Maria Caredda

Aripiprazole augmentation in patients with resistant obsessive compulsive disorder: A pilot study

Background: Antipsychotic augmentation is an effective treatment intervention for Obsessive Compulsive Disorder (OCD) patients resistant to Selective Serotonin Reuptake Inhibitors (SSRI) agents. This pilot study was conducted to evaluate the effectiveness and tolerability of Aripiprazole for the augmentation of standard treatments in patients with resistant OCD. Methods: Twenty patients diagnosed with OCD according to DSM-IV TR criteria and having a history of resistance to standard pharmacological treatment were included in the study. Aripiprazole was added to ongoing SSRI or clomipramine treatment with a starting dose of 5 mg/day and titrated up to a maximum of 20 mg/day (mean dose 12.62 mg ± 4.25). Efficacy was assessed with the Yale-Brown obsessive compulsive scale (Y-BOCS) and the Clinical Global Improvement-severity scale (CGI-S) at baseline and at week 12 of Aripiprazole augmentation. Side effects were monitored by the Udvalg for Kliniske Undersogelser (UKU) side effect rating scale. Results: All 20 subjects enrolled in our study completed the full 12-week course of treatment. A significant improvement over the 12-week study period was observed (paired t-test for mean Y-BOCS total score at week 12 as compared with baseline – all patients: t = 13.146, d.f. = 19, p= 0.0001). Aripiprazole was generally well tolerated and no changes were observed in vital signs. The most commonly observed side effects after the introduction of the augmenting agent included: akathysia, nausea/vomiting, hyperkinesia, tension/inner unrest, tremors, asthenia/lassitude/increased fatiguability. Conclusions: Although results of this pilot study are preliminary and require confirmation in randomized controlled trials, our experience suggested that Aripiprazole is effective and well-tolerated as an augmenting agent in patients with treatment resistant OCD.

Group Psychoeducation Normalizes Cortisol Awakening Response in Stabilized Bipolar Patients under Pharmacological Maintenance Treatment

Patients in the TAU group participated to 21 weekly group meetings in which no special instruction was delivered. Assessments were performed before the beginning of PE (baseline) and at the end of the program (end point). Mental status was evaluated with the Hamilton Depression Rating Scale (HDRS, 21 items) and with the Young Mania Rating Scale (YMRS), while treatment compliance used the Adherence to Refills and Medications Scale (ARMS). Criteria for relapses were HDRS-21 >8 or YMRS >8. Saliva cortisol levels were assessed to evaluate the functional status of the HPA axis (CAR and cortisol circadian fluctuation). Samples were collected with the Salivette sampling device (Sarstedt, Italy) upon waking (08: 00 h ± 15 min), 30 and 60 min thereafter; additional samples were collected at 13: 00 and 20: 00 h. Patients avoided food, coffee or alcohol, teeth brushing, smoking or physical exercise for 60 min after waking and for 30 min prior to the other saliva collection. Saliva samples were recovered from a polyester swab by centrifugation at 3,000 rpm for 15 min and frozen at –20 ° C until analysis [7] . For each sample, duplicate measurements were performed on 25 μl of saliva using an immunoenzymatic Cortisol Saliva kit (Diametra, Italy) for the direct measurement of salivary cortisol (interassay coefficient of variation was <10%, and intra-assay coefficient of variation <7%, with a minimum detectable concentration of 0.5 ng/ml). For intergroup comparisons a Student t test was used, while χ 2

Bipolar Spectrum Disorders in Patients With Cerebellar Lesions: A Comparison With Parkinson's Disease.

Abstract Nonmotor functions of the cerebellum are well known. Within this frame, the aim of this study was to compare psychiatric morbidity rates among patients affected by cerebellar diseases or Parkinsons disease (PD). Forty-seven patients (27 cerebellar and 20 PD) underwent a comprehensive psychiatric evaluation (psychopathological rating scales and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders). Psychiatric disorders were slightly more frequent among cerebellar than among PD patients (89% vs. 75%; p = 0.21). Mood disorders were more frequent in the cerebellar than in the PD group (90% vs. 55%; p < 0.01). Among those subjects with no psychiatric history prior to the onset of neurological disease, bipolar spectrum disorders were more frequent within the cerebellar group (p < 0.01). These results confirm high rates of psychiatric disorders among cerebellar patients. The higher frequency of bipolar spectrum presentations found in the cerebellar group may suggest a specific involvement of cortico-cerebellar circuits in the pathophysiology of mood dysregulation.

[Hikikomori (ひきこもり): a culture-bound syndrome in the web 2.0 era].

In 1998 the Japanese psychiatrist Tamaki Sait¯o invented the term hikikomori, referring to a condition characterised by a state of social withdrawal and avoidance (education, work, friendships) combined with a persistent isolation and confinement in the own home for at least 6 months, due to various factors. Initially it undoubtedly regarded a disorder related to a specific socio-cultural context, however in the last couple of years some cases of hikikomori behaviour have also been observed in other countries far from Japan, both geographically and culturally. By way of hypothesis this diffusion can probably be attributed to the cultural revolution represented by mass communication in the internet era; in particular, it seems to be closely related to the immediateness and diffusion of web 2.0, i.e. of social networks. Therefore, we report a case of hikikomori behaviour, who was referred to our ward. M. is a 28-year-old man, who has lived the last 10 years in a state of almost complete isolation. He has maintained contacts with the outside world almost exclusively via internet. He started several therapies with psychiatrists and psychologists, without achieving significant results. The case of M. represents, to our knowledge, the first case of hikikomori described in Italy.

Diagnostic Accuracy of the Primary Care Screener for Affective Disorder (PC-SAD) in Primary Care

Background: Depression goes often unrecognised and untreated in non-psychiatric medical settings. Screening has recently gained acceptance as a first step towards improving depression recognition and management. The Primary Care Screener for Affective Disorders (PC-SAD) is a self-administered questionnaire to screen for Major Depressive Disorder (MDD) and Dysthymic Disorder (Dys) which has a sophisticated scoring algorithm that confers several advantages. This study tested its performance against a ‘gold standard’ diagnostic interview in primary care. Methods: A total of 416 adults attending 13 urban general internal medicine primary care practices completed the PC-SAD. Of 409 who returned a valid PC-SAD, all those scoring positive (N=151) and a random sample (N=106) of those scoring negative were selected for a 3-month telephone follow-up assessment including the administration of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) by a psychiatrist who was masked to PC-SAD results. Results: Most selected patients (N=212) took part in the follow-up assessment. After adjustment for partial verification bias the sensitivity, specificity, positive and negative predictive value for MDD were 90%, 83%, 51%, and 98%. For Dys, the corresponding figures were 78%, 79%, 8%, and 88%. Conclusions: While some study limitations suggest caution in interpreting our results, this study corroborated the diagnostic validity of the PC-SAD, although the low PPV may limit its usefulness with regard to Dys. Given its good psychometric properties and the short average administration time, the PC-SAD might be the screening instrument of choice in settings where the technology for computer automated scoring is available.

Anti-Purkinje Cell and Natural Autoantibodies in a Group of Psychiatric Patients. Evidences for a Correlation with the Psychopathological Status

Phenomena of autoimmunity are frequent among psychiatric patients, but we don’t know yet if they should be considered primary and linked to the pathophisiology of the disorder, or aspecific and associated to a general immune system activation. Paraneoplastic Cerebellar Degeneration (PCD) represents a well known model of specific autoimmunity. In order to better understand the abovementioned issues, we used this condition to compare a set of immune dysfunctions found in a group of psychiatric patients. For this reason we tested sera from 48 psychiatric patients (24 schizophrenics, 17 bipolars and 7 obsessive-compulsive), 22 PCD patients and 52 healthy controls for the presence of anti-Purkinje autoantibodies and of some natural autoantibodies (ANAs, AMAs, APCAs, ASMAs). Psychopatological status of the psychiatric patients was assessed with BPRS, SANS, SAPS, HAM-D, CGI-S. In the psychiatric group anti-Purkinje autoantibodies were identified in 11/48 (22,9%) patients, while they were present in 22/22 (100%) PCD patients and in 0/52 (0%) healthy controls. Among all anti-Purkinje autoantibody positive patients (in the PCD and psychiatric samples), only those belonging to the psychiatric sample, but not those with PCD, were frequently found positive also for natural autoantibodies, that are considered good markers of aspecific immune activation. In these patients, both anti-Purkinje and natural autoantibodies were found associated with acute/positive psychopathological symptoms. These results seem to point out that some phenomena of auto-immunity described in psychiatric patients could be aspecific, unrelated to the pathophysiology of the concomitant mental disorders and could be more frequent during phases of acute/positive symptoms.

Seizure threshold variations in ECT-treated chronic patients with schizophrenia: a brief report

Seizure threshold (ST) is a parameter that differs in each person and can be modified both spontaneously and because of drug intake and/or other exogenous factors. A rise in ST during a course of electroconvulsive therapy (ECT) has been demonstrated in patients with depression and mania, but little information has been available as to whether the same result occurs in schizophrenia (SCZ). 11 male patients underwent estimation of the seizure threshold over a bilateral ECT course. Mean ST changed not significantly. No correlations were found between baseline ST and Positive and Negative Syndrome Scale (PANSS) scores. A significant positive correlation emerged between baseline ST and the variation of Hamilton Depression Rating Scale (HDRS) total and cognitive scores. The results suggest that ST in SCZ patients is not related to baseline psychopathological features, it is not related to clinical improvements of negative or positive SCZ symptoms and it does not change during the ECT course but it appears predictive of the improvement of affective and cognitive symptmos.

Immediate serum growth hormone decrease as a potential index of dopamine-related response to electroconvulsive therapy in schizophrenic patients.

Objectives: The objective of this study was to investigate the immediate response of the dopamine-regulated growth hormone (GH) to electroconvulsive therapy (ECT) in schizophrenic patients and the changes in the serum GH levels throughout the consecutive sessions of the therapeutic ECT course. Methods: Serum GH levels were measured in a sample of 11 men with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, who were administered a course of 8 bilateral ECT treatments. Measurements were performed 5 minutes before ECT, during ECT, 15 minutes after an ECT session, and 30 minutes after an ECT session during the first, fourth, and eighth ECT sessions. Results: At both the fourth and the eighth ECT sessions, a significant decrease in GH levels 15 and 30 minutes after ECT was observed compared with the baseline values. No change in baseline serum GH levels was observed either during or at the end of the treatment. Clinical improvement was indicated by a significant reduction in the total score, negative subscale score, and positive subscale score of the Positive and Negative Syndrome Scale. Conclusions: The results are consistent with the potential role of immediate serum GH changes as an index of potential dopamine-mediated response to ECT. It can be assumed that GH reduction may be partially related to an antidopaminergic action of ECT, but further research is still needed to better evaluate the correlation of the dopamine system instability during the course of the illness with the previously mentioned immediate treatment response. Also, the role of other neurotransmitters in the regulation of GH production and ECT response must be taken into account for the purpose of an overall evaluation of the results and of their potential clinical implications.

Symptomatic subsyndromal depression in hospitalized hypertensive patients.

BACKGROUND Clinicians generally agree on the association between depression and hypertension. Less clear is if the nature of the link is direct or indirect and if this should be considered confined only to syndromal forms or if it concerns also subsyndromal affective presentations. This study investigated the nature of the association between hypertension and subsyndromal depression in hospitalized hypertensive patients. METHODS 196 hypertensive and 96 non hypertensive inpatients underwent a SCID interview, to exclude patients positive for any Axis I or Axis II diagnosis. Symptomatic Subsyndromal Depression (SSD) was identified according to criteria proposed by Judd. Psychopathological assessment was performed with Anxiety Sensitivity Index (ASI) and Hopkins Symptom Checklist-90 (SCL-90). Clinical assessments included blood pressure measurement, evaluation of general health conditions and screening cardiovascular risk factors (smoke, alcohol, body weight, sedentary life style). RESULTS Hypertensives met more frequently criteria for SSD. They also scored higher on ASI and SCL-90. However, those with more severe physical conditions, if compared with more healthy patients, did not show increased psychopathological severity. Similarly, psychopathological symptom severity did not differ among hypertensives positive for other cardiovascular risk factors, commonly more frequent among depressed subjects. LIMITATIONS Further analyses are needed to explore the potential advantage obtained on blood pressure control by treating SSD. CONCLUSIONS Hospitalized hypertensives, more frequently satisfied criteria for Symptomatic Subsyndromal Depression. These milder affective forms are probably directly linked to the presence of hypertension, rather than being indirectly associated to physical impairment or to higher prevalence of other cardiovascular risk factors.

[Predictive factors for further suicide attempts in individuals presenting to an emergency service for an attempted suicide. A one-year longitudinal study].

UNLABELLED Suicide attempts (SA) have been recognized among the most important predictors of suicide. AIM The aim of this study was to assess suicidal ideation, socio-demographic and clinical characteristics in patients admitted to the emergency room for a SA and to identify factors associated with clinical outcome. Admission to a Psychiatric Intensive Care Unit and further SA within one year were considered. MATERIALS AND METHODS Patients that agreed to participate in the study were evaluated in the emergency room with a clinical interview and they were administered the Intent Score Scale. Patients were then contacted and interviewed by telephone 1, 6, and 12 months after the SA. Clinical outcomes and the occurrence of new SA were investigated. RESULTS Seventy-four patients were enrolled and 49, 24, and 20 patients were reassessed at the 1, 6, and 12 month follow-up respectively. Eight patients reported at least one new SA within one year. Six SA occurred within the first month. Unemployment and underemployment were significantly associated with further SA. The time interval before a new SA was longer for patients admitted at the Psychiatric Intensive Care Unit and shorter for those with high suicidal intent at the first SA. CONCLUSIONS Although with limitations, our study might suggest that future research should focus on the role of hospitalization in the management of SA.