Ricardo Coentre

Depressive symptoms and suicidal behavior after first-episode psychosis: A comprehensive systematic review

Depressive symptoms and suicidal behavior are common among patients that suffered a first-episode psychosis. We searched Web of KnowledgeSM and Pubmed® for English and Portuguese original articles investigating prevalence of depressive symptoms and/or suicidal behavior and associated factors after first-episode psychosis. We included 19 studies from 12 countries, 7 studied depressive symptoms and 12 suicidal behavior. The findings confirm that depressive symptoms and suicidal behavior have high rates in the years after first-episode psychosis. Factors identified as being associated with depressive symptoms after first-episode psychosis were anomalies of psychosocial development, poor premorbid childhood adjustment, greater insight, loss, shame, low level of continuing positive symptoms and longer duration of untreated psychosis. Suicidal behavior was associated with previous suicide attempt, sexual abuse, comorbid polysubstance use, lower baseline functioning, longer time in treatment, recent negative events, older patients, longer duration of untreated psychosis, higher positive and negative psychotic symptoms, family history of severe mental disorder, substance use, depressive symptoms and cannabis use. Data also indicate that treatment and early intervention programs reduce depressive symptoms and suicidal behavior after first-episode psychosis. Future research should overcome some methodological discrepancies that exist between studies and limit generalization of current findings.

Retrospective study on structural neuroimaging in first-episode psychosis

Background. No consensus between guidelines exists regarding neuroimaging in first-episode psychosis. The purpose of this study is to assess anomalies found in structural neuroimaging exams (brain computed tomography (CT) and magnetic resonance imaging (MRI)) in the initial medical work-up of patients presenting first-episode psychosis. Methods. The study subjects were 32 patients aged 18–48 years (mean age: 29.6 years), consecutively admitted with first-episode psychosis diagnosis. Socio-demographic and clinical data and neuroimaging exams (CT and MRI) were retrospectively studied. Diagnostic assessments were made using the Operational Criteria Checklist +. Neuroimaging images (CT and MRI) and respective reports were analysed by an experienced consultant psychiatrist. Results. None of the patients had abnormalities in neuroimaging exams responsible for psychotic symptoms. Thirty-seven percent of patients had incidental brain findings not causally related to the psychosis (brain atrophy, arachnoid cyst, asymmetric lateral ventricles, dilated lateral ventricles, plagiocephaly and falx cerebri calcification). No further medical referral was needed for any of these patients. No significant differences regarding gender, age, diagnosis, duration of untreated psychosis, in-stay and cannabis use were found between patients who had neuroimaging abnormalities versus those without. Discussion. This study suggests that structural neuroimaging exams reveal scarce abnormalities in young patients with first-episode psychosis. Structural neuroimaging is especially useful in first-episode psychosis patients with neurological symptoms, atypical clinical picture and old age.

Assessment of depression and suicidal behaviour among medical students in Portugal

Objectives To examine depression and suicidal behaviour and associated factors in a sample of medical students in Portugal. Methods We conducted a cross-sectional study design of 456 native Portuguese medical students from the 4th and 5th year at the University of Lisbon. Participants answered a self-report survey including questions on demographic and clinical variables. Statistical analyses were conducted using the chi-square test, with a Monte Carlo simulation when appropriate. Results Depression among medical students was 6.1% (n=28) and suicidal behaviour 3.9% (n=18). Higher depression scores were noted in female medical students (χ2=4.870,df=2,p=0.027), students who lived alone (χ2=8.491,df=3,p=0.037), those with poor physical health (χ2=48.269,df=2,p<0.001), with poor economic status (χ2=8.579,df=2,p=0.014), students with a psychiatric diagnosis (χ2=44.846,df=1,p=0.009), students with a family history of psychiatric disorders (χ2=5.284,df=1,p=0.022) and students with high levels of anxiety (χ2=104.8, df=3, p<0.001). Depression scores were also higher in students with suicidal ideation (χ2=85.0,df=1,p<0.001), suicidal plan (χ2=47.9,df=1,p<0.001) and suicidal attempt (χ2=19.2,df=1,p<0.001). Suicidal behaviour was higher in medical students who lived alone (χ2=16.936,df=3,p=0.001), who had poor physical health (χ2=18,929,df=2,p=0.001), poor economic status (χ2=9.181,df=2,p=0.01), who are/were in psychopharmacology treatment (χ2=30.108,df =1,p<0.001), and who had high alcohol use (χ2=7.547,df=2,p=0.023), severe depression (χ2=88.875,df=3,p<0.001) and high anxiety levels (χ2=50.343,df=3,p<0.001). The results also revealed that there were no differences between students in the 4th and 5th years of medical school regarding rate of depression and suicidal behaviour. Conclusions Since depression and suicidal behaviour are mental health problems affecting a significant proportion of medical students, medical schools should implement programs that promote mental health wellness, physical health and economic status between other factors.

P03-198 - Retrospective study of socio-demographic and clinical characteristics of new patients admitted to an alcohol unit of a general hospital

Objectives Alcohol is the most widely psychoactive substance consumed in Portugal. The aim of this study is to describe the socio-demographics and clinical characteristics of alcohol abuse and dependence new patients of an Alcohol Unit in a University General Hospital. Methods We collected retrospectively data from all admitted patients to our Alcohol Unit between January and October 2009 with alcohol abuse or dependence diagnosis. Results Fifty three patients were admitted during the period, 40 (75%) males and 13(25%) females. The mean age was 45.4 years (s.d.:10.6; median: 42), range between 24-67 years. Thirteen percent of patients were single, 26% divorced, 4% widowed and 57% married/with partner. Fifty-seven percent were employed, 30% unemployed and 13% retired. Twenty one percent of patients had known cardiovascular disease and 19% percent alcoholic liver cirrhosis. As Psychiatric comorbities 19% percent of patients had depressive disorders, 6% personality disorders and 6% other psychiatric disorders (anxiety and psychotic disorders). Mean AST value was 67.3 IU/L (s.d.:64.3), mean ALT 52.9 IU/L (s.d.:47.9), mean GGT 258.6 IU/L (s.d.:367.6) and mean MCV 92.3 um3 (s.d.:8.3). Forty percent of patients made an acute detoxification (77% as outpatient and 33% as inpatient). Fifty five percent of patients attended our psychotherapy group. Benzodiazepines (96%), antidepressants (25%) and naltrexone (22%) were the most used psychopharmacological treatments. Conclusions This study shows that there was predominance of male, married/with partner and employed patients in our sample. Alcohol biomarkers were high on the majority of patients, and there was also a high prevalence of medical diseases.

P02-85 Maintenance ECT in affective disorders

ECT is the most powerful therapeutic tool in the treatment of acute mood episodes. However, data on the efficacy and safety of ECT in the long term management of affective disorders is lacking, despite overwhelming rates of chronicity and/or frequent relapses among patients with unipolar and bipolar depression. In this presentation we will review the data of the ECT unit of Hospital de Santa Maria, Lisboa, on maintenace ECT (m-ECT) in these patients. We compare intra and inter-individual evolution prior and after the institution of m-ECT. Considering the number of hospital admissions, mood symptoms and other parameters, our data support the use of this technique as a prophylatic approach for patients with mood disorders and a previous good response to ECT in the acute phase of disease.

P03-127 Factors involved in treatment adherence in psychosis: Importance of treatment effectiveness for the patients

Aims Treatment adherence is crucial to the therapeutic success in psychiatric disorders. Evaluating factors involved in treatment adherence will allow to modify treatment strategies for greater compliance. The aim of the study was to evaluate factors involved in treatment adherence, including subjective patients’ satisfaction. Method The study included in- and outpatients who met the criteria according to DSM-IV TR of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, psychosis not otherwise specified, brief psychotic disorder and bipolar disorder. The following questionnaires were applied: 1. Demographic and clinical questionnaire; 2. Treatment Satisfaction Questionnaire for Medication Version II (TSQM vII); 3. Medication Adherence Rating Scale (MARS); 4. Schedule for Assessment of Insight (SAI); 5. World Health Organization Quality of Life-BREF Scale (WHOQoL-BREF). TSQM vII is a self-reporting questionnaire to assess the major dimensions of patients’ satisfaction with their medication, includes 11 items that make up three specific scales (effectiveness, side-effects and convenience). Results Twenty patients, between 18 and 65 years of age, were included. An interview was made and the 5 questionnaires were applied. The statistical analysis, using Regression Analysis Stepwise, showed a significant positive correlation between medication adherence, evaluated by MARS, and treatment effectiveness to the patients, evaluated by TSQMvII effectiveness scale (p=0.028). The correlations between the others parameters were not statistically significant. Conclusion In this study the authors found that the self-experience of treatment effectiveness, which is a major dimension for treatment satisfaction, had a positive correlation with treatment adherence. Strategies to enhance subjective treatment effectiveness are needed to improve medication adherence.

FC03-05 Low bone mineral density and psychosis: A multifactorial relation

Aims Low bone mineral density (BMD) is a major public health issue leading to fractures, pain and disability. The association between psychosis and low bone density has been suggested in the last years. Method The authors review the literature in Medline database using the words ‘bone mineral density’, ‘psychosis’, ‘antipsychotic’, ‘schizophrenia’, ‘bipolar disorder’ and ‘psychiatry disorders’. Results Some studies show elevated prevalence of changes in BMD in patients with psychiatry disorders, namely psychosis. These changes are multifactorial, due to therapeutic factors and/or to the disorder per se . The low BMD induced by some antipsychotic drugs has been attributed mostly to hyperprolactinaemia and its consequences. Lithium, carbamazepine, sodium valproate and the use of thyroid-stimulating hormone-suppressive doses of L-thyroxin used in bipolar disorder also have a negative impact on bone health. Patients with psychosis could be vulnerable to bone abnormalities even without treatment, environmental factors like smoking, sedentary lifestyle, decreased exposure to sunlight, alcoholism, dietary deficiencies and polydipsia are partially responsible for that. Also genetic factors (vitamin D receptor gene, estrogen receptor gene etc.) and biological factors (gender, decreased of peak bone mass, abnormalities in immune-inflammatory mechanisms, hypercortisolemia stress-induced etc.) contribute to the abnormalities in bone dynamics in psychosis. Conclusion The association between low BMD and psychosis has been demonstrated in literature, understanding all the factors involved in this process will help the development of preventive and treatment strategies. A large study including first psychotic episode patients could be useful to distinguish between disorder and drug induced factors of low BMD in psychosis.

P03-126 First psychotic episode and early intervention: An opportunity to change the course of the illness

Aims Early intervention in psychosis constitutes an important opportunity to change the classic limited outcome associated with the patients who suffer of psychotic disease. Methods Based on literature review the authors analyse the evidence for early intervention in first psychotic episode. Results The evidence for the effectiveness of interventions in early psychosis can be considered in two stages: 1. first stage before the onset of full symptoms of psychosis, in people with high risk of developing psychosis or in the prodrome phase of the illness; 2. second stage includes the therapeutic focus on the period after the first psychotic episode, reducing the duration of untreated psychosis (DUP) and ameliorate the recovery. Preventing psychosis by intervene in the prodrome or in people with high risk of developing psychosis remains ethically contentious because of the non-specificity of the symptoms. By the contrary there is evidence that early and specialised intervention in first psychotic episode improves outcome. Besides the controversy of the relation between long DUP and poor outcome, there is agreement that clinicians should identify and treat psychosis early with a great impact in patients and their familys life. Effective care during first psychotic episode includes proactive engagement and initiation of low doses of antipsychotics and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Conclusion There is evidence that early intervention in first psychotic episode improve clinical effectiveness over standard care. Further studies are important to make evidence more robust.