P. Zeppegno

The influence of illness-related variables, personal resources and context-related factors on real-life functioning of people with schizophrenia.

In people suffering from schizophrenia, major areas of everyday life are impaired, including independent living, productive activities and social relationships. Enhanced understanding of factors that hinder real‐life functioning is vital for treatments to translate into more positive outcomes. The goal of the present study was to identify predictors of real‐life functioning in people with schizophrenia, and to assess their relative contribution. Based on previous literature and clinical experience, several factors were selected and grouped into three categories: illness‐related variables, personal resources and context‐related factors. Some of these variables were never investigated before in relationship with real‐life functioning. In 921 patients with schizophrenia living in the community, we found that variables relevant to the disease, personal resources and social context explain 53.8% of real‐life functioning variance in a structural equation model. Neurocognition exhibited the strongest, though indirect, association with real‐life functioning. Positive symptoms and disorganization, as well as avolition, proved to have significant direct and indirect effects, while depression had no significant association and poor emotional expression was only indirectly and weakly related to real‐life functioning. Availability of a disability pension and access to social and family incentives also showed a significant direct association with functioning. Social cognition, functional capacity, resilience, internalized stigma and engagement with mental health services served as mediators. The observed complex associations among investigated predictors, mediators and real‐life functioning strongly suggest that integrated and personalized programs should be provided as standard treatment to people with schizophrenia.

Cinema in the training of psychiatry residents: focus on helping relationships

BackgroundMedical schools are currently charged with a lack of education as far as empathic/relational skills and the meaning of being a health-care provider are concerned, thus leading to increased interest in medical humanities.DiscussionMedical humanities can offer an insight into human illness and in a broader outlook into human condition, understanding of one self, responsibility. An empathic relation to patients might be fostered by a matching approach to humanities and sciences, which should be considered as subjects of equal relevance, complementary to one another. Recently, movies have been used in medical – especially psychiatric - trainees education, but mainly within the limits of teaching a variety of disorders. A different approach dealing with the use of cinema in the training of psychiatry residents is proposed, based on Jung and Hillman’s considerations about the relation between images and archetypes, archetypal experience and learning.SummarySelected full-length movies or clips can offer a priceless opportunity to face with the meaning of being involved in a care-providing, helping profession.

Suicide attempts and emergency room psychiatric consultation

BackgroundSuicidal behaviours are major public health concerns worldwide. They are associated with risk factors that vary with age and gender, occur in combination, and may change over time. The aim of our study was to investigate how frequently patients visiting a hospital emergency room (ER) require a psychiatric consultation for attempted suicide, and to outline the characteristics of this population.MethodsDeterminants of emergency room visits for psychiatric reasons were studied prospectively from 2008 to 2011 at the “Maggiore” Hospital in Novara.Results280 out of 1888 patients requiring psychiatric consultation were referred to the ER because of suicide attempt. Suicide attempters were more often female. The rate of suicide attempters among Italian people was 14.2%, compared to 19.5% in foreigners. Subjects living with parents or own family and those having a permanent job had a higher frequency of suicide attempt. Suicide attempts were more frequent among patients with a history of psychiatric disorders; nonetheless, suicide attempts were more common among those who had not previously been hospitalized in a psychiatric ward or were not under the care of a psychiatrist. The multivariate analysis found that female gender was a risk factor for suicide attempt, while being in the colder months of the year and, surprisingly, unemployment were protective factors.ConclusionsA better understanding of patients referring to the ER due to attempted suicide may allow the identification of at-risk subjects and the implementation of targeted treatment approaches.

Risperidone-associated hyperprolactinemia: evaluation in twenty psychiatric outpatients

Despite the lack of extrapyramidal side effects, some atypical antipsychotics can induce an increase in prolactinemia, as the conventional neuroleptics do. We decided to evaluate the effects of risperidone on serum prolactin levels and prolactin-related adverse effects in 20 outpatients of an Italian community psychiatric service. Patients enrolled in this study were on risperidone (2-8 mg per day; mean dose=4.15+/-0.4 mg per day) treatment in the period May-November 2002. The 20 patients, 13 women and 7 men (mean age=36.38+/-3.2 years for women and 29.7+/-2.2 for men) who accomplished inclusion criteria, participated in the study after giving informed written consent. Raised prolactin levels were observed in 13 (9 women and 4 men) out of 20 patients, but only 8 patients presented prolactin-related adverse effects, libido reduction being the most frequent. In this observational study, risperidone enhanced serum prolactin in 65% of patients. A good correlation was found between age and prolactin levels in pre-menopausal women, although no clear correlation among duration of treatment, dose used, prolactin levels and prolactin-related adverse effects could be established.

Social cognition in people with schizophrenia: a cluster-analytic approach.

BACKGROUND The study aimed to subtype patients with schizophrenia on the basis of social cognition (SC), and to identify cut-offs that best discriminate among subtypes in 809 out-patients recruited in the context of the Italian Network for Research on Psychoses. METHOD A two-step cluster analysis of The Awareness of Social Inference Test (TASIT), the Facial Emotion Identification Test and Mayer-Salovey-Caruso Emotional Intelligence Test scores was performed. Classification and regression tree analysis was used to identify the cut-offs of variables that best discriminated among clusters. RESULTS We identified three clusters, characterized by unimpaired (42%), impaired (50.4%) and very impaired (7.5%) SC. Three theory-of-mind domains were more important for the cluster definition as compared with emotion perception and emotional intelligence. Patients more able to understand simple sarcasm (⩾14 for TASIT-SS) were very likely to belong to the unimpaired SC cluster. Compared with patients in the impaired SC cluster, those in the very impaired SC cluster performed significantly worse in lie scenes (TASIT-LI <10), but not in simple sarcasm. Moreover, functioning, neurocognition, disorganization and SC had a linear relationship across the three clusters, while positive symptoms were significantly lower in patients with unimpaired SC as compared with patients with impaired and very impaired SC. On the other hand, negative symptoms were highest in patients with impaired levels of SC. CONCLUSIONS If replicated, the identification of such subtypes in clinical practice may help in tailoring rehabilitation efforts to the persons strengths to gain more benefit to the person.

Consumption of Antidepressants in Italy: Recent Trends and Their Significance for Public Health

OBJECTIVES The study assessed the consumption of antidepressants in Italy between 2000 and 2011 and identified trends in use. METHODS Data on use of antidepressant drugs between 2000 and 2011 were collected from the Italian Medicines Agency database. Data were expressed as the daily defined dose (DDD) per 1,000 inhabitants. Trends in drug consumption were ascertained by logarithmic transformation of incidence rates by using the formula ln(y)=b × x, where y is the incidence rate, b is the regression coefficient, and x represents the calendar years. Time trends were expressed as expected annual percentage change (EAPC). A significance level of .05 was chosen. RESULTS Antidepressant consumption increased drastically between 2000 and 2011, from 8.18 to 36.12 DDD per 1,000 inhabitants per day. A single joinpoint (time point with a significant trend change) occurred in 2002 (EAPC=56.4%, 2000-2002, and 6.2%, 2002-2011). The trend analysis stratified by type of drug showed a huge increase in consumption of selective serotonin reuptake inhibitors and other antidepressants and a decrease in consumption of tricyclic antidepressants. CONCLUSIONS Mental disorders are less stigmatized now than in the past. In Italy and elsewhere, antidepressant use is growing, and it would be important to monitor this trend, especially considering the possible effects of the current economic crisis on mental health. In this scenario, the role of public health in mental health promotion has become fundamental.

Pathways to functional outcome in subjects with schizophrenia living in the community and their unaffected first-degree relatives

RATIONALE Variables influencing real-life functioning have repeatedly been modeled in schizophrenia subjects but not systematically investigated in their unaffected first-degree relatives (SRs), in whom milder forms of deficits reported in schizophrenia have been observed, but confounders of clinical cohorts are not in play. Demonstrating that pathways to functional outcome are similar between patients and SRs would validate structural models developed in schizophrenia subjects. The present multicenter study aimed to explore whether variables associated with real-life functioning are similar in schizophrenia patients and their unaffected relatives. METHODS The study sample included 921 schizophrenia patients, 379 SRs and 780 healthy controls. Structural Equation Models (SEMs) were used in patients and SRs to test associations of psychopathological dimensions, neurocognition, social cognition, resilience, perceived stigma and functional capacity with real-life functioning domains, impaired in both patients and SRs. RESULTS Interpersonal Relationships and Work Skills were the only functional domains impaired in both patients and SRs. For both domains, functional impairment in patients was found to predict impairment in unaffected relatives, suggesting the involvement of similar illness-related vulnerability factors. In both groups variables significantly associated with Interpersonal Relationships included Social Cognition, Neurocognition, Avolition, Resilience, Disorganization, Perceived Stigma and Gender, and those significantly associated with Work Skills included Social Cognition, Neurocognition and Disorganization. CONCLUSIONS Pathways to functional outcome for Interpersonal relationships and Work skills are similar between schizophrenia patients and their unaffected first-degree relatives. These findings validate, in the absence of confounders of clinical cohorts, structural models of determinants of functional outcome in people with schizophrenia.

Predictors of orthorexic behaviours in patients with eating disorders: a preliminary study.

BackgroundThe construct of orthorexia in eating disorders (EDs) has received very little attention despite clinical observations of a possible overlap between the two. The aim of this study was: 1) to assess orthorexic behaviours, eating disorder pathology and attitudinal body image in ED patients; 2) to identify possible predictors of orthorexia nervosa among ED patients.MethodsFifty-two women diagnosed with EDs were recruited. Patients’ assessment included the following: the ORTO-15 test (Polish version) for orthorexic behaviours; the Eating Attitude Test-26 (EAT-26) to identify ED symptoms; the Multidimensional Body-Self Relations Questionnaire (Polish version) to assess body image.ResultsA latent class analysis was performed and differences between identified classes were assessed. The main differences concerned weight, ED pathology and orthorexic behaviours within the same group of ED patients. In order to examine predictors of orthorexia nervosa, we investigated a structural equation model, which excellently fitted to the data (χ2(17) = 23.05; p = .148; CFI = .962; RMSEA = .08; p = .25; SRMR = .05). In ED patients, orthorexic behaviour was negatively predicted by eating pathology, weight concern, health orientation and appearance orientation.ConclusionThe assessment of the orthorexia construct in EDs may add to the paucity of studies about this issue and may help to clarify the relationship between the two. Differences and similarities seem to exist between these disorders, and may benefit from specific treatment approaches. Moreover, these preliminary findings open tracks for future research in the field of the psychology of eating.

Asenapine increases nitric oxide release and protects porcine coronary artery endothelial cells against peroxidation.

Changes in endothelial function and peroxidation could play a significant role in the pathophysiology of cardiovascular disease in psychiatric patients. In particular, endothelial nitric oxide (NO) could either exert a beneficial or detrimental effect depending on the involvement of NO synthase (NOS) subtype. Therefore, we planned to examine the effects of asenapine on NO release and protection against oxidative stress in porcine coronary endothelial cells (CEC). The Griess system and Western blot were used for NO detection and to examine changes in protein activation and expression. In addition, cell oxidative/antioxidant status and mitochondrial membrane potential were measured by specific fluorescent dyes. Asenapine caused a concentration-dependent increase of NO production (p<0.05) by the involvement of cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA), phospholipase C (PLC), β2-adrenoceptor-related pathway, Akt, extracellular-signal-regulated kinases 1/2 (ERK1/2) and p38 mitogen-activated protein kinases (p38 MAPK). Furthermore, asenapine protected CEC against oxidative stress by preventing reactive oxygen species production and glutathione reduction, mitochondrial membrane potential collapse and apoptosis, and by modulation of the inducible NOS (iNOS). In conclusion, in CEC asenapine induced eNOS-dependent NO production through an intracellular signaling leading to Akt, ERK1/2 and p38MAPK activation. Moreover, asenapine protected CEC against oxidative stress by modulation of antioxidant system, apoptosis, cell survival signaling and mitochondria functioning.

Recurrent major depressive disorder: Imbalance of neurokinin (NK)-1 and NK-2 receptor expression in monocytes

Increasing evidence suggests that tachykinins are involved in the control of different pathological conditions, including psychiatric disorders. In this study we evaluated the expression of NK(1) and NK(2) receptors (NK-1R and NK-2R), as well as the effects of substance P (SP) and neurokinin A (NKA), in monocytes isolated from 15 healthy subjects and 15 patients with recurrent major depressive disorder (RMDD), under stable antidepressant therapy. NK-1R expression in monocytes from RMDD patients was significantly decreased as compared to healthy subjects, whereas NK-2R expression was markedly increased. Both NK-1R and NK-2R expression correlated with HAM-D, but not HAM-A, score. SP, NKA and selective NK-1R and NK-2R agonists stimulated TNF-α release in monocytes of both groups, with a significant higher effect observed in RMDD. Moreover they induced NF-κB activation, which was reversed by selective NK-1R and NK-2R antagonists, so demonstrating that it was receptor-mediated. The occurrence of a profound alteration in NK receptor expression in RMDD is a novel finding that suggests NK-1R and NK-2R pathways as possible relevant players in major depressive disorder, so improving our understanding of the complex pathogenesis of the disease.