Depression, distress and their association with patterns of psychoactive substance use during the COVID-19 emergency state in latvia

Introduction

The WHO warned that the COVID-19 pandemic could have psychiatric consequences such as elevated levels depression, increased alcohol and drug use, and other behaviours that exert a strong influence on health. In Latvia a state of emergency was announced on March 12^th, was extended twice and lifted on June 10th.

Objectives

To estimate the prevalence of depression and distress in the general population of Latvia and association with substance use during the state of emergency.

Methods

The nationwide representative online study in the general population of Latvia was conducted in July 2020 during three week period. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to determine the presence of distress/depression. The structured questionnaire to determine psychoactive substance use was applied. Proportions of independent variables across the study groups were compared using Chi-square test.

Results

The study sample included 2608 respondents. The prevalence of depression and distress was estimated at 5.7% (95%CI 4.92 – 6.71) and 13.5% (95%CI 6.85 – 8.91), respectively. Patients with depression (28% vs. 7.4%, p <0.001) and distress (30.9% vs. 7.4% p <0.05) smoked more tobacco compared to respondents without distress/depression. Those with depression or distress were significantly more likely to consume more alcohol during the emergency state than people without depression or distress (14.0% and 17.7% vs. 6.6%, p <0.001). The changes in the use of other psychoactive substances in those who had depression or distress were not statistically significant.

Conclusions

Preparing support systems to mitigate mental health consequences is needed urgently.

Position statement of the European Psychiatric Association (EPA) on the value of antidepressants in the treatment of unipolar depression

This position statement will address in an evidence-based approach some of the important issues and controversies of current drug treatment of depression such as the efficacy of antidepressants, their effect on suicidality and their place in a complex psychiatric treatment strategy including psychotherapy. The efficacy of antidepressants is clinically relevant. The highest effect size was demonstrated for severe depression. Based on responder rates and based on double-blind placebo-controlled studies, the number needed to treat (NNT) is 5–7 for acute treatment and four for maintenance treatment. Monotherapy with one drug is often not sufficient and has to be followed by other antidepressants or by comedication/augmentation therapy approaches. Generally, antidepressants reduce suicidality, but under special conditions like young age or personality disorder, they can also increase suicidality. However, under the conditions of good clinical practice, the risk–benefit relationship of treatment with antidepressants can be judged as favourable also in this respect. The capacity of psychiatrists to individualise and optimise treatment decisions in terms of ‘the right drug/treatment for the right patient’ is still restricted since currently there are no sufficient powerful clinical or biological predictors which could help to achieve this goal. There is hope that in future pharmacogenetics will contribute significantly to a personalised treatment. With regard to plasma concentration, therapeutic drug monitoring (TDM) is a useful tool to optimize plasma levels therapeutic outcome. The ideal that all steps of clinical decision-making can be based on the strict rules of evidence-based medicine is far away from reality. Clinical experience so far still has a great impact.

Effects of exercise training with traditional dancing on functional capacity and quality of life in patients with schizophrenia: a randomized controlled study

OBJECTIVE

To examine the effects of an eight-month exercise training programme with Greek traditional dancing on functional capacity and quality of life in patients with schizophrenia.

DESIGN

Randomized controlled trial.

SETTING

Sports Medicine Laboratory.

SUBJECTS

A total of 31 patients, aged 59.9 ± 14.1 years.

INTERVENTIONS

They were randomly assigned either to a Greek traditional dancing programme (Group A) or to a sedentary control group (Group B).

MAIN MEASURES

A functional capacity assessment was performed at baseline and the end of the study. Global Assessment of Functioning Scale and Positive and Negative Syndrome Scale were also used. Quality of life was examined using the Quality of Life and Satisfaction questionnaire.

RESULTS

After the eight months, Group A increased walking distance in the 6-minute walk test (328.4 ± 35.9 vs. 238.0 ± 47.6 m), sit-to-stand test (19.1 ± 1.8 vs. 25.1 ± 1.4 seconds), Berg Balance Scale score (53.1 ± 2.1 vs. 43.2 ± 6.7), lower limbs maximal isometric force (77.7 ± 25.7 vs. 51.0 ± 29.8 lb), Positive and Negative Syndrome Scale total score (77.0 ± 23.1 vs. 82.0 ± 24.4), Global Assessment of Functioning Scale total score (51.3 ± 15.5 vs. 47.7 ± 13.3) and Quality of Life total score (34.9 ± 5.2 vs. 28 ± 4.5), compared with Group B.

CONCLUSIONS

Our results demonstrate that Greek traditional dances improve functional capacity and quality of life in patients with schizophrenia.

[Neurological soft signs in schizophrenia: correlations with age, sex, educational status and psychopathology]

Though the pathobiology of schizophrenia can be examined in multiple levels, the organic notion of brain disease suggests that neurological features will be present. One straightforward, inexpensive method of investigating brain dysfunction in schizophrenia is thought the bedside assessment of neurological abnormalities with a standard neurological examination. Neurological abnormalities are traditionally classified as "hard signs" (impairments in basic motor, sensory, and reflex behaviors, which do not appear to be affected in schizophrenia) and "soft signs", which refer to more complex phenomena such as abnormalities in motor control, integrative sensory function, sensorimotor integration, and cerebral laterality. Additionally, neurological soft signs (NSS) are minor motor and sensory abnormalities that are considered to be normal in the course of early development but abnormal when elicited in later life or persist beyond childhood. Soft signs also, have no definitive localizing significance but are indicative of subtle brain dysfunction. Most authors believe that they are a reflection not only of deficient integration between the sensory and motor systems, but also of dysfunctional neuronal circuits linking subcortical brain structures such as the basal ganglia, the brain stem, and the limbic system. Throughout the last four decades, studies have consistently shown that NSS are more frequently present in patients with schizophrenia than in normal subjects and non-psychotic psychiatric patients. However, the functional relevance of NSS remains unclear and their specificity has often been challenged, even though there is indication for a relative specificity with regard to diagnosis, or symptomatology. Many studies have considered soft signs as categorical variables thus hampering the evaluation of fluctuation with symptomatology and/or treatment, whereas other studies included insufficient number of assessed signs, or lacked a comprehensive assessment of extrapyramidal symptomatology. Factors such as sex, age or family history of schizophrenia, are said to influence the performance of neurological examination, whereas relative few studies have provided longitudinal follow-up data on neurological soft signs in a sufficient number of patients, in order to address a possible deterioration of neurological functions. Finally, one additional difficulty when analyzing the NSS literature lies in the diversity of symptoms that are evaluated in the studies and/or non-standardized procedures or scoring. We will review some basic issues concerning recurrent difficulties in the measurement and definition of soft signs, as well as controversies on the significance of these signs with respect to clinical subtyping of schizophrenia, and social and demographic variables.

Meta-analytic studies in depression and the role of placebo response

During the last few years there is a growing concern about the increasing response to placebo seen in trials of antidepressants and the ever increasing difficulty in detecting the therapeutic signal. Even worse, recently there was much debate on the true usefulness of antidepressant therapy itself, especially after the publication of a meta-analysis by Kirsch et al in 2008. However the re-analysis of these data suggested that the correct drug-placebo difference is 2.18 or 2.68 instead of 1.80. Kirsch et al failed to report that that the change in HDRS score was 3.15 or 3.47 points for venlafaxine and 3.12 or 3.22 for paroxetine, which are above the NICE threshold. It is of prime importance that although a large percentage of the placebo response is due to expectancy this is not true for the active drug and effects are not additive. This might mean a distinct mechanism underlying the placebo and the drug effect. Also, the drug effect is always present and is unrelated to depression severity, while this is not true for placebo. It is interesting that by passing the years there seems to be an increasing absolute both placebo and drug effect but the effect size of the difference remains stable. Meta-analytic studies in larger data sets are necessary in order to further elucidate the relationship between the drug and the placebo response and the nature of the latter.

Monotherapy vs combination therapy in bipolar disorder: What does the evidence say?

The treatment of bipolar disorder is complex and the overall results of monotherapy are not satisfactory. Combination and add-on studies suggest that in acutely manic patients who are partial responders to lithium, valproate or carbamazepine, a good strategy would be to add haloperidol, risperidone, olanzapine, quetiapine or aripiprazole. Adding oxcarbazepine to lithium is also a choice. For patients with refractory bipolar depression the only positive data concern adding lamotrigine to lithium. During the maintenance phase the combination of quetiapine plus mood stabilizer is superior to monotherapy in the prevention of manic and depressive recurrences in either manic, depressive, or mixed index episode over a period of 2-years. These combination studies appear to be the first to report prevention on both depression and mania regardless of the type of index episode.

Discontinuation studies suggest that patients stabilized on combination therapy (olanzapine plus lithium/valproate or mood stabilizer plus ziprasidone) do worse when the antipsychotic is discontinued. The recently published BALANCE could neither reliably confirm nor refute a benefit of combination therapy compared with lithium monotherapy. Add on studies suggest that at least some strategies could be useful in patients with inadequate response to monotherapy. Overall, although there is no compelling data that combination treatment does better than monotherapy, the data suggest that those patients stabilized on combination treatment might do worse if shifted from combination, and patients refractory to monotherapy could benefit with add on treatment with olanzapine, valproate, an antidepressant or lamotrigine, depending on the index acute phase.

Is anticonvulsant treatment of mania a class effect? Data from randomized clinical trials

Our aim was to evaluate the efficacy and tolerability of anticonvulsant agents for the treatment of acute bipolar mania and ascertain if their effects on mania are a "class" effect. We conducted a systematic review of randomized controlled trials (RCTs) with placebo or active comparator, in acute bipolar mania in order to summarize available data on anticonvulsant treatment of mania/mixed episodes. We searched (PubMed/MEDLINE) with the combination of the words "acute mania" and "clinical trials" with each one of the following words: "anticonvulsants/antiepileptics,""valproic/valproate/divalproex,""carbamazepine,""oxcarbazepine,""lamotrigine,""gabapentin,""topiramate,""phenytoin,""zonisamide,""retigabine,""pregabalin,""tiagabine,""levetiracetam,""licarbazepine,""felbamate," and "vigabatrin." Original articles were found until November 1, 2008. Data from 35 randomized clinical trials suggested that not all anticonvulsants are efficacious for the treatment of acute mania. Valproate showed greater efficacy in reducing manic symptoms, with response rates around 50% compared to a placebo effect of 20-30%. It appears to have a more robust antimanic effect than lithium in rapid cycling and mixed episodes. As valproate, the antimanic effects of carbamazepine have been demonstrated. Evidences did not support the efficacy of the gabapentin, topiramate as well as lamotrigine as monotherapy in acute mania and mixed episodes. Oxcarbazepine data are inconclusive and data regarding other anticonvulsants are not available. Anticonvulsants are not a class when treating mania. While valproate and carbamazepine are significantly more effective than placebo, gabapentin, topiramate, and lamotrigine are not. However, some anticonvulsants may be efficacious in treating some psychiatric comorbidities that are commonly associated to bipolar illness.

Functional outcome in bipolar disorder: the role of clinical and cognitive factors

INTRODUCTION

Few studies have examined the clinical, neuropsychological and pharmacological factors involved in the functional outcome of bipolar disorder despite the gap between clinical and functional recovery.

METHODS

A sample of 77 euthymic bipolar patients were included in the study. Using an a priori definition of low versus good functional outcome, based on the psychosocial items of the Global Assessment of Functioning (GAF, DSM-IV), and taking also into account their occupational adaptation, the patients were divided into two groups: good or low occupational functioning. Patients with high (n = 46) and low (n = 31) functioning were compared on several clinical, neuropsychological and pharmacological variables and the two patient groups were contrasted with healthy controls (n = 35) on cognitive performance.

RESULTS

High- and low-functioning groups did not differ with respect to clinical variables. However, bipolar patients in general showed poorer cognitive performance than healthy controls. This was most evident in low-functioning patients and in particular on verbal memory and executive function measures.

CONCLUSIONS

Low-functioning patients were cognitively more impaired than highly functioning patients on verbal recall and executive functions. The variable that best predicted psychosocial functioning in bipolar patients was verbal memory.

The value of neurophysiological and MRI assessment in demyelinating optic neuritis (DON)

PURPOSE

To study, by neurophysiological means, the possible involvement of the retina, in demyelinating optic neuritis (DON).

MATERIAL AND METHODS

Thirty-five patients fulfilling strict criteria of unilateral DON were investigated with a battery of neurophysiological tests and MRI within 3 weeks of the onset of their symptoms. Flash-ERG (F-ERG) in photopic conditions, Flash-VEPs and PR-VEPs were recorded. MRI of the brain and the optic nerve were performed.

RESULTS

The amplitude of b-wave of F-ERG in photopic conditions was statistically significantly lower in the affected eye (p < 0.001) compared to normal controls, whereas in the unaffected eye, it was also statistically significantly lower than normal controls (p < 0.01). All patients had statistically significant prolongation of P100 latency in PR-VEPs of the affected eye (p < 0.001) in comparison to normal controls. The P100 wave of the unaffected eye was also delayed (p < 0.01). In MRI, Gd-DTPA enhancement was observed in 7 symptomatic nerves with only minimal enhancement of the optic nerve between optic chiasm and optic canal, whereas 11 patients were presented with intracranial associated plaques. Five of the above patients had optic nerve enhancement and diffused demyelinating findings simultaneously.

CONCLUSION

These results are a neurophysiological indication of involvement of the retina in DON, probably of vascular origin.

Changes in pupil reaction to light in melancholic patients

The aim of the current study was to compare the pupil reaction to light in depressed patients and normal control subjects. Seven depressed patients with melancholic features according to DSM-IV criteria and 14 age- and gender-matched control subjects took part in the study. All were free of any medication for at least 2 weeks. All were aged between 25 and 50 years. An optical method was used to assess the pupil reaction to a single flash. Depressed patients manifested shorter latency for constriction than control subjects, and a marginal difference in the total work produced by acetylcholine. The results of the current study support the theory that there is a norepinephrine hypoactivity in melancholic depression, with less affected acetylcholine activity.

The concept of mental disorder in Greek cinema

Mental patients in Greek society have never been considered as 'sacred', but on the contrary as handicapped, and cinema largely reflects these concepts. A total of 30 films that appeared to deal with mental disorder in a direct or indirect way have been reviewed. The identification of each mental disorder was made according to DSM-IV criteria. Five of these cases were presented as having a factitious disorder, seven were psychotic and two had dissociative (hysterical) disorders. The remaining eight cases related to personality disorder or character deviance. In two cases diagnosis was impossible. The image of mental disorder is consistent with psychiatric nosology, and disorders with 'dramatic' or 'impressive' manifestation of symptomatology are chosen. No real solutions, proposals or ideology on mental illness emerge.

Changes in psychophysiological processing of vision in myasthenia gravis

OBJECTIVE

To investigate the possibility of impaired central nervous system (CNS) cholinergic transmission in myasthenia gravis (MG), and the effect of eye movements and particularly of micromovements in the psychophysiology of vision.

MATERIALS AND METHODS

Fourteen patients with clinical manifestations of external ophthalmoplegia due to different causes (nine patients with myasthenia gravis and five with ocular myopathy) were examined. Simultaneous recording of eye movements (optical method) and pattern reversal-visual evoked potentials (PR-VEPs) were performed.

RESULTS

Eye micromovements during fixation were impaired in both groups. A statistically significant difference (P < 0.01) was found in the amplitude of P100 of PR-VEPs before and after treatment in MG patients, and also between normal controls and MG patients before (P < 0.001) and after treatment (P < 0.01). P100 latency of the PR-VEPs in MG patients before and after treatment was delayed compared to normal controls, while there were no differences between ocular myopathy patients and normal controls.

CONCLUSION

The eye movement impairment observed in MG patients is not sufficient to explain abnormal PR-VEPs detected in these patients. These results provide neurophysiological evidence of impaired cholinergic transmission in the central nervous system in patients with MG and suggest that PR-VEPs offer an easily applicable non-invasive method to study the central effects of MG.

Burnout in nursing staff: a clinical syndrome rather than a psychological reaction?

The aim of this study was to investigate the relationship between the development of burnout in the nursing staff and traits of personality, as well as sociodemographic and professional characteristics. Maslach Burnout Inventory and Eysenck Personality Questionnaire were used to evaluate all the members of the nursing staff of General Hospital AHEPA. Data on sociodemographic and professional characteristics of the staff were gathered as well. The analysis showed that there is a complex interaction of the measured characteristics of the sample that leads to the development of burnout. The model of burnout development is not only nonlinear, that is, different variables play a different role in each level of burnout development, but also points to a discontinuity between 'normal' attitude towards work and true burnout. This suggests the possibility that burnout is a true clinical syndrome with neurotic features rather than a magnification of normal tiredness from work.

Alzheimer's Disease Assessment Scale: the validation of the scale in Greece in elderly demented patients and normal subjects

INTRODUCTION

The Alzheimer Disease Assessment Scale (ADAS) is a scale specifically structured for the assessment of the cognitive decline and behavioral disorder seen in Alzheimer disease (AD) patients.

AIM OF THE STUDY

The validation of ADAS in the Greek population.

MATERIAL

One hundred and thirty-one subjects took part in the current study. Fifty of them were nondemented subjects (35 normal subjects and 15 suffering from age-associated memory impairment) and 81 demented patients (68 AD patients and 13 vascular dementia, VD, patients).

METHOD

Diagnosis was made according to DSM-IV and NINCDS-ADRDA criteria. Hachinski Ischemia Scale was used to help to differentiate between AD and VD patients. Geriatric Depression Scale was used to quantify depressive symptomatology. MMSE and CAMCOG were used to assess the cognitive functioning of all subjects and FRSSD for the assessment of daily functioning. All subjects underwent a complete laboratory and biochemical testing, according to the protocol proposed in CAMDEX. All demented patients underwent brain CT.

RESULTS

ADAS-Cog discriminates perfectly AD patients and nondemented subjects at the score level of 13/14 and/or 14/15. Principal components analysis, using only AD patients, revealed 4 factors: cognitive, psychotic, depressive, and 'severe apraxia' factors.

CONCLUSION

ADAS is suitable for use in the discrimination between AD patients and nondemented subjects. It is also suitable for a more comprehensive assessment of the clinical symptomatology of AD patients, and for the evaluation of new therapeutic methods for AD, as well.

Risk factors for clinically diagnosed Alzheimer's disease: a case-control study of a Greek population

Many efforts have been made to trace the causes of Alzheimer's disease (AD). There are, however, many points of controversy among reports from the same country as well as among reports from different countries. The current study is a case-control study to determine the risk factors in the development of AD in Greece. Sixty-five patients with AD and 69 age-matched controls were examined. All patients with AD fulfilled the DSM-IV criteria for AD and NINCDS-ADRDA criteria for probable AD. Demographic characteristics such as gender, current marital status, who he/she is living with, education, main place of residence in childhood, adulthood, and late life, occupational hazards, patient's medical history (history of diabetes mellitus and hypertension), life habits like alcohol consumption and smoking, and a history of head trauma, heart attack, stroke, parkinsonism, or depression were collected from the subject or from an informant. A family history of selected diseases (hypertension, diabetes mellitus, dementia, Parkinson's disease, Down's syndrome, stroke) was also elicited. Ages of father and mother at birth were also recorded. Chi-square test, Kruskal-Wallis analysis of variance, cluster analysis, and logistic regression analysis were used for statistical analysis. The results (chi-square test) showed a statistically significant difference between patients with dementia of the Alzheimer type and controls as far as marital status (p = .04), the subject's history of major depressive episode (p = .02), and family history of dementia (p = .002) were concerned. Logistic regression analysis results produced a complex model of family aggregation of dementia, with patients with a history of depression and family history of dementia having an up to seven times higher risk of developing AD. These findings, especially a family history of dementia, are consistent with most of the literature.

Dermatomal SEPs--a complementary study in evaluating patients with lumbosacral disc prolapse

We investigated the value of Dermatomal Somatosensory Evoked Potentials in 24 patients with unilateral radiculopathy due to lumbosacral disk prolapse. All patients had clinical signs and symptoms of disk prolapse and positive findings on neuroradiologic testing. We assessed the latency and the amplitude of the first positive waveform of Dermatomal SEPs, as well as conducting peripheral nerve conduction studies and electromyography. Our studies showed a clear correlation of Dermatomal SEP abnormalities and radiculopathy in up to 83.3% of subjects studied. Use of electromyography testing provided this correlation in about 62.5% of the same subjects. On the basis of these results, we propose that Dermatomal SEPs have value in complementing the routine electrophysiological testing of the patients with radiculopathy and provide a sensitive non-invasive technique for defining the level of disk prolapse.