“Flexible Assertive Community Mental Health Teams for the Treatment of Psychosis in Extraordinary Circumstances during Pandemics and Earthquakes 2020/2021: are we Flexible Enough?”

During the ongoing COVID-19 pandemic, two regions in Croatia, Zagreb and Petrinja in the Sisak-Moslavina County experienced strong earthquakes, on the March 22^nd 2020 and on the 29th of December 2020. Both earthquakes, but especially the later one resulted on severe damage of the regions and caused severe disruptions in (mental) health service delivery. In these circumstances, the RECOVER-E project (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE), which was ongoing in Croatia from 2018-2022 aimed to implement flexible assertive community treatment as the new health care service for persons with severe mental illness (SMI). Since the pandemic and earthquakes have significantly influenced the life circumstances of all RECOVER-E project participants with SMI, we wanted further to examine the impact of health care delivery on mental health and the response to stress caused by a pandemic and earthquake in the patients with SMI involved in the project, in the first and second wave of the COVID-19 pandemics. Additionally, using case series, we will demonstrate the community mental health teams’ contributions in managing SMI after a double disaster in providing feasible, comprehensive, and accessible mental health services.1

Tinnitus as a comorbidity to depression and transcranial magnetic stimulation as a treatment for both - case report

Introduction

Depressive symptoms are common in individuals with tinnitus, however, the mechanisms of their interaction are not fully understood. There is neurobiological evidence that might help understanding the interplay between tinnitus and depression which, in turn, helps in making the right choice for treating both conditions.

Objectives

This case report describes a 70-year old female patient that presented with tinnitus and depressive symptoms lasting for the past 5 years.

Methods

The patient showed limited treatment results with different antidepressants. The otorhinolaryngologist ruled out any possible somatic causes of her tinnitus. Tinnitus was causing her sleep disturbances, which worsened her everyday functioning that was already quite poor even further.

Results

After being administered with 30 rounds of TMS, her symptoms either completely resolved or at least reached a level that was adequate for her to start functioning normally on a day-to-day basis.

Conclusions

TMS is a technique that provides non-invasive cortical stimulation, more specifically, when used for depression treatment it stimulates the left dorsolateral prefrontal cortex, a brain region synaptically connected to the limbic system involved in mood regulation that is proven to be hypoactive in depression. The limbic system is where tinnitus-related brain networks and regions involved in the pathophysiology of depression overlap. Further research is needed to deepen the understanding of this topic.

Disclosure

No significant relationships.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries

Background

While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.

Methods

We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.

Results

SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.

Conclusions

The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

The role of zinc, albumin, c reactive protein, and interleukin-6 in differentiation of unipolar depression and depression in bipolar disorder

Introduction

There is no clinical difference between depressive episodes in bipolar disorder compared to major depressive disorder, which is why bipolar disorder remains unrecognized. Correctly distinguishing these disorders is of great importance because the therapeutic approach differs significantly. According to previous research, zinc, albumin, C reactive protein (CRP), and interleukin-6(IL-6) seem to play a role in differentiating these two types of depressive episodes.

Objectives

To determine zinc, albumin, CRP and IL-6 serum concentrations in patients with major depressive disorder and depressive episode of bipolar disorder.

Methods

Research involved 60 participants. Participants signed informed consent prior to inclusion in the study. Sociodemographic data have been collected using a previously structured questionnaire. The severity of depressive symptoms has been measured by the Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Depression Scale (HAM-D-17). Blood samples were obtained from each study participant’s brachial vein, to determine zinc, albumin, C reactive protein and interleukin-6 serum concentrations.

Results

Statistically significant difference was found in zinc serum levels between the two analysed groups. In the overall sample, there is a significant positive correlation between the results on the rating scales and the serum level of CRP.

Conclusions

We confirmed an association between serum levels of CRP and the severity of the illness. Regardless, these are preliminary results of the research. Sufficient final conclusion cannot yet be drawn because it is being limited by the sample size and further investigation is needed.

Assessment and Treatment of Negative Symptoms in Schizophrenia-A Regional Perspective

Clinicians and researchers consider that there are a variety of symptoms that constitute negative symptoms in schizophrenia, and they may use different definitions for the same symptoms. These differences are also reflected in a variety of negative symptom rating scales. Both research and clinical work are negatively affected by the lack of consensus regarding the symptoms that constitute negative symptoms in schizophrenia. Leading research groups have investigated ways to reduce heterogeneity in the domain of negative symptoms in schizophrenia; however, little attention has been paid to regional differences in the concepts of negative symptoms in schizophrenia. The objective of this review was to collect and summarize information about the assessment and treatment of negative symptoms of schizophrenia in Central and Eastern Europe (CEE). Nineteen experts from 17 countries in CEE participated in this project. The participants collected information about their countries, including the following: (1) the most important publications about negative symptoms in schizophrenia (irrespective of the time of their publication); (2) the most frequently used negative symptom of schizophrenia in clinical practice; (3) definitions of frequently used negative symptoms; and (4) treatment of negative symptoms in schizophrenia. The participating experts/countries most frequently reported the following five negative symptoms: avolition, blunted affect, alogia, asociality, and anhedonia. Several experts also considered other symptoms as belonging to the negative symptom domain, such as a decrease in energy level and changes in personality. The importance of evaluating the long-term course and the relationship between negative symptoms and other symptom domains was also noted. No noticeable differences were reported in the treatment of negative symptoms compared to currently published guidelines and algorithms. The most frequently reported negative symptoms included those defined by the NIMH-MATRICS consensus statement on negative symptoms and recently endorsed in a guidance paper of the European Psychiatric Association. The main differences in the concepts, names, and definitions of primary negative symptoms, especially those related to personality changes, and to the evaluation of the long-term course and relationship between different symptom domains in CEE compared to the current English language literature deserve the attention of psychiatrists and other professionals in this field.

Remission Is not Associated with DRD2 rs1800497 and DAT1 rs28363170 Genetic Variants in Male Schizophrenic Patients after 6-months Monotherapy with Olanzapine

BACKGROUND

Symptomatic remission is an achievable goal in the treatment of schizophrenia. The type of antipsychotic medication and particular genetic variants of the dopaminergic system might be associated with remission. Potential pharmacogenetic markers of the treatment response to antipsychotic medication are missing. This study assessed the possible association between dopamine receptor type 2 (DRD2 rs1800497) and dopamine transporter (DAT1 rs28363170) gene variants with symptomatic remission in schizophrenia.

SUBJECTS AND METHODS

Olanzapine (5-20 mg/d) monotherapy was administered for 6 months to 150 male Caucasian subjects with schizophrenia. Remission was evaluated according to "Remission in Schizophrenia Working Group" criteria. Genotyping was performed by PCR-RFLP.

RESULTS

Symptomatic remission was found in 31% of patients. DRD2 rs1800497 and DAT1 rs28363170 gene variants were not significantly associated with symptomatic remission. The limitations are a relatively small sample size of patients with schizophrenia (N=150), especially of group with symptomatic remission (N=45). However, the study had moderate but adequate sample sizes for most of the comparisons. Only two dopaminergic polymorphisms were analyzed, and plasma concentration of olanzapine was not determined.

CONCLUSION

These results revealed a lack of association between DRD2 rs1800497 and DAT1 rs28363170 genetic variants and symptomatic remission in male patients treated with olanzapine, suggesting that these genetic variants could not be used to predict symptomatic remission to olanzapine monotherapy. Negative results should be further confirmed or rejected in the larger samples, including haplotype analyses, to detect clinically useful and easy obtainable pharmacogenetic markers that might predict therapeutic response or remission in schizophrenia.

HTR1A, HTR1B, HTR2A, HTR2C and HTR6 Gene Polymorphisms and Extrapyramidal Side Effects in Haloperidol-Treated Patients with Schizophrenia

Schizophrenia is a serious, chronic psychiatric disorder requiring lifelong treatment. Extrapyramidal side effects (EPS) are common adverse reactions to antipsychotic medications. In addition to the dopaminergic system, serotonergic mechanisms, including serotonin (5-HT) receptors, might be involved in EPS development. This study aimed to examine molecular associations of HTR1A, HTR1B, HTR2A, HTR2C and HTR6 gene polymorphisms with acute EPS in 229 male schizophrenia patients, following two weeks of haloperidol monotherapy. The Simpson-Angus Rating Scale for Extrapyramidal Side Effects (SAS), Barnes Akathisia Rating Scale (BARS) and Extrapyramidal Symptom Rating Scale (ESRS) were used to evaluate EPS severity. Genotyping was performed using real-time PCR, following extraction of blood DNA. Significant acute EPS appeared in 48.03% of schizophrenia patients. For the rs13212041 HTR1B gene polymorphism, affecting microRNA regulation of HTR1B gene expression, a higher frequency of TT carriers was found among haloperidol-treated patients with akathisia when compared to the group without akathisia symptoms. In comparison to C-allele carriers, patients carrying the TT genotype had higher akathisia severity, as determined by the SAS, BARS and ESRS scales. These molecular findings suggest potential involvement of 5-HT_1B receptors in akathisia development following haloperidol treatment, as well as possible epigenetic mechanisms of serotonergic modulation associated with antipsychotic-induced EPS.

Latent Toxoplasma gondii infection is associated with decreased serum triglyceride to high-density lipoprotein cholesterol ratio in male patients with schizophrenia

BACKGROUND

Previous studies suggested a complex association between Toxoplasma gondii (TG) infection and host lipid metabolism. Both TG infection and metabolic disturbances are very common in patients with schizophrenia, but this relationship is not clear.

METHODS

In this cross-sectional study, we evaluated the association between TG seropositivity, serum lipid levels, body mass index (BMI) and metabolic syndrome (MetS) in 210 male inpatients with schizophrenia.

RESULTS

In our sample of schizophrenia patients, with the mean age of 43.90 ± 12.70 years, the rate of TG seropositivity was 52.38% and the prevalence of MetS was 17%. Patients with the TG antibodies had lower serum triglyceride levels and body weight compared to TG seronegative patients, despite having more frequently received antipsychotics (clozapine, olanzapine risperidone and quetiapine), which are well known to induce weight gain and metabolic abnormalities. However, the only significant change in metabolic parameters, observed in TG seropositive patients with schizophrenia, was decreased serum triglyceride to high-density lipoprotein cholesterol (HDL-C) ratio. No associations were observed between TG seropositivity and serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and glucose levels, waist circumference, BMI and the rate of MetS.

CONCLUSION

This is the first report of the association between TG infection and decreased serum triglyceride to HDL-C ratio in a sample of carefully selected men with chronic schizophrenia.

Brain-derived neurotrophic factor serum and plasma levels in the treatment of acute schizophrenia with olanzapine or risperidone: 6-week prospective study

Antipsychotics have been the mainstay of the treatment of schizophrenia, and their potential role in neuroprotection could be related to brain-derived neurotrophic factor (BDNF). So far different effects on both serum and plasma levels of BDNF were reported related to the various antipsychotic treatments. Aim of this study was to investigate the influence of olanzapine or risperidone on both plasma and serum levels of BDNF in patients with acute schizophrenia. For 50 participants with acute episode of schizophrenia both plasma and serum BDNF, along with the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression scale, were assessed pretreatment and post treatment - after 6 weeks of either risperidone or olanzapine. Results show that a weak correlation between pretreatment plasma and serum levels of BNDF was found no longer significant after 6 weeks of treatment. Antipsychotics, olanzapine and risperidone showed no significant effect on post treatment plasma and serum levels of BDNF. Pretreatment plasma level of BDNF and PANSS positive subscale were positively correlated. Post treatment serum level of BDNF and Clinical Global Impression were negatively correlated. In conclusion, plasma and serum BDNF levels could be different markers to some extent with regard to clinical symptoms, response to therapy and outcome. The interrelation between serum and plasma BDNF should be established in further studies.

Increased prevalence of toxoplasma gondii seropositivity in patients with treatment-resistant schizophrenia

Introduction

Previous studies suggested that patients with schizophrenia had an increased prevalence of antibodies against toxoplasma gondii (TG) and that those seropositive patients had higher symptom severity. However, there is no data on the relationship between treatment-resistant schizophrenia (TRS) and TG seroprevalence.

Objectives

To determine the association between TRS and TG seropositivity, and to further investigate the relationship between TG seropositivity and different clinical features of schizophrenia.

Methods

In this cross-sectional study, we included 210 male inpatients with schizophrenia. TG seropositivity was determined by ELFA assay. Treatment-resistance was defined as a failure of at least 2 adequate anti-psychotic trials. Data were analyzed using χ2 test or Mann–Whitney test.

Results

The rate of TG seropositivity in the entire sample was 52.3%, whereas 47.6% of patients met the definition for treatment-resistance. Seropositive patients had twice the rate of treatment–resistance compared to seronegative patients (63.6% vs. 30.0%, P < 0.0001). Moreover, in the seropositive group, the patients were older (47.6 ± 12.2 vs. 39.81 ± 12.01 years, P < 0.0001), had higher number of previous hospitalizations (13.9 ± 11.7 vs. 9.6 ± 8.5, P = 0.0073), and increased Calgary depression scale for schizophrenia (CDSS) total score (7.8 ± 4.5 vs. 6.3 ± 3.8, P = 0.012). There were no differences between the groups in the age of disease onset, smoking, positive and negative syndrome scale (PANSS) total, positive and negative scores, and the life-time history of suicide attempts.

Conclusions

Our results support the hypothesis that TG seropositivity might contribute to treatment-resistance in schizophrenia, at least in male patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Remission and employment status in schizophrenia and other psychoses: One-year prospective study in Croatian patients treated with risperidone long acting injection

BACKGROUND

While numerous studies have confirmed the efficacy of risperidone long-acting injectable (RLAI) on many clinical outcomes in patients with schizophrenia, there is no data regarding its influence on employment status.

SUBJECT AND METHODS

This was a 12-month observational study with flexible doses of RLAI on a Croatian population of patients with schizophrenia and other psychoses. Visits were at baseline and after 1, 3, 6 and 12 months of treatment. Treatment response was evaluated using Clinical Global Impression of Illness Severity (CGI-S) and Improvement (CGI-I) scales, while remission was defined by 8 items of Positive and Negative Syndrome Scale (PANSS). Employment status was determined at baseline and at study endpoint.

RESULTS

A total of 362 patients were included, with a median age of 37 (interquartile range 29-47) years, 63.5 % were males and 67.4% were hospitalised at baseline. Overall 258 (71.3%) patients completed the study. Improvements in CGI-S scores from baseline were significant (p<0.001) at all visits. Remission criteria were met in 9 (2.5%) patients at baseline, and in 199 (54.9%) at endpoint, while 144 patients (52.7%) achieved symptomatic remission. Female patients were five times more likely to achieve symptomatic remission (OR=5.2; 95%CI=2.64-10.19). At baseline, 74/362 (20.4%) patients were employed, compared to 77/257 (30.0%) at endpoint (p<0.001). Adverse events were spontaneously reported in 55 (15.2%) patients. Three patients died (judged not to be related to RLAI) and one patient committed homicide.

CONCLUSIONS

Patients treated with RLAI had significant improvements in CGI-S scale scores, hospitalization status, rates of remission and employment status, indicating the benefits of continuous treatment over time. Further studies on the comparative impact of different treatment strategies on functional recovery are needed.

Lipid levels in female patients with affective disorders

The role of serum lipids [total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG)] in the pathophysiology of mood disorders is not clear. The aim of this study was to determine lipid profiles in patients with affective disorders. The study included medication-free female subjects (41 patients with bipolar disorder, 22 in a manic and 19 in a depressive phase), 34 patients with major depression, and 50 healthy controls. Serum lipid levels were determined using standard laboratory tests. All patients had significantly lower HDL-C values than control subjects. Increased TG levels were found in patients with bipolar disorder compared with healthy subjects. The changes in lipid profiles persisted when data were adjusted for age, smoking and menopausal status. The results revealed no differences in cholesterol and LDL-C levels and body mass index, but significant differences in the ratios of cholesterol/HDL-C and LDL-C/HDL-C (atherogenic index) among groups. Our results suggest that low HDL-C levels and a high atherogenic index might be a hallmark of affective disorders. Since low HDL-C levels could be a risk factor for the development of coronary heart disease, further investigation of lipid metabolism in affective disorders is warranted.

The effects of olanzapine and fluphenazine on plasma cortisol, prolactin and muscle rigidity in schizophrenic patients: a double blind study

Pharmacotherapy of schizophrenia is associated with the stressful side effects. Muscle rigidity causes distress, discomfort and poor compliance. The aim of the study was to determine the relationship between plasma hormones (cortisol and prolactin/PRL) and muscle rigidity in female schizophrenic patients treated with olanzapine or fluphenazine. In a randomized, double-blind 22-weeks study, 12 patients were treated with olanzapine (5-20 mg/day) and 10 patients received fluphenazine (6-21 mg/day). Treatment with olanzapine moderately decreased, while treatment with fluphenazine significantly increased plasma cortisol levels and muscle rigidity. The marked and moderate increase in plasma PRL levels were found in patients treated with fluphenazine and olanzapine, respectively. The results suggested that olanzapine induced moderate neuroendocrine effects and a reduction in rigidity as compared to fluphenazine treatment.

Platelet serotonin and serum lipids in psychotic mania

BACKGROUND

The role of serotonergic system and lipid status in the etiology of mania and its subtypes is not clear. The aims of the study were to determine platelet serotonin (5-HT) concentration, platelet monoamine oxidase (MAO) activity, and serum total cholesterol, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL) and triglycerides (TG) in patients with psychotic and nonpsychotic subtypes of mania and in healthy control subjects.

METHODS

The serum lipids, platelet 5-HT and MAO were determined in 40 (17 psychotic, 23 nonpsychotic) drug free male inpatients with type I bipolar affective disorder, current episode mania (DSM-IV criteria), and in 32 healthy male subjects.

RESULTS

Platelet 5-HT levels in manic patients were similar to the values in healthy controls. Serum cholesterol and LDL values were significantly lower in manic patients than in healthy controls. Patients with psychotic features had increased platelet 5-HT concentrations and decreased levels of cholesterol and LDL as compared to the nonpsychotic manic patients and healthy controls. There was no significant difference in age, body mass index, platelet MAO activity, serum levels of TG and HDL between psychotic and nonpsychotic manic patients and healthy subjects.

LIMITATION

Data on physical activity, dietary habits and alcohol consumption before hospitalization were not collected.

CONCLUSION

The results of the present study suggest that biological differences between subtypes of mania might depend upon the presence of the psychotic symptoms. Our data confirm our previous results showing the increased platelet 5-HT concentration in psychotic disorders across the different diagnoses.

Low arylsulphatase A activity in the development of psychiatric disorders

Previous studies have suggested that arylsulphatase A (ASA) deficiency may be present in psychiatric patients. A number of patients with low ASA activity and various neuropsychiatric symptoms have been observed. Metachromatic leucodystrophy (MLD) is a disease caused by deficiency of the enzyme ASA. Clinically, adult MLD may present as a schizophrenia-like psychosis, deterioration of cognitive functions, personality changes, depression and dementia. However, there are individuals with low ASA activity without clinical symptoms of MLD. This state is described as ASA pseudodeficiency. It remains controversial whether low ASA activity predisposes to or influences the development of psychiatric symptoms. Relatively little attention has been paid to the role of neurodegenerative processes in the pathophysiology of psychiatric disorders. The hypothesis underlying this work is that there is a subclass of mentally ill patients whose psychiatric problems are at least partly caused by an abnormal ASA. The purpose of this particular study was to determine whether an abnormal ASA could be detected in schizophrenic, major depressed and demented patients and control subjects. There were 66 schizophrenic, 59 major depressed and 61 demented patients. The control group consisted of 102 healthy volunteers. Leucocyte ASA activity was determined from blood samples, using p-nitrocatechol sulphate as substrate. Our results show that low ASA activity is more frequently found in psychiatric patients than in control subjects. Our findings indicate that clinical types of major depression and schizophrenia could be connected with low ASA activity. The presence of a decreased ASA activity points to the conclusion that an enzyme deficit entails vulnerability to psychiatric disorders.