability of updating5,10, which were previously linked to food intake reduction in AN10. Some additional hypotheses have been proposed based on research on neuropsycho‐ logical functioning1,4,6,10 in patients with AN but they require specific testing. For example, some evidence suggests that people with AN not only focus on details (weak central coher‐ ence) but they also seem to have an attentional bias towards negatively charged details6. This feature has been suggested to affect both the perception of the body and how it is remem‐ bered6. Another hypothesis states that weak set shifting (that is, reduced mental flexibility as indicated by the ability to move back and forth between tasks) and poor visuospatial memory could affect the ability to adapt offline body representation based on new information and form a correct visual representation of the body, respectively6,10,14. C O R R E S P O N D E N C E

Predictors of initiation and persistence of recurrent binge eating and inappropriate weight compensatory behaviors in college men

OBJECTIVE The transition to college is considered as a risk period for the development of behavioral symptoms of eating disorders (BSEDs) and some evidence suggests that, amongst men, these symptoms occurring on a regular basis remain relatively stable over the college period. Nevertheless, little is known about factors associated with persistent engagement in and initiation of recurrent (or regular) binge eating and inappropriate weight compensatory behaviors in this population. The objective of this report was to address these research gaps. METHOD Data were examined from 2,555 male first-year college students who completed an assessment of potential vulnerability factors and BSEDs at the beginning of the autumn semester (baseline) and nine months later (end of the spring semester; follow-up). RESULTS Elevated negative affectivity, body dissatisfaction, self-objectification, and lower self-esteem at baseline were predictive of persistent engagement in regular binge eating and four compensatory behaviors (self-induced vomiting, laxative/diuretic abuse, fasting, exercise) at follow-up, as well as initiation of all these behaviors occurring regularly (i.e., at least weekly for 3 months). Self-objectification (thinking and monitoring the bodys outward appearance from a third-person perspective) emerged as the largest contributor of both the initiation and persistence of all behavioral symptoms. DISCUSSION Data emphasize that the same psychological factors underlie initiation and persistence of recurrent BSEDs and should shape the focus of future interventions for college men.

Dual Diagnosis—Policy and Practice in Italy

In Italy, dual diagnosis issues are affected by distinctive historical pathways. Since the end of the 1970s, the addiction field has been starved of psychiatric contribution, with the emphasis being on a pedagogical model of substance-related disorders and a bio-psycho-social model for mental health. As such, dual diagnosis treatment, service models, and research have only been developed in the last fifteen years. Substantial training needs with regard to dual diagnosis are identified in addiction and mental health professionals, and new graduate and undergraduate programs are required. Further research is needed as well as an evidence-based health policy from national and regional government.

Substance abuse and psychopathology. A diagnostic screening of Italian narcotic addicts

SummaryThis report evaluates, using DSM III, the psychopathological profile of 226 heroin users taken in at the clinical centre of “Cascina Verde” Therapeutic Community (Milan, Italy) and admitted to a psychotherapeutic, retraining, integrated, both out-and-in-patient treatment. The outcome shows that 30% of subjects are to be diagnosed according to Axis I while 61% are to be considered among Axis II personality disorders. A portion of 16% is to be referred to the “schizophrenic spectrum”, 25% has histrionic, narcissistic, antisocial and borderline personality disorders and the remaining are to be referred to an extremely heterogeneous category. The report shows also data concerning Axes IV and V, always according DSM III.

The Efficacy of an Information Group Intervention On Relatives of Schizophrenics

Socio-therapy of schizophrenia cannot fail to consider such an important element as assistance to relatives. This report will review the main treatment methods used today and presents an intervention model which acts on the family of the schizophrenic at different levels. While the schizophrenic patient receives an individual treatment (pharmacological and psychotherapeutic), his/her relatives undergo a two-step group intervention. The first phase concerns an information group. This paper gives an early assessment as to the efficacy of the information groups for relatives. Particularly, it focuses on the actual ability of the group in conveying information to relatives. Such transfer of information is measured by means of a structured interview (Knowledge Interview). Results demonstrate that after an information group family members had a significant statistical increase of their information level (p<0.001). Some areas recorded a considerable increase in the knowledge levels, as far as the legitimacy of the illness and the management of symptoms are concerned.

Classifying Adults with Binge Eating Disorder Based on Severity Levels

The clinical utility of the severity criterion for binge eating disorder (BED), introduced in the DSM-5 as a means of addressing heterogeneity and variability in the severity of this disorder, was evaluated in 189 treatment-seeking adults with (DSM-5) BED. Participants classified with mild, moderate, severe and extreme severity of BED, based on their weekly frequency of binge eating episodes, differed significantly from each other in body mass index (BMI), eating disorder features, putative factors involved in the maintenance process of the disorder, comorbid mood, anxiety and personality disorders, psychological distress, social maladjustment and illness-specific functional impairment (medium-to-large effect sizes). They were also statistically distinguishable in metabolic syndrome prevalence, even after adjusting for BMI (large effect size), suggesting the possibility of non-BMI-mediated mechanisms. The implications of the findings, providing support for the utility of the binge frequency as a severity criterion for BED, and directions for future research are outlined. Copyright

And how shall we deal with adaptation and implementation of NICE schizophrenia guidelines in Italy

During the 1990s Evidence-Based Medicine emphasized the need to promote evidence-based practice, leading to a rise of practice guidelines throughout medicine (Audet et al., 1990; Lomas, 1991), and expanding the systematic use of scientific evidence in clinical decisionmaking (Guyatt & Rennie, 2002). Though administrators, clinicians, advocates and researchers generally agree that they should provide the most effective mental health treatments, implementing evidence-based practices in standard settings is not straightforward (Drake et al., 2003). Indeed, there is some evidence to suggest that organisational culture may be a relevant factor in health care performance, still articulating the nature of that relationship proves tricky. Current policy prescriptions, which seek service improvements through organisational transformation, are in need of a more secure evidential base (Scott et al., 2003). Evidence-Based Medicine currently enjoys a good reputation in Italy (Ballini & Liberati, 2004), but the complexity and potential utility of information now available for guiding policy and practice decisions make vital methods for synthesis, adaptation and implementation of research information (Anderson et al., 2005). However, simply publishing and distributing clinical guidelines – formulated to help to translate the scientific evidence literature into concise statements (Rogers, 1995) – is not enough to change the practice of clinicians (Cabana et al., 1999). The mental health field is no exception (Hickie & Blashki, 2006) – practice guidelines being perceived as externally imposed and cost-containment tools rather than as decision-supporting tools (Grilli et al., 1996; Formoso et al., 2001). The NICE-Schizophrenia Guidelines (SG) (National Collaborating Centre For Mental Health, 2003) were translated into Italian at a significant time as concerns upcoming review of National mental health care models (Carrà et al., 2004). NHS mental health services in England and in Italy, share indeed principles – e.g. providing a universal and comprehensive service with equal access for all, free at the point of use, based on clinical need, not ability to pay – but also weaknesses such as difficulties in translating the best research evidence available to implementable clinical practice recommendations (Carrà et al., 2004; Kendall et al., 2004; 2005). In a word, translating good guidelines does not ensure their use in practice in Italian mental health services. Therefore, to maximise the likelihood of NICE-SG being used we need somewhat coherent dissemination and implementation strategies to capitalise on known positive factors and to deal with obstacles to implementation that have to be identified (Feder et al., 1999; Grol et al., 2005). G. Carrà et al.