Cross-cultural differences through subjective cognition: illustration in translatology with the SSTIC-E in the UAE

The development of appropriate and valid multicultural and multilingual instruments research is necessary due to a growing multicultural and multilingual society in the 21st century. We explored the use of a cognitive scale related to subjective complaints, focusing on the first step: a cross-cultural and semantic validation. This study presents the translation and cross-validation process of the "Subjective Scale to Investigate Cognition in Schizophrenia" (SSTICS) for the United Arab Emirates (UAE) region via different languages used in Dubaï/Abu Dhabi. This scale measures cognitive complaints and has been validated with psychosis and used in 20 clinical trials worldwide. It evaluates areas of the illness related to self-awareness focusing on memory dysfunction and deficits of attention, language, and praxis. We described the method of cross-cultural validation, with back-translation, semantic steps, and societal contexts. The use of the Subjective Scale to Investigate Cognition in Emirates (SSTIC-E) was explored with different samples of UAE Arabic-speaking subjects. First, a pilot sample mean SSTICS total score was 16.5 (SD:16.9); (p < 0.001). The SSTIC-E was then administered to 126 patients and 84 healthy control participants. The healthy group has a lower mean score of 22.55 (SD = 12.04) vs. 34.06 (SD = 15.19). The method was extended to nine other languages, namely, Pakistani/Urdu, Hindi, Marathi, Lithuanian, Serbian, German, Romanian, Sinhala, and Russian. The scales are provided in the article. The overall aim of the translation process should be to stay close to the original version of the instrument so that it is meaningful and easily understood by the target language population. However, for construct validity, some items must be adapted at the time of translation to ensure that the questioned cognitive domain is respected. For example, cooking, an executive function, does not have the same occurrence for an Emirati male, or remembering a prime minister's name, semantic memory, requires an electoral system to appoint the leader of a country. Translation methods and processes present many challenges but applying relevant and creative strategies to reduce errors is essential to achieve semantic validation. This study aims to measure personally experienced knowledge or attitudes; such language effects can be a thorny problem.

Treatment with psychostimulants and atomoxetine in people with psychotic disorders: reassessing the risk of clinical deterioration in a real-world setting

BACKGROUND

Although attention-deficit hyperactivity disorder (ADHD) is often comorbid with schizophrenia spectrum and other psychotic disorders (SZSPD), concerns about an increased risk of psychotic events have limited its treatment with either psychostimulants or atomoxetine.

AIMS

To examine whether the risk of hospital admission for psychosis in people with SZSPD was increased during the year following the introduction of such medications compared with the year before.

METHOD

This was a retrospective cohort study using Quebec (Canada) administrative health registries, including all Quebec residents with a public prescription drug insurance plan and a diagnosis of psychotic disorder, defined by relevant ICD-9 or ICD-10 codes, who initiated either methylphenidate, amphetamines or atomoxetine, between January 2010 and December 2016, in combination with antipsychotic medication. The primary outcome was time to hospital admission for psychosis within 1 year of initiation. State sequence analysis was also used to visualise admission trajectories for psychosis in the year following initiation of these medications, compared with the previous year.

RESULTS

Out of 2219 individuals, 1589 (71.6%) initiated methylphenidate, 339 (15.3%) amphetamines and 291 (13.1%) atomoxetine during the study period. After adjustment, the risk of hospital admission for psychosis was decreased during the 12 months following the introduction of these medications when used in combination with antipsychotics (adjusted HR = 0.36, 95% CI 0.24-0.54; P < 0.0001).

CONCLUSIONS

These findings suggest that, in a real-world setting, when used concurrently with antipsychotic medication, methylphenidate, amphetamines and atomoxetine may be safer than generally believed in individuals with psychotic disorders.

Prevalence and risk factors for metabolic syndrome in schizophrenia, schizoaffective, and bipolar disorder

BACKGROUND

Metabolic Syndrome (MetS) is a risk for developing cardiovascular diseases and its prevalence is especially high in psychiatric patients. To date, there is limited data from the United Arab Emirates (UAE) on the prevalence of MetS. Therefore, we aimed to investigate its prevalence and possible risk factors in a large sample of psychiatric patients in the UAE.

METHODS

A cross-sectional study was conducted at Al-Ain Hospital, in Al-Ain City, UAE. We collected demographic and clinical data on patients diagnosed with schizophrenia, schizoaffective, and bipolar affective disorder in the period between January 2017 and December 2020. This included their secondary diagnosis (psychiatric or medical), vital signs (heart rate, systolic and diastolic blood pressure, Body Mass Index [BMI]), metabolic parameters (fasting blood glucose, cholesterol, triglycerides, low-density lipoprotein, high-density lipoproteins), and prescribed medications. We used the American Association of Clinical Endocrinology (AACE) criteria to diagnose MetS.

RESULTS

We included 889 subjects and of these, 79.8% (N = 709) had a BMI ≥25 kg/m2 and 9.8% (N = 87) had no abnormal metabolic parameters. Overall, 28.1% (N = 250) had MetS with no statistical difference between the three groups. Fasting blood glucose levels and abnormally elevated triglycerides were significant predictors for MetS.

CONCLUSION

Our study found that around one in three patients had MetS irrespective of the three diagnoses. Some variables were significant predictors for MetS. Our findings were consistent with other studies and warrant the need for regular screening and management of abnormal metabolic parameters.

Metabolic syndrome and its relation to antipsychotic polypharmacy in schizophrenia, schizoaffective and bipolar disorders

The risk of metabolic syndrome (MetS) has been attributed to antipsychotic use in psychiatric patients. To date, there is limited data on the relationship between antipsychotic polypharmacy and MetS in patients with schizophrenia, schizoaffective disorder and bipolar disorder. Therefore, we aimed to investigate the rate of MetS in patients with these disorders receiving antipsychotic monotherapy and polypharmacy. We conducted a cross-sectional study on patients seen between January 2017 and December 2020, collecting data on the class, type, route of administration and number of antipsychotics received. We used the American Association of Clinical Endocrinology criteria to diagnose MetS. We included 833 subjects of whom 573 (68.8%) received antipsychotic monotherapy and 260 (31.2%) received polypharmacy. Overall, 28.6% (N = 238) had MetS with no statistical difference between the two groups. Diastolic blood pressure and receiving olanzapine were significant predictors for developing MetS. In conclusion, our study found no significant difference in the rate of MetS between antipsychotic monotherapy and polypharmacy. A number of variables were significant predictors for MetS. Our findings were consistent with other studies and warrant the need for careful choice of antipsychotics and regular screening and management of abnormal metabolic parameters.

Evaluating real-world effectiveness of accelerated transcranial magnetic stimulation for treatment-resistant depression in a tertiary referral center based in Quebec, Canada

OBJECTIVE

To assess the effectiveness of accelerated transcranial magnetic stimulation (TMS) for treatment-resistant depression (TRD) in a tertiary referral center in Quebec, Canada, focusing on a real-world clinical setting.

METHODS

We reviewed the data of 247 TRD patients treated between January 2012 and May 2022 who received accelerated TMS. Participants were adults diagnosed with unipolar or bipolar depression, resistant to at least two antidepressant trials, and assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Significant symptom reduction was found in the completer sample (N = 147), with 46.3 % of patients meeting post-treatment response criteria and 36.1 % achieving remission. Baseline severity of depression, age, and the number of antidepressant trials were key predictors of treatment outcomes. Patients who did not complete treatment had generally more severe depressive and anxious symptoms and greater treatment resistance. No significant differences in response rates were observed across different TMS coils.

CONCLUSION

The study demonstrated the effectiveness and tolerability of accelerated TMS for TRD in a real-world clinical setting.

Happy Birthday "One Flew Over the Cuckoo's Nest": A Momentous Tale in the Quest for an Effective and Ethical Approach to Psychosurgery

The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.

The Utility of CYP2D6 and CYP2C19 Variants to Guide Pharmacological Treatment in Complex Unipolar Major Depression: A Pilot Longitudinal Study

Major depression is a frequent condition which variably responds to treatment. In view of its high prevalence, the presence of treatment resistance in major depression significantly impacts on quality of life. Tailoring pharmacological treatment based on genetic polymorphisms is a current trend to personalizing pharmacological treatment in patients with major depressive disorders. Current guidelines for the use of genetic tests in major depression issued by the Clinical Pharmacogenomics Implementation Consortium (CPIC) are based on CYP2D6 and CYP2C19 polymorphisms which constitute the strongest evidence for pharmacogenomic guided treatment. There is evidence of increased clinical response to pharmacological treatment in major depression although largely in non-treatment resistant patients from Western countries. In this study, well characterised participants (N = 15) with complex, largely treatment resistant unipolar major depression were investigated, and clinical improvement was measured at baseline and at week-8 after the pharmacogenomics-guided treatment with the Montgomery Åsberg Depression Rating Scale (MÅDRS). Results suggested a statistically significant improvement (p = 0.01) of 16% at endpoint in the whole group and a larger effect in case of changes in medication regime (28%, p = 0.004). This small but appreciable effect can be understood in the context of the level of treatment resistance in the group. To our knowledge, this is the first study from the Middle East demonstrating the feasibility of this approach in the treatment of complex major depressive disorders.

Can Cotard Syndrome Be Induced?: Illustration With a Rare Case of Potential Organ Transplant

ABSTRACT

Cotard syndrome is a rare condition characterized by delusions ranging from a belief that one has lost organs to insisting that one has lost one's soul or is dead. This is the report a case of a 45-year-old man who was comatose after an attempted suicide. This was initially diagnosed as brain death and use of his organs for transplantation was actively considered. However, he awakened days later with new-onset Cotard syndrome. It remains difficult to know the link, unconscious or conscious, between this patient's delusions and the fleeting intention of doctors who intended to transplant his organs. This is the first description of a coincidence between delusional denial of an organ and the potential medico-surgical act of having an organ removed. This case is an opportunity to revisit the philosophical concepts of negation and nihilism. A multidisciplinary reflection is needed to give meaning to other clinical presentations.

Head to Toe Psychiatry: The Lady Who Limped in front of a Psychiatrist

Physical examination is a core component of any assessment done by a physician. Despite that, a physical examination is not always a top priority in many patients with psychiatric illnesses. We present the case of a woman with a prior diagnosis of a delusional disorder with overinvested religious beliefs. The patient had been stable on treatment for many years and only recently presented with a physical complaint, and manifestation assumed to be due to the nature of her psychiatric illness and, hence, overlooked by many physicians before being examined by her last psychiatrist. This resulted in a significant mobility problem for the patient. The patient showed partial insight, linking her pain to a “message from God.” Despite the delusional context, the psychiatrist was allowed to examine her feet and discovered significant neglect and poor foot hygiene. This case emphasizes the importance of conducting thorough physical examinations in psychiatric settings. Moreover, it presents an example of situations preventing psychiatric patients from being examined despite displaying obvious physical signs.

Prevalence and correlates of health anxiety among medical students: a cross-sectional study from the United Arab Emirates

Background

It is often reported that medical students repeatedly develop health anxiety related to the diseases that they are studying. To the best of our knowledge, health anxiety has not been investigated in medical students in the United Arab Emirates (UAE). Therefore, we aimed to investigate the prevalence of health anxiety among a sample of medical students attending the United Arab Emirates University (UAEU). We conducted a cross-sectional study of 193 undergraduate medical students (68 males, 125 females) across the 6 years of the College of Medicine at the UAEU. Students were screened for health anxiety using the Short Health Anxiety Inventory (SHAI).

Results

Eighteen students (9.3%) reached the threshold for clinically significant health anxiety on the SHAI (score ≥ 27). There was no statistically significant difference between those with and those without health anxiety in age, gender, place of origin, or year of study. There was a statistically significant difference (p < 0.05) between the two groups as regards a past history of medical or mental health conditions influencing their choice of college. No specific student demographic or background characteristics significantly predicted the occurrence of clinically significant health anxiety.

Conclusions

Health anxiety was prevalent in a significant proportion of subjects in our sample (almost one in every ten students). Individual experiences of medical and mental illness may play a role in the development of health anxiety and in the choice of studying medicine.

Effectiveness of pharmacogenomic tests including CYP2D6 and CYP2C19 genomic variants for guiding the treatment of depressive disorders: Systematic review and meta-analysis of randomised controlled trials

Major depressive disorders are prevalent conditions with limited treatment response and remission. Pharmacogenomics tests including CYP2D6 and CYP2C19 genomic variants provide the most reliable actionable approach to guide choice and dosing of antidepressants in major depression to improve outcomes. We carried out a meta-analysis and meta-regression analyses of randomised controlled trials evaluating pharmacogenomic tests with CYP2D6 and CYP2C19 polymorphisms in major depression. A systematic review was conducted according to PRISMA and Cochrane guidelines to search several electronic databases. Logarithmically transformed odds ratios (OR) and confidence intervals (CI) for improvement, response and remission were calculated. A random-effects meta-analysis and meta-regression analyses were subsequently carried out. Twelve randomised controlled trials were included. Pharmacogenomic tests in the treatment of depression were more effective than treatment as usual for improvement (OR:1.63, CI: 1.19-2.24), response (OR: 1.46; CI: 1.16-1.85) and remission (OR: 1.85; CI: 1.23-2.76) with no evidence of publication bias. Remission was less favourable in recent studies. The results are promising but cautious use of pharmacogenomics in major depression is advisable. PROSPERO registration ID: CRD42021261143.

Subjective cognitive complaints in first episode psychosis: A focused follow-up on sex effect and alcohol usage

A network of early psychosis-specific intervention programs at the University of Montreal in Montreal, Quebec, Canada, conducted a longitudinal naturalistic five-year study at two Urban Early Intervention Services (EIS). In this study, 198 patients were recruited based on inclusion/exclusion criteria and agreed to participate. Our objectives were to assess the subjective cognition complaints of schizophrenic patients assessed by Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) in their first-episode psychosis (FEP) in relation to their general characteristics. We also wanted to assess whether there are sex-based differences in the subjective cognitive complaints, as well as differences in cognitive complaints among patients who use alcohol in comparison to those who are abstainers. Additionally, we wanted to monitor the changes in the subjective complaints progress for a period of five years follow-up. Our findings showed that although women expressed more cognitive complaints than men [mean (SD) SSTICS, 28.2 (13.7) for women and 24.7 (13.2) for men], this difference was not statistically significant (r = −0.190, 95 % CI, −0. 435 to 0. 097). We also found that abstainers complained more about their cognition than alcohol consumers [mean (SD) SSTICS, 27.9 (13.4) for abstainers and 23.7 (12.9) for consumers], a difference which was statistically significant (r = −0.166, 95 % CI, −0. 307 to −0.014). Our findings showed a drop in the average score of SSTICS through study follow-up time among FEP patients. In conclusion, we suggest that if we want to set up a good cognitive remediation program, it is useful to start with the patients' demands. This demand can follow the patients' complaints. Further investigations are needed in order to propose different approaches between alcohol users and abstinent patients concerning responding to their cognitive complaints.

Frequency of illness anxiety (hypochondriasis) by proxy encountered by doctors in parents towards their children

BACKGROUND

Illness anxiety disorder is a condition of having a persistent fear of having a serious or life-threatening illness despite few or no symptoms. Current classification systems assume that illness anxiety is experienced relative to one's own health, and not towards others ("by proxy"), yet it has been observed to occur in parents towards their children. This study was designed to survey doctors about how commonly they encounter illness anxiety by proxy (IAP).

METHODS

We conducted a qualitative survey of 149 physicians who work with children (pediatricians, psychiatrists, and general practitioners) from the United Arab Emirates (UAE) and Egypt. The survey was administered via email and a paper-based form. In the UAE, 108 physicians were emailed the survey; 55 (50.1%) responded. For the email survey we used items from the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). An additional 100 physicians were surveyed in person; 94 (94%) responded.

RESULTS

Nearly all respondents (98.7%) reported having encountered IAP in parents. Of these, 51 (34.2%) reported frequently encountering these types of health anxieties, and 50 (33.6%) reported that the parents' concern that their child had a serious disease persisted despite reassurance and appropriate medical evaluation. Seventy-eight (52.3%) respondents reported that exaggeration of actual existing symptoms was the most common reason for parents' fears; 72 (48.3%) reported that the concerned parent was more likely to be the mother; and 36 (24.2%) reported that most parents were not 100% certain of their own beliefs.

CONCLUSIONS

IAP is frequently encountered by pediatricians, psychiatrists, and general practitioners. Practitioners who work with children and their parents need to be aware of this phenomenon to provide appropriate support and treatment. More research is needed to screen for the extent and severity of this phenomenon.

A functional neuroimaging study of self-other processing alterations in atypical developmental trajectories of psychotic-like experiences

Self-disturbances constitute a hallmark of psychosis, but it remains unclear whether these alterations are present in at-risk populations, and therefore their role in the development of psychosis has yet to be confirmed. The present study addressed this question by measuring neural correlates of self-other processing in youth belonging to three developmental trajectories of psychotic experiences. Eighty-six youths were recruited from a longitudinal cohort of over 3800 adolescents based on their trajectories of Psychotic-Like Experiences from 12 to 16 years of age. Participants underwent neuroimaging at 17 years of age (mean). A functional neuroimaging task evaluating self- and other-related trait judgments was used to measure whole-brain activation and connectivity. Youth who showed an increasing trajectory displayed hypoactivation of the dorsomedial prefrontal cortex and hypoconnectivity with the cerebellum. By contrast, youth who showed a decreasing trajectory displayed decreased activation of the superior temporal gyrus, the inferior frontal gyrus, and the middle occipital gyrus. These findings suggest that the increasing trajectory is associated with alterations that might erode distinctions between self and other, influencing the emergence of symptoms such as hallucinations. The decreasing trajectory, in comparison, was associated with hypoactivations in areas influencing attention and basic information processing more generally. These alterations might affect the trajectories’ susceptibilities to positive vs. negative symptoms, respectively.

Impact of early use of long-acting injectable antipsychotics on functional outcome in first episode psychosis: a 3-year longitudinal study

OBJECTIVES

To describe, in a naturalistic setting, the impact of the early use of LAI-AP on functional outcomes of early psychosis patients as compared to oral antipsychotics (OAP).

METHODS

Longitudinal prospective 3-year naturalistic study of all consecutive admissions (n = 416) to two Early intervention services (EIS) for psychosis comparing baseline characteristics and the evolution of global functioning, occupation (work and studies), and living arrangements autonomy according to the route of administration of the antipsychotic medication. The cohort was divided into four groups: LAI-AP first (started on LAI-AP and later received OAP), OAP first, LAI-AP only, and OAP only.

RESULTS

Global assessment of functioning (GAF) improved in all groups, but our mixed-effect model did not show any significant association between the route of administration and the GAF outcome. The LAI-AP only group was significantly less likely to have extreme residential instability at 3 years than the other groups despite its highest proportion of homeless youth and their poor prognostic factors at baseline.

CONCLUSIONS

Our naturalistic study suggests a significant protective effect of LAI-AP on extreme residential instability for the most vulnerable patients, but no impact of the first AP administration route on other functional outcomes was observed at 3 years of follow-up. Key pointsLong-acting injectable antipsychotics seem promising to avoid extreme residential instability in early psychosis.Global assessment of functioning (GAF) improved in all groups.There was no significant association between the first route of administration and global functionning.

Comparative effectiveness and safety of antipsychotic drugs in patients with schizophrenia initiating or reinitiating treatment: A Real-World Observational Study

OBJECTIVE

To compare the effectiveness and safety of various second-generation antipsychotics (SGAs), newer oral and long-acting injectable (LAI) SGAs, and first-generation antipsychotics (FGAs) treatments in patients with schizophrenia or schizoaffective disorder (SCZ).

METHODS

This retrospective cohort study included medical administrative information for patients with a diagnosis of SCZ living in Quebec (Canada), initiating or reinitiating at least one antipsychotic (AP) drug (with a clearance baseline period of 12 months without any APs). Effectiveness was defined by a reduced risk of hospitalization for mental disorder and discontinuation, and safety by a reduced risk of all-cause death and hospitalization for non-mental disorder, 2 years after AP initiation or reinitiation. Cox proportional hazard models were used to estimate the events associated with different antipsychotics compared with oral olanzapine.

RESULTS

The study cohort included 19,615 patients initiating or reinitiating an antipsychotic drug between January 2006 and December 2015. Results showed better effectiveness of clozapine (adjusted HR 0.36, 95% CI 0.30-0.42, p < 0.0001) and LAI SGAs (adjusted HR 0.56, 95% CI 0.51-0.61, p < 0.0001) compared with oral olanzapine when adding discontinuation to hospitalizations for mental disorder as a composite measure of effectiveness, as opposed to oral FGAs (adjusted HR 1.36, 95% CI 1.27-1.46, p < 0.0001) and LAI FGAs (adjusted HR 1.22, 95% CI 1.12-1.32, p < 0.0001). Most APs were as safe as oral olanzapine.

CONCLUSION

The effectiveness of LAI SGAs and clozapine appears to justify their use and are as safe as a recognized treatment (oral olanzapine) in Quebec (Canada).

Antipsychotic utilization trajectories three years after initiating or reinitiating treatment of schizophrenia: A state sequence analysis approach

OBJECTIVE

This study aims to describe the utilization patterns of antipsychotic (AP) medication in patients with schizophrenia (SCZ), three years after initiating or reinitiating a given AP.

METHODS

Based on medico-administrative information on patients living in Quebec (Canada), this retrospective cohort study included 6444 patients with a previous diagnosis of SCZ initiating or reinitiating AP medication between January 1, 2012, and December 31, 2014, with continuous coverage by public drug insurance. For each day of follow-up (1092 days), patient was either exposed to one of the chosen categories of APs, or to none. This patient's sequence of AP exposure overtime has been referred to as the "antipsychotic utilization trajectory". These trajectories were analyzed using a State Sequence Analysis, an innovative approach which provides useful visual information on the continuation and discontinuation patterns of use over time.

RESULTS

Clozapine and long-acting injectable second-generation APs had the best continuation and discontinuation patterns over 3 years among all other groups, including less switching of APs, while oral first-generation APs had the poorest patterns. These findings were comparable among incident and non-incident cohorts. Oral second-generation antipsychotics, excluding clozapine, had a poorer continuation and discontinuation pattern than long-acting injectable antipsychotics.

CONCLUSION

State Sequence Analysis provides a clear representation of treatment adherence in comparison with dichotomous indicators of adherence or discontinuation. Consequently, this innovative method has shed light on the impact of the AP chosen to initiate or reinitiate treatment in SCZ, which has been identified as a key factor for long-term treatment continuation and discontinuation.

Association between previous and future antipsychotic adherence in patients initiating clozapine: real-world observational study

BACKGROUND

Although recognised as the most effective antipsychotic for treatment-resistant schizophrenia, clozapine remains underused. One reason is the widespread concern about non-adherence to clozapine because of poor adherence before initiating clozapine.

AIMS

To determine if prior poor out-patient adherence to treatmentbefore initiating clozapine predisposes to poor out-patient adherence to clozapine or to any antipsychotics (including clozapine) after its initiation.

METHOD

This cohort study included 3228 patients with schizophrenia living in Quebec (Canada) initiating (with a 2-year clearance period) oral clozapine (index date) between 2009 and 2016. Using pharmacy data, out-patient adherence to treatment was measured by the medication possession ratio (MPR), over a 1-year period preceding and following the index date. Five groups of patients were formed based on their prior MPR level (independent variable). Two dependent variables were defined after clozapine initiation (good out-patient adherence to any antipsychotics and to clozapine only). Along with multiple logistic regressions, state sequence analysis was used as a visual representation of antipsychotic-use trajectories over time, before and after clozapine initiation.

RESULTS

Although prior poor adherence to antipsychotics was associated with poor adherence after clozapine initiation, the absolute risk of subsequent poor adherence remained low, regardless of previous adherence level. Most patients adhered to their treatment after initiating clozapine (>68% to clozapine and >84% to any antipsychotics).

CONCLUSIONS

Despite the fact that poor adherence prior to initiating clozapine is widely recognised by clinicians as a barrier for the prescription of clozapine, the current study supports the initiation of clozapine in all eligible patients.

Perception of Cosmetic Procedures among Middle Eastern Youth

BACKGROUND

In the past decade, there has been an increase in the number of cosmetic procedures performed globally. About one-third of individuals who undergo cosmetic procedures are under the age of 35. The United Arab Emirates (UAE) has become a regional hub for cosmetic procedures. This cross-sectional study examines the perception of cosmetic procedures among youth in the UAE.

METHODS

A 63-question survey was electronically disseminated to university students to identify factors associated with the use of cosmetic procedures in this population.

RESULTS

Ninety-one percent of the 178 participants were female, and 58 percent of them were aged 19 to 21. The majority of the participants felt cosmetic procedures are gaining acceptance in UAE society. Nearly 70 percent of participants felt that a legal and regulatory framework was important to determine the permissible age for undergoing cosmetic surgeries.

LIMITATIONS

One limitation of the study lies in a modest response rate of 35.6 percent. There was a small number of male responders, and the assessment of differences between sex was not easy to conduct.

CONCLUSION

Cosmetic procedures are increasingly being accepted among youth in the Middle East, with skin and nasal procedures being the most popular. The youth's concept of ideal body shape is in alignment with the Western ideas of beauty. Future research could characterize these perceptions in other cultures and explore differences in what is perceived to be beautiful in various parts of the world.

More than just anti-NMDAR: the many facets of autoimmune encephalitis

This editorial expands on a Praxis article published by Beattie and colleagues in the trainees' section of this journal. The authors describe an interesting case of anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, outline the clinical presentation and make suggestions on ways to approach this rare disorder. Here we provide an overview of autoimmune conditions that result in the production of autoantibodies targeting central nervous system proteins mediating autoimmune encephalitis and offer a perspective on approaches to diagnosis and treatment.

Exploring cannabidiol effects on inflammatory markers in individuals with cocaine use disorder: a randomized controlled trial

Cocaine use disorder (CUD) is a major public health issue associated with physical, social, and psychological problems. Excessive and repeated cocaine use induces oxidative stress leading to a systemic inflammatory response. Cannabidiol (CBD) has gained substantial interest for its anti-inflammatory properties, safety, and tolerability profile. However, CBD anti-inflammatory properties have yet to be confirmed in humans. This exploratory study is based on a single-site randomized controlled trial that enrolled participants with CUD between 18 and 65 years, randomized (1:1) to daily receive either CBD (800 mg) or placebo for 92 days. The trial was divided into a 10-day detoxification (phase I) followed by a 12-week outpatient follow-up (phase II). Blood samples were collected from 48 participants at baseline, day 8, week 4, and week 12 and were analyzed to determine monocytes and lymphocytes phenotypes, and concentrations of various inflammatory markers such as cytokines. We used generalized estimating equations to detect group differences. Participants treated with CBD had lower levels of interleukin-6 (p = 0.017), vascular endothelial growth factor (p = 0.032), intermediate monocytes CD14⁺CD16⁺ (p = 0.024), and natural killer CD56^negCD16^hi (p = 0.000) compared with participants receiving placebo. CD25⁺CD4⁺T cells were higher in the CBD group (p = 0.007). No significant group difference was observed for B lymphocytes. This study suggests that CBD may exert anti-inflammatory effects in individuals with CUD.

Cannabidiol as a treatment for craving and relapse in individuals with cocaine use disorder: a randomized placebo-controlled trial

BACKGROUND AND AIMS

Cocaine use disorder (CUD) is a significant public health concern for which no efficacious pharmacological interventions are available. Cannabidiol (CBD) has attracted considerable interest as a promising treatment for addiction. This study tested CBD efficacy for reducing craving and preventing relapse in people with CUD.

DESIGN

Single-site double-blind randomized controlled superiority trial comparing CBD with placebo.

SETTING AND PARTICIPANTS

Centre Hospitalier de l'Université de Montréal, Canada. Seventy-eight adults (14 women) with moderate to severe CUD participated.

INTERVENTION

Participants were randomly assigned (1 : 1) by stratified blocks to daily 800 mg CBD (n = 40) or placebo (n = 38). They first underwent an inpatient detoxification phase lasting 10 days. Those who completed this phase entered a 12-week outpatient follow-up.

MEASUREMENTS

Primary outcomes were drug-cue-induced craving during detoxication and time-to-cocaine relapse during subsequent outpatient treatment.

FINDINGS

During drug-cue exposure, craving scores [mean ± standard deviation (SD)] increased from baseline by 4.69 (2.89) versus 3.21 (2.78) points, respectively, in CBD (n = 36) and placebo (n = 28) participants [confidence interval (CI) = -0.33 to 3.04; P = 0.069; Bayes factor = 0.498]. All but three participants relapsed to cocaine by week 12 with similar risk for CBD (n = 34) and placebo (n = 27) participants (hazard ratio = 1.20, CI = 0.65-2.20, P = 0.51; Bayes factor = 0.152). CBD treatment was well tolerated and associated mainly with diarrhoea.

CONCLUSIONS

CBD did not reduce cocaine craving or relapse among people being treated for CUD.

Efficacy of onabotulinumtoxinA in the treatment of unipolar major depression: Systematic review, meta-analysis and meta-regression analyses of double-blind randomised controlled trials

BACKGROUND

OnabotulinumtoxinA is a novel therapeutic intervention whose mechanism of action is believed to modify the negative facial feedback, thus abating symptoms of depression. This putative new antidepressant agent offers minimal systemic side effects and negligible risk of pharmacological interactions. We set out to examine the evidence for the use of onabotulinumtoxinA in major depression.

METHODS

A systematic search of the literature identified double-blind randomised controlled trials (RCTs) investigating the use of onabotulinumtoxinA in the treatment of major depression versus placebo. Data, reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), was combined in meta-analyses (PROSPERO registration ID: CRD42020183538).

RESULTS

The search identified five RCTs (four double-blind) comparing onabotulinumtoxinA to placebo. OnabotulinumtoxinA was more effective than placebo when administered within the 20-40 IU dose range in double-blind RCTs. The analysis was free of publication bias and significantly heterogeneous. Meta-regression analyses indicated that onabotulinumtoxinA was more efficacious in women and in higher doses in female patients and less effective with polypharmacy, especially when an increasing number of antidepressants were prescribed. The effectiveness of onabotulinumtoxinA was higher in more recently published double-blind RCTs.

CONCLUSION

The meta-analysis supports the efficacy of the intervention with the results being highly heterogeneous across studies. In view of the heterogeneity of the findings and the significant moderators of benefit (sex, year of study completion and the interaction between sex and dose), more research is required to better understand the role of onabotulinumtoxinA in the treatment of depression.

Classical Koro and Koro-Like Symptoms: Illustration from Canada

Koro syndrome has been colorfully described as a pathological distortion of one’s body image of the genital organ. In Koro, body image dysphoria is characterized by severe anxiety related to the delusional idea that one’s genitals will shrink and retract into one’s abdomen, eventually leading to death. This syndrome was first reported in South East Asia, where endemics have been described, but it has also sporadically occurred globally. We present a systematic literature review on Koro syndrome and report 7 cases from Canada. A search review with PubMed and Google Scholar resulted in 504 entries. Sixty-seven manuscripts were eventually selected following a thorough elimination process. The resultant literature underscored the cultural diversity that underlay the reported cases. Various aspects of Koro have been examined (eg, etiological, clinical, diagnostic, and cultural aspects). It has stimulated substantial scholarly debate, discussions, correspondences, and arguments from anthropological, psychiatric, psychological, and biological perspectives. In our series, it seems that Koro could have been misattributed here. The primary concern was not with penile retraction of the cases. To our knowledge, this is the first time that a series of cases is documented from North America where the syndrome is often ignored. We highlight the potential differences between the classical Koro syndrome and a collection of beliefs related to the perception or delusion of penile retraction in other codable psychiatric disorders, Koro-like syndrome. Understanding Koro syndrome beyond geographic boundaries is in line with our collected case reports of Koro from outside Asia.

Measures of gluten-related reactivity in children with autism spectrum disorders in the absence of overt gastrointestinal symptoms: a pilot study from the United Arab Emirates

Objectives

The aetiology of autism spectrum disorder (ASD) is multifactorial, sometimes genetic, and may be associated with abnormal immunological responses to peptides from proteins such as gluten. These peptides may cross the blood-brain barrier and affect neurotransmission, resulting in behavioural symptoms consistent with ASD. The aim of this study was to screen for markers of gluten-related immune reactivity in the absence of overt gastrointestinal symptoms in patients with ASD in the United Arab Emirates, a country associated with a high prevalence of ASD but lacking this type of research.

Methods

Patients diagnosed with ASD (using Diagnostic and Statistical Manual of Mental Disorders-IV-based criteria and Autism Diagnostic Observational Schedules) were compared with controls, regarding anti-tissue transglutaminase (tTG) immunoglobulin (Ig) A and anti-deamidated gliadin peptide (DGP) IgA levels.

Results

Sixty-six patients with ASD and 101 controls were included. Patients with ASD showed statistically significant lower anti-DGP IgA levels, but no significant difference in anti-tTG IgA levels, versus healthy controls. Correlations between immunological data and clinical symptoms were synergistic, but not statistically significant.

Conclusion

ASD may be associated with reduced levels of anti-DGP IgA.

The psychological impact of the COVID-19 pandemic on adults and children in the United Arab Emirates: a nationwide cross-sectional study

BACKGROUND

The psychosocial impact of previous infectious disease outbreaks in adults has been well documented, however, there is limited information on the mental health impact of the COVID-19 pandemic on adults and children in the United Arab Emirate (UAE) community. The aim of this study was to explore anxiety levels among adults and children in the UAE and to identify potential risk and protective factors for well-being during the COVID-19 pandemic.

METHODS

Using a web-based cross-sectional survey we collected data from 2200 self-selected, assessed volunteers and their children. Demographic information, knowledge and beliefs about COVID-19, generalized anxiety disorder (GAD) using the (GAD-7) scale, emotional problems in children using the strengths and difficulties questionnaire (SDQ), worry and fear about COVID-19, coping mechanisms and general health information were collected. Descriptive analysis was carried out to summarize demographic and participant characteristics, Chi-square analysis to explore associations between categorical variables and anxiety levels and multivariable binary logistic regression analysis to determine predictors of anxiety levels in adults and emotional problems in children.

RESULTS

The overall prevalence of GAD in the general population was 71% with younger people (59.8%) and females (51.7%) reporting highest levels of anxiety. Parents who were teachers reported the highest percentage of emotional problems in children (26.7%). Adjusted multivariable logistic regression for GAD-7 scores showed that being female, high levels of worry associated with COVID-19, intention to take the COVID-19 vaccine and smoking were associated with higher levels of anxiety. Adjusted multivariable logistic regression for SDQ showed that higher emotional problems were reported for children in lower and higher secondary education, and parents who had severe anxiety were seven times more likely to report emotional problems in their children.

CONCLUSIONS

This study reports the psychological impact of COVID-19 among adults and children in the UAE and highlights the significant association between parental and child anxiety. Findings suggest the urgency for policy makers to develop effective screening and coping strategies for parents and especially children.

Disaster management of the psychological impact of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has exposed a suboptimal response to this threatening global disaster, including the response to the psychological impact. Both the economic hardship and the continuous media coverage of alarming news have exacerbated this effect which also includes increased domestic violence.

AIM

To address this important aspect of disaster management and provide recommendations on how to mitigate these effects.

METHODS

This is a narrative review written by three experts in community medicine, disaster medicine and psychiatry reflecting the interdisciplinary approach in managing disasters. Selected important papers, personal published papers, PUBMED articles and media news related to the disaster management of the psychological effects of COVID-19 pandemic were collected over the last year, critically appraised and used in writing this manuscript.

RESULTS

The COVID-19 pandemic causes major emotional distress. Lack of effective treatments and availability of the current vaccines for this virus increases the fear of being infected and infecting others. Negative emotions are common and are related to adjustment but may progress in the long term to anxiety, depression, and post-traumatic stress syndrome. The COVID-19 pandemic has a major impact on mental health. The most common distress reactions include anxiety, insomnia, perception of insecurity, anger, fear of illness, and risky behaviors. Patients having mental disorders are vulnerable during the pandemic because of (1) somatic vulnerability, (2) cognitive and behavioral vulnerability, (3) psychosocial vulnerability, and (4) disruption to psychiatric care. Psychiatric wards, which are commonly separate from main hospitals, should be included in the disaster management plans. Acute care physicians carry the psychological and ethical impact of difficult triage decisions when ending the support of some patients to save others. A combination of fear and guilt may overcome normal human tolerance levels in vulnerable health workers. The moral injuries can be carried for a long time.

CONCLUSIONS

Addressing the psychological effects is an essential component of disaster management of infectious pandemics. This should be implemented through the whole spectrum of disaster management including preparedness, mitigation, response, and recovery.

The Roko Syndrome: A Mirror of Koro Syndrome

It is well established that 1 in 50 individuals receives a diagnosis of body dysmorphic disorder (BDD). Within body image disorders, there is genital retraction syndrome also known as Koro. A unique syndrome in which there is a heightened belief that one’s genitals will diminish in size, retract into the abdomen and ultimately lead to death. However, we have recently discovered a separate form of BDD that is directly opposite of Koro, in which the patient presents a strong belief that his penis will enlarge and extend out of their body. We present a unique case report of a counter-Koro syndrome. This syndrome is characterized by the delusion that one’s penis is growing larger and that it will result in its extreme protrusion from the abdomen and a consequent fear of recurring and visible erections. Given its mirror-like presentation and uniqueness to occurring only in males, we refer to it as Roko Syndrome. To our knowledge, this syndrome has not yet been reported in the literature and requires further study to understand whether it fits as a separate syndrome or falls along the spectrum of body dysmorphia. Thus, assessments used to identify body image disorders can be broadened to include items representing the behavior and presentation of Roko that we delineate in comparison of Koro. The new syndrome is also easily distinguishable from a priapism which is a urological emergency.

[Psychopharmacology of First Episode Psychosis: An Approach Based on Recovery]

Objectives Individuals with first-episode psychosis (FEP) are poorly represented in clinical trials leading to drug approval. As a result, there is a relative paucity of empirical data to guide the psychopharmacological treatment of these youths. This article provides a synthesis of this literature, informed by the authors' clinical experience in treating FEP over the past 25 years. Methods This selective review of the literature focuses on the psychopharmacological treatment of FEP and includes both randomized trials and observational studies. It is organized around the following themes for FEP: response and remission rates; relapse rates; specifics regarding susceptibility to adverse events; comparisons of efficacy, safety and relapse prevention among various molecules and dosage forms; recommendations for duration of treatment; approach to treatment resistance; and use of clozapine. For each of these themes, research data are interpreted and supplemented by commentary based on the authors' clinical experience, with a strong focus on the individual's recovery. Results Symptom remission is achieved in approximately 75% of individuals during the initial treatment of a FEP, its maintenance being a very strong predictor of functional recovery. The rate of psychotic relapse during the three years following a FEP is about 60%, the problem of adherence to treatment being the main cause of these relapses. The FEP population is distinguished by a greater propensity for adverse events, including weight gain and extrapyramidal reactions. With the exception of treatment-resistant FEP, no clear difference has been demonstrated in the efficacy of the various molecules, but they do differ in their adverse events profile and formulations. As such, the use of long-acting injectable antipsychotics (LAIs) is superior to oral agents in preventing relapse. While the guidelines recommend continued treatment for 18 months after remission is achieved, these recommendations are based on empirical data that are still unclear, necessitating the use of a shared-decision approach with the patient and his/her family. In the group of people who do not achieve a satisfactory response after two trials of antipsychotics, clozapine is effective in up to 80% of people. Conclusions The FEP population is characterized by a high response rate, relapses frequently related to non-adherence to treatment, and increased susceptibility to adverse events. Tailoring pharmacological treatment for FEP aims at sustained remission of all symptom dimensions combined with proactive management of adverse events, including through judicious use of LAIs and clozapine.

The Large Action of Chlorpromazine: Translational and Transdisciplinary Considerations in the Face of COVID-19

Coronavirus disease 2019 (COVID-19) is a severe acute respiratory syndrome (SARS) in humans that is caused by SARS-associated coronavirus type 2 (SARS-CoV-2). In the context of COVID-19, several aspects of the relations between psychiatry and the pandemic due to the coronavirus have been described. Some drugs used as antiviral medication have neuropsychiatric side effects, and conversely some psychotropic drugs have antiviral properties. Chlorpromazine (CPZ, Largactil®) is a well-established antipsychotic medication that has recently been proposed to have antiviral activity against SARS-CoV-2. This review aims to 1) inform health care professionals and scientists about the history of CPZ use in psychiatry and its potential anti- SARS-CoV-2 activities 2) inform psychiatrists about its potential anti-SARS-CoV-2 activities, and 3) propose a research protocol for investigating the use of CPZ in the treatment of COVID-19 during the potential second wave. The history of CPZ's discovery and development is described in addition to the review of literature from published studies within the discipline of virology related to CPZ. The early stages of infection with coronavirus are critical events in the course of the viral cycle. In particular, viral entry is the first step in the interaction between the virus and the cell that can initiate, maintain, and spread the infection. The possible mechanism of action of CPZ is related to virus cell entry via clathrin-mediated endocytosis. Therefore, CPZ could be useful to treat COVID-19 patients provided that its efficacy is evaluated in adequate and well-conducted clinical trials. Interestingly, clinical trials of very good quality are in progress. However, more information is still needed about the appropriate dosage regimen. In short, CPZ repositioning is defined as a new use beyond the field of psychiatry.

Pattern of psychiatric in-patient admissions in Al Ain, United Arab Emirates

An understanding of the current state of mental health services in the United Arab Emirates (UAE) from a clinical perspective is an important step in advising government and stakeholders on addressing the mental health needs of the fast-growing population. We conducted a retrospective study of data on all patients admitted to a regional psychiatric in-patient unit between June 2012 and May 2015. More Emiratis (UAE nationals) were admitted compared with expatriates. Emiratis were diagnosed more frequently with substance use disorders and expatriates with stress-related conditions. Psychotic and bipolar disorders were the most common causes for admission and had the longest in-patient stays; advancing age was associated with longer duration of in-patient stay.

Bibliotherapy: Reading OVID During COVID

An epidemic of an infectious disease such as COVID-19 is often a source of emotional distress, even among those who have not been directly exposed to the disease. The period following the acute phase of the coronavirus epidemic and the mitigation measures will likely be hardest for medical professionals in terms of psychological impact. Bibliotherapy is a systematic intervention regarding the use of carefully selected reading materials in order to help persons to cope with stress and personal problems. This therapy can be used easily during the pandemic. The review of evidence shows that this kind of intervention can be helpful in educational and clinical contexts. During the crisis, it can be an alternative to video and film entertainment and a transition from serious medical journal clubs to a softer medical humanities experience. In this article, we summarized the historical background of bibliotherapy. We also proposed a reading list from different times, and cultures relating to pandemic, quarantine, symptoms, confinement, and social impacts (e.g., Camus, Moravia, London, Le Clezio etc.). Bibliotherapy can be a way for doctors and healthcare workers fighting on the frontline of the pandemic to find psychological support and for debriefing. Bibliotherapy can help individuals that need support for emotional distress during the pandemic to verbalize their feelings and emotions and identify new ways of addressing problems.

Mutations associated with neuropsychiatric conditions delineate functional brain connectivity dimensions contributing to autism and schizophrenia

16p11.2 and 22q11.2 Copy Number Variants (CNVs) confer high risk for Autism Spectrum Disorder (ASD), schizophrenia (SZ), and Attention-Deficit-Hyperactivity-Disorder (ADHD), but their impact on functional connectivity (FC) remains unclear. Here we report an analysis of resting-state FC using magnetic resonance imaging data from 101 CNV carriers, 755 individuals with idiopathic ASD, SZ, or ADHD and 1,072 controls. We characterize CNV FC-signatures and use them to identify dimensions contributing to complex idiopathic conditions. CNVs have large mirror effects on FC at the global and regional level. Thalamus, somatomotor, and posterior insula regions play a critical role in dysconnectivity shared across deletions, duplications, idiopathic ASD, SZ but not ADHD. Individuals with higher similarity to deletion FC-signatures exhibit worse cognitive and behavioral symptoms. Deletion similarities identified at the connectivity level could be related to the redundant associations observed genome-wide between gene expression spatial patterns and FC-signatures. Results may explain why many CNVs affect a similar range of neuropsychiatric symptoms.

From QAAPAPLE 1 to QAAPAPLE 2: how do we move from one algorithm to another one with Long Acting Antipsychotics (LAIs)

BACKGROUND

In 2011, the authors published an algorithm summarizing practice guidelines related to the use of long-acting antipsychotics (LAIs) called the Québec Algorithme Antipsychotique à Action Prolongée (QAAPAPLE), and proposed that it be revised every 5-10 years to update it according to most recent scientific knowledge. Therefore, a re-evaluation of the algorithm was conducted to determine which recommendations were still relevant and which needed modification.

METHODS

The authors conducted a two-fold approach: a review of the literature to include new evidence since 2011 (controlled trials, meta-analyses, and practice guidelines); and a participatory component involving electronic surveys, conferences, encounters with opinion leadres, and patients' representatives.

RESULTS

Overall, prescribers tended to make decisions based on personal experience and conversations with colleagues rather than consulting evidence-based guidelines. To test if the algorithm was useful worldwide, it was presented in the United Arab Emirates, where the feedback was in agreement with the algorithm and its limitations.

CONCLUSIONS

Since its initial publication, the QAAPAPLE algorithm has been updated to guide clinicians on the use of LAIs. The new algorithm has also been assessed outside Canada to test its generalizability worldwide, and indicated its flexibility, efficiency, and user-friendliness in order to guide clinicians on the use of LAIs.

Chronic Neuroleptic-Induced Parkinsonism Examined With Positron Emission Tomography

BACKGROUND

Neuroleptic drug-induced parkinsonism (NIP) is a leading cause of parkinsonism, particularly in aging. Based on abnormal dopamine transporter scan results, individuals displaying chronic NIP are often diagnosed with Lewy-body Parkinson's disease (PD), but this assumption needs further substantiation.

OBJECTIVE

To quantitate the profile of striatal dopaminergic nerve terminal density in NIP relative to PD.

METHODS

We used the positron emission tomography ligand [¹¹ C](+)-dihydrotetrabenazine targeting vesicular monoamine transporter type 2 (VMAT2) binding sites and collected various clinical parameters (motor ratings, olfaction, polysomnography to document rapid eye movement sleep muscle activity, quantitative sensory testing for pain thresholds) possibly predicting binding results in patients older than age 50 living with schizophrenia spectrum disorders under long-term stable antipsychotic drug treatment, with (N = 11) or without (N = 11) chart documention of chronic NIP, and compared them to healthy volunteers (N = 11) and others medicated for PD (N = 12).

RESULTS

Striatal VMAT2 binding was dichotomous in the NIP group between those with spared (N = 5) or low (N = 6) PD-like values. Striatal binding reduction in the low VMAT2-NIP group was asymmetric without the gradient of maximal involvement in the posterior putamen typical of PD. Anosmia was the only nonmotor parameter measured matching the abnormal striatal VMAT2 binding status.

CONCLUSION

These preliminary observations suggest that striatal VMAT2 binding is abnormal in a fraction of chronic NIP cases and differs in spatial distribution from PD. The possibility of a drug-induced axonopathy and resultant synaptopathy, as well as the evolution of the binding deficit, warrant further longitudinal studies in a large cohort. © 2020 International Parkinson and Movement Disorder Society.

Correlations between sadness-induced cerebral activations and schizophrenia symptoms: An fMRI study of sex differences

Background

The functional neuroimaging studies of emotion processing in schizophrenia have revealed variable results attributed partly to differential symptomatology and sex of tested patients. The aim of the present study was to investigate the relationship between cerebral activations during exposure to emotional material and schizophrenia symptoms in men versus women.

Method

Fifteen men and 10 women with schizophrenia, equivalent in terms of age, medication and experienced symptomatology, underwent functional MRI during viewing sad and neutral film excerpts. Data were analyzed using Statistical Parametric Mapping Software (SPM2).

Results

Across all the patients there was a significant inverse relationship between negative symptoms and activations in the right prefrontal cortex during processing of sad versus neutral stimuli. In men, activations during sad versus neutral stimuli in the prefrontal, temporal and anterior cingulate cortex, as well as the caudate and cerebellum, were positively correlated with negative symptoms. In women, there were inverse correlations between positive symptoms and activations in the hippocampus, parietal and occipital cortex during the same condition.

Conclusion

Present results confirmed association of prefrontal hypofunction with negative symptoms in schizophrenia. More interestingly, the results revealed a diametrically different pattern of symptom-correlated brain activity in men and women with schizophrenia, suggesting that the processing of sadness is mediated via neurophysiological mechanism related to negative symptoms in men and the mechanism related to positive symptoms in women.

Computerized assessment of cognition in schizophrenia: Promises and pitfalls of CANTAB

Objective

Over the last decade, the Cambridge Neuropsychological Test Automated Battery (CANTAB), which comprises visuo-spatial tasks, has been utilized in cognitive studies of schizophrenia. A clear approach concerning the usage of CANTAB for the appraisal of neurocognitive dysfunction in schizophrenia is currently lacking.

Method

In this paper, we have first reviewed the overall applications of CANTAB and then evaluated methodological strengths and weaknesses of CANTAB as a neurocognitive battery for schizophrenia. We carried out a systematic search and assessment of studies where CANTAB was utilized to measure cognitive function in schizophrenia. We have also attempted to quantify the available data and perform a meta-analysis, but this approach turned out to be still premature.

Results

CANTAB has enabled researchers to highlight significant deficits affecting broad cognitive domains in schizophrenia, such as working memory, decision-making, attention, executive functions and visual memory. So far, the most consistent deficit observed with CANTAB testing has been attentional set-shifting, suggestive of fronto-striatal dysfunctions. In addition, preliminary evidence points towards the potential use of CANTAB to identify cognitive predictors of psychosocial functioning, to describe the relationships between symptoms and cognition, and to measure the impact of pharmacological agents on cognitive functioning.

Conclusion

CANTAB has been used successfully to highlight the range of visuo-spatial cognitive deficits in schizophrenia, producing similar results to those obtained with some traditional neuropsychological tests. Further studies validating the use of CANTAB following the standard set by Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) are warranted.

Long-acting antipsychotic medication as first-line treatment of first-episode psychosis with comorbid substance use disorder

AIM

Substance use disorder (SUD) is highly prevalent among patients with first-episode psychosis (FEP) and associated with poor adherence and worst treatment outcomes. Although relapses are frequent in FEP, current literature on long-acting injectable antipsychotics (LAI-AP) use in FEP is scarce and studies often exclude patients with SUD.

OBJECTIVES

To determine the impact of LAI-AP as first-line treatment on psychotic relapses or rehospitalizations in FEP patients with comorbid SUD (FEP-SUD).

METHODS

This is a naturalistic, longitudinal, 3-year prospective and retrospective study on 237 FEP-SUD admitted in two EIS in Montreal, between 2005 and 2012. The patients were divided on the basis of first-line medication introduced, either oral antipsychotics (OAP, n = 206) or LAI-AP (n = 31). Baseline characteristics were compared using χ² test and analysis of variance, and Kaplan-Meier survival analysis was performed on relapse and rehospitalization.

RESULTS

Compared to the OAP group, patients in the LAI-AP group presented worse prognostic factors (eg, history of homelessness). Despite this, the LAI-AP group presented a lower relapse rate (67.7% vs 76.7%), higher relapse-free survival time (694 vs 447 days, P = 0.008 in Kaplan-Meier analysis), and trends for reduced rehospitalization rates (48.4% vs 57.3%) and hospitalization-free survival time (813 vs 619 days, P = 0.065 Kaplan-Meier analysis). Of those receiving OAP as first-line, 41.3% were eventually switched to LAI-AP and displayed worst outcome in relapse and rehospitalization.

CONCLUSION

LAI-AP should be strongly considered as first-line treatment of FEP-SUD patients since this pharmacological option reduces the risk of relapse and rehospitalization even in the individuals with poor prognostic factors.