Salvatore Rizzato

Comparative response to electroconvulsive therapy in medication-resistant bipolar I patients with depression and mixed state.

Objectives: We compared the response with electroconvulsive therapy (ECT) of bipolar I patients resistant to pharmacological treatment, who presented depression or mixed state (MS). Methods: Ninety-six bipolar I patients according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition were included in the study (46 with major depressive episode and 50 with MS). Bilateral ECT was delivered using a brief pulse stimulator Mecta 5000Q (Mecta Corp, Lake Oswego, Ore) on a twice-a-week schedule. The patients were evaluated before ECT (baseline) and a week after the ECT course (final score), using the Hamilton Rating Scale for Depression (HAM-D), Mania Rating Scale, Brief Psychiatric Rating Scale (BPRS), and Clinical Global Improvement (CGI). Results: Global response rate (CGI ≤2) was similar in bipolar depression and MS (67.4% and 76.0%, respectively); no difference was found in global remission rate (CGI ≤1) between depression (41.3%) and MS (34.8%). The response rate of depressive symptoms (HAM-D ≤50% was 69.6% for bipolar depression and 66.0% for MS; remission rate (HAM-D ≤8) was 26.1% and 30.0%, respectively. At the end of the ECT course, CGI-Severity, HAM-D total, Young Mania total, BPRS total, and psychotic cluster scores showed a progressive reduction in both groups. A significant group effect was present for Young mania total score, BPRS total score, and psychotic cluster. Limitations: With the exception of anticonvulsants, concomitant psychotropic medications were permitted during ECT course, based on the physicians decision. Conclusions: Electroconvulsive therapy should be considered a viable treatment alternative in bipolar I patients with depression or MS who do not respond to conventional pharmacologic management. The only difference is that MS may present more residual agitation or psychotic features in comparison with depressive patients.

Attention Deficit/Hyperactivity Disorder symptoms in Italian bipolar adult patients: A preliminary report

BACKGROUND It has been recently suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. With the aim to assess the impact of ADHD symptoms, we investigated the prevalence, epidemiological and clinical features associated with such a comorbidity in a sample of adult BD patients. METHODS A total of 96 outpatients (aged 18-65 years) with BD were included. All patients were screened using the Adult ADHD Self-report Scale (ASRS) and the Diagnostic, Clinical and Therapeutic Checklist (DCTC), a semi-structured interview developed for systematic collection of familial, demographic, anamnestic and clinical informations and exploration of DSM-IV-TR diagnostic criteria for mood, anxiety, eating, impulse control and alcohol and substance use disorders. The DCTC also includes the Clinical Global Impression Bipolar scale (CGI-BP), the Global Assessment of Functioning scale (GAF) and the Sheehan Disability Scale (SDS). RESULTS In our sample, 19 (19.8%) out of 96 BD patients fulfilled ASRS criteria for current and lifetime (onset before 7 years of age) ADHD symptoms (ADHD+). Compared to BD probands without ADHD symptoms (ADHD-), ADHD+ patients showed higher rates of current mixed episode, and lower rates of mania. ADHD+ resulted in more severe mean scores on the CGI-BP mixed, depressive and global subscales. None of the ADHD+ patients were in remission of BD at the time of the evaluation, versus 24 (31.2%) of the ADHD- group. ADHD+ patients also reported higher rate of lifetime comorbidity with Substance Use Disorder (SUD) and Alcohol Abuse in comparison to ADHD- patients. In particular the different rate in substance abuse was related to cocaine and poly-drug abuse. The two groups did not report significant differences in functioning and social adjustment with the exception of familial adjustment that was more compromised in ADHD+ than in ADHD- patients. LIMITATIONS Retrospective design and limited sample size. CONCLUSIONS In ADHD+ patients, BD is associated with higher rate of mixed states, more severe psychopathology and more impaired familial functioning as well as higher rates of comorbid substance, alcohol and poly-drug abuse compared to BD patients without adult ADHD. Our findings suggest that ADHD symptoms in adults may influence clinical presentation, course and prognosis of BD. Further prospective research is needed to confirm our findings and to explore treatment implications for the management of BD.

Different measures of impulsivity in patients with anxiety disorders: A case control study

The relationship between anxiety and impulsivity is controversial and not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in patients with anxiety disorders vs. healthy controls. Forty-seven subjects with different anxiety disorders and 45 matched controls underwent diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0, Bech-Raphaelsen Depression and Mania Scale (BRDMS), State-Trait Anxiety Inventory (STAI), Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); temperamental evaluations by the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI); and psychometric and a neurocognitive evaluations of impulsivity using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT-DMT). Subjects with anxiety disorders were more impulsive than the controls in all the explored measures, with higher scores in symptomatological and, temperamental scales. Patients with anxiety disorders but without a lifetime history of comorbid major mood episodes had greater trait and state impulsivity than controls. Further investigations are needed to assess the extent to which impulsivity might or might not be directly related to the anxiety disorder.

Clinical subtypes of severe bipolar mixed states.

OBJECTIVE The aim of the present study was to identify different clinical subtypes in severe, treatment resistant bipolar mixed state (MS). METHOD The sample comprised 202 Bipolar I patients currently in MS referred for an Electro-convulsive Therapy (ECT) trial and evaluated in the first week of hospitalization and one week after the ECT course. Principal component factor analysis (PCA) followed by Varimax rotation was performed on 21 non-overlapping items selected from Hamilton rating-scale for depression (HAMD) and from Young mania rating-scale (YMRS) at baseline evaluation. Cluster subtypes derived from the factor scores were compared in clinical variables and final HAMD, YMRS, Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores. RESULTS The principal-component analysis extracted 6 interpretable factors explaining 55.9% of the total variance. Cluster analysis identified four groups, including respectively 63 (31.2%) subjects with Agitated-Irritable Mixed-Depression, 59 (29.2%) with Psychotic Mixed-Mania, 17 (8.5%) with Anxious-Irritable-Psychotic Mixed-Mania, and 63 (31.2%) with Retarded-Psychotic Mixed-Depression. The four clusters were statistically distinct and did not show significant overlap in the main symptomatological presentation. Cluster subtypes reported differences in number of past mood episodes, duration of the current episode, suicide attempts, lifetime comorbidity with panic and eating disorders, baseline and final rating-scale scores and rate of remission after ECT trial. CONCLUSIONS Our study indicates that, at least in severe treatment resistant MS, multiple depressive and manic subtypes can be observed with substantial differences in terms of clinical presentation, course, associated comorbidities and treatment response.

Obsessive-compulsive disorder and related disorders: a comprehensive survey.

Our aim was to present a comprehensive, updated survey on obsessive-compulsive disorder (OCD) and obsessive-compulsive related disorders (OCRDs) and their clinical management via literature review, critical analysis and synthesis.Information on OCD and OCRD current nosography, clinical phenomenology and etiology, may lead to a better comprehension of their management. Clinicians should become familiar with the broad spectrum of OCD disorders, since it is a pivotal issue in current clinical psychiatry.

A case of severe oral self-injurious Tourette's syndrome alleviated by pregabalin

Self-injurious behavior (SIB) associated with Tourettes syndrome (TS) is a severe neuropsychiatric condition that causes significant distress and can impair social functioning. The current treatment options for the condition include pharmacological, physical and psychosocial interventions. However, given the need for more effective interventions, especially for those patients who are unresponsive and/or intolerant to standard medications, further exploration of novel treatments is imperative. In this report, we present a case of SIB-TS that was successfully treated with pregabalin. The patient received 1-year of follow-up and was noted to have considerable improvement in symptoms. Although rigorous controlled studies are required, based on our case study, pregabalin may be a potential treatment option in some cases of SIB with TS.

Impulsivity in anxiety disorders: the role of affective temperaments and current comorbid mood symptomatology

Objective: Higher level of impulsivity has been reported in patients with anxiety disorders than in healthy controls. The presence of both trait and state impulsivity was associated with the presence of comorbid cyclothymic disorder. In the present study we explore the relationship among impulsivity and co-morbid cyclothymia, affective temperaments and current mood symptomatology in patients with anxiety disorders.