Being a psychiatric resident during COVID times – personal experiences of Hungarian trainees

Introduction

During the COVID-19 pandemic residents of the central region of Hungary also had to adapt to several challenges such as changes of hospitals’ specialty profiles and delegation of health care workers to COVID wards.

Hungarian residents have their practical training in various hospitals, while their psychiatric academic training is organised in groups.

Objectives

Our aim is to share our personal experiences about how our work and training have changed during the pandemic and it’s effect on our patients.

Methods

Participants of the study were the authors of the poster. Responses to open questions were structured based on the following topics: competencies in internal medicine, infectious diseases and psychiatry, our collaboration with other medical disciplines, psychiatric training and attitudes towards mental health patients.

Results

We worked min 2 weeks max 8 months at COVID wards and also treated COVID-19 infected psychiatric patients, thus gaining a greater experience in general medicine. In psychiatric work, acute care became prominent, communication in PPE and restricted contact with patients’ relatives were particularly difficult. Our relationship with other specialists has improved, consultation became easier. Increased use and misuse of psychiatric consultation requests led to further pressure. Restrictions, stigmatisation and discrimination increased against psychiatric patients, including difficult access to care. Psychiatric training in the hospitals became limited, however seminars organized by the university continued online with our active participation.

Conclusions

During the pandemic we gained greater experience in general medicine. Psychiatric care and our training was negatively affected, however the latter was mitigated by online seminars.

Disclosure

No significant relationships.

Simultaneous study of behavioral synchronization of two individuals during a cooperative task

Introduction

Interpersonally coordinated behaviors are crucial for social interactions.The “Theory of Mind,” or mentalization capacity, of an individual is essential for the establishment of behavioral synchronization. The Reading the Mind in the Eyes Test (RMET) is used to assess mentalization, social cognition and empathy. Previous RMET studies, investigated people in isolation, not in social situations. It is unclear how the RMET predicts functioning during real-life social interactions.

Objectives

To investigate the relationship between the performance measured on the RMET test and the synchronous behavior of two individuals interacting with each other during tasks requiring social collaboration.

Methods

Sample included healthy controls (HC,n=48) and patients with ADHD (n=26) or schizophrenia (SCH,n=36) from an ongoing EEG-hyperscanning study, employing a social coordination condition.We applied a Go/NoGo reaction time(RT) task performed by pairs of participants. Synchronous behavior was characterized by the correlation of participants’ RTs.We used the percent (%) correct responses from the RMET to characterize social cognition.

Results

In HC, with better social cognitive performance, the correlation of behavioral responses was significantly (p<0.05) higher. In ADHD, better performance on the RMET was also accompanied by better behavioral synchronization, but the association did not reach significance due to the smaller sample size. In SCH, no relationship was detected.

Conclusions

In HC and ADHD, the mentalization ability as measured by RMET is associated with the behavioral synchronization between individuals in social interaction.The lack of association in the schizophrenia group may be due to psychopathological symptoms, which should be elucidated in future research. Funding: Supported by the Hungarian Brain Research program#2017-1.2.1-NKP-2017-0002

Disclosure

No significant relationships.

EPA guidance on treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms.

However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

BDNF and DISC1 are associated with cognitive dysfunction but not with schizophrenia in a hungarian sample

Introduction

Previous studies have found association between several schizophrenia candidate genes and neurocognition in schizophrenia patients and healthy individuals. Both brain-derived neurotrophic factor (BDNF) and disrupted in schizophrenia 1 (DISC1) are important for neurodevelopmental processes and have been implicated as schizophrenia candidate genes, as well as genes influencing neurocognition.

Objectives and aims

To test for the previously described association of these genes with schizophrenia and neurocognition.

Methods

DNA samples from a homogeneous sample of 280 schizophrenia patients and 230 healthy controls were genotyped for polymorphisms in schizophrenia candidate genes DISC1 (rs821597 and rs821616) and BDNF (rs6265). Clinical assessment was performed using the Schedule for Deficit Syndrome and the Positive and Negative Symptom Scale. Neurocognitive functioning was assessed in a subsample of 263 patients and 135 healthy controls by a comprehensive neuropsychological test-battery. Based on the raw neuropsychological measures we calculated a global index of cognitive impairment and domain-specific composite z-scores. Association between the above composite scores and the SNPs was examined using GLM and GENMOD analysis.

Results

The investigated SNPs were not associated with schizophrenia, nor with the deficit or non-deficit subgroups. However we found significant association between global cognitive impairment and rs821616 in DISC1 (F = 3.02, p = 0.05) and rs6265 in BDNF (F = 4.47, p = 0.01); moreover rs6265 was associated with working memory (F = 6.22, p = 0.002) and attention (F = 7.27, p = 0.0074)

Conclusion

Using neurocognition as an endophenotype for psychotic disorders in genetic studies has the potential to determine common and separate genetic factors influencing disease risk and neurocognition.

A systematic review of the efficacy and safety of second generation antipsychotics in the treatment of mania

Second generation antipsychotic agents are increasingly used in the management of acute mania. A systematic review of the efficacy and safety of these agents, as both monotherapy and in combination with mood stabilisers, was performed to establish the evidence for their use. Randomised controlled trials (RCTs) were critically appraised in more detail than studies that presented lower levels of evidence such as case reports, case series and open label follow up studies. We found 11 RCTs reporting on patients treated with second generation antipsychotics for acute bipolar mania, of which three included randomisation between the second generation antipsychotic and placebo, and eight between a mood stabiliser combined with either the second generation antipsychotic or placebo. Data from non-randomised trials is also presented.

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.

Monotherapy treatment with cariprazine for the treatment of predominant negative symptoms of patients with schizophrenia: A double-blind, active comparator-controlled trial

Objective

To examine the effect of cariprazine, a dopamine D3/D2 receptor partial agonist with preferential binding to D3 receptors, on predominant negative symptoms of schizophrenia.

Methods

Subjects with schizophrenia and PANSS factor score for negative symptoms (PANSS-FSNS) ≥ 24 and no pseudospecific factors (e.g. extrapyramidal symptoms, depression) were randomized to cariprazine 4.5 mg/d (dose range: 3-6 mg/d) or risperidone 4 mg/d (dose range: 3-6 mg/d) for 6 months.

Results

Four hundred and sixty-one patients were randomized 1:1 to double-blind risperidone (n = 231) or cariprazine (n = 230) treatment. Change from Baseline (CfB) at week 26 in the primary parameter, PANSS-FSNS, was larger in the cariprazine group than in the risperidone group (LSMD = −1.47; 95% CI: [−2.39, −0.53]; P = 0.002) significant from week 14 onwards. CfB at week 26 in the functional parameter, Personal and Social Performance (PSP) total score, showed similarly greater improvement with cariprazine than risperidone (LSMD = 4.63; 95% CI: [2.71, 6.56]; P < 0.001) significant from week 10 onward. Statistically significant differences in favor of cariprazine at week 26 were shown in the PSP areas of self-care, socially useful activities and personal and social relationships. Most patients tolerated the study treatment well, as reflected by low discontinuation rates due to adverse events (AEs). Adverse event profiles of cariprazine and risperidone were similar. The most common AEs during study treatment were insomnia (10.0%), and headache (10.4%), both in the risperidone group.

Conclusion

26-week cariprazine treatment, given as antipsychotic monotherapy, was significantly more effective on negative symptoms and on functioning than risperidone in patients with predominant negative symptoms of schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Mortality and the relationship of somatic comorbidities to mortality in schizophrenia. A nationwide matched-cohort study

AIM

We conducted a matched-cohort study to assess mortality in schizophrenia and the relationship of mortality with comorbid somatic conditions and suicide attempts.

METHOD

A full-population register-based prospective matched-cohort study was performed including all eligible patients with schizophrenia in Hungary between 01/01/2005 and 31/12/2013. Control subjects were individually matched to patients with schizophrenia at a 5:1 ratio. The principal outcome measure was death due to any reason. A non-parametric approach was used for descriptive statistical purposes, the Kaplan-Meier model for survival analysis, and the Cox proportional-hazards regression model for inferential statistics.

RESULTS

Patients with schizophrenia (n=65,169) had substantially higher risk of all-cause mortality than the control subjects (n=325,435) (RR=2.4; P<0.0001). Comorbidities and suicide attempts were associated with significantly increased mortality in both groups. As compared to the controls, 20-year old males with schizophrenia had a shorter life expectancy by 11.5years, and females by 13.7years; the analogous numbers for 45-year old schizophrenics were 8.1 and 9.6years, respectively.

CONCLUSIONS

A significant mortality gap - mainly associated with somatic comorbidities - was detected between patients with schizophrenia and individually matched controls. Improved medical training to address the disparity in mortality, and many other factors including lack of resources, access to and model of medical care, lifestyle, medication side effects, smoking, stigma, need for early intervention and adequate health care organization could help to better address the physical health needs of patients with schizophrenia.

Once-monthly paliperidone palmitate in recently diagnosed and chronic non-acute patients with schizophrenia

Objective: To explore the treatment response, tolerability and safety of once-monthly paliperidone palmitate (PP1M) in non-acute patients switched from oral antipsychotics, stratified by time since diagnosis as recently diagnosed (≤3 years) or chronic patients (>3 years).

Research design and methods: Post hoc analysis of a prospective, interventional, single-arm, multicentre, open-label, 6-month study performed in 233 recently diagnosed and 360 chronic patients.

Main outcome measures: The proportion achieving treatment response (defined as ≥20% improvement in Positive and Negative Syndrome Scale [PANSS] total score from baseline to endpoint) and maintained efficacy (defined as non-inferiority in the change in PANSS total score at endpoint [Schuirmann’s test]).

Results: 71.4% of recently diagnosed and 59.2% of chronic patients showed a ≥20% decrease in PANSS total score (p = 0.0028 between groups). Changes in PANSS Marder factors, PANSS subscales, and the proportion of patients with a Personal and Social Performance scale (PSP) total score of 71–100 were significantly greater in recently diagnosed compared with chronic patients. PP1M was well tolerated, presenting no unexpected safety findings.

Conclusion: These data show that recently diagnosed patients treated with PP1M had a significantly higher treatment response and improved functioning, as assessed by the PSP total score, than chronic patients.

P300 deficits in adults with attention deficit hyperactivity disorder: a meta-analysis

BACKGROUND

The P300 (P3) event-related potential (ERP) component, a possible endophenotype for attention deficit hyperactivity disorder (ADHD), has been widely examined in children, but received little attention in adults. Our objective was to conduct a meta-analysis of P3 studies in adults with ADHD.

METHOD

We searched the Medline and PsycINFO databases for controlled studies examining both adult ADHD and matched healthy controls. Six relevant publications were identified for the meta-analysis, which had comparable data across studies with regard to the amplitude of ERP components related to target detection (P3, P3b). Pooled effect size (ES) for P3 amplitude as well as the association of the ES with age and gender were investigated using meta-regression.

RESULTS

Comparing the ADHD group versus controls, the pooled effect size for a decrease in P3 amplitude was in the medium range (Cohen's d=-0.55, p=0.0006). Additionally, meta-regression revealed that decrease in P3 amplitude significantly varied with the mean age of ADHD patients (p=0.0087), with a gradual increasing of the difference at higher ages. Results also showed a significant association between the ES and gender, indicating a more pronounced reduction of P3 amplitude in the ADHD group versus controls when females were predominantly represented in the sample.

CONCLUSIONS

To our knowledge, this is the first meta-analysis of P3 characteristics in adults with ADHD. It reveals a significantly decreased P3 amplitude during target detection. Our result that the reduction in P3 amplitude increases with age is interpreted in a neurodevelopmental context.

The association of NRG1, DTNBP1, RGS4, G72/G30 and PIP5K2A candidate genes with cognition in patients with schizophrenia and healthy controls

Introduction

Previous studies have indicated association of schizophrenia candidate genes with cognition both in patients with schizophrenia and healthy individuals. In the same sample we have shown differential association of candidate genes with symptom severity in patients.

Objectives and aims

To test the most extensively researched schizophrenia candidate genes for association with domain-specific cognitive functions.

Methods

Cognitive functioning was assessed in a subsample of 263 patients with a DSM-IV diagnosis of schizophrenia and 135 healthy controls by a neuropsychological test-battery measuring the domains of sustained vigilance/attention, working memory, short-term memory, verbal memory, cognitive flexibility, and ideation fluency. Using the raw neuropsychological measures we calculated a global index of cognitive impairment and domain-specific composite z-scores. Clinical assessment was performed using the Schedule for Deficit Syndrome and the Positive and Negative Symptom Scale. DNA samples were genotyped for polymorphisms of the candidate genes NRG1, DTNBP1, RGS4, G72/G30 and PIP5K2A. Association between the above composite scores and the SNPs was examined using the General Linear Model (GLM) analysis.

Results

The preliminary analyses uncovered statistically significant associations between DTNBP1 rs909706 and the global index of cognitive impairment (F = 3,39; p = 0,03), and cognitive flexibility (F = 4,81; p = 0,01), and DTNBP1 rs1011313 and short-term memory (F = 3,66; p = 0,02). Moreover RGS4 rs10917670 was associated with working-memory (F = 4,28; p = 0.01). We found no association of NRG1, G72/G30 or PIP5K2A with the domains of cognitive functioning.

Conclusions

Our results support the association of DTNBP1 and RGS4 candidate genes with cognition, as a possible endophenotype of schizophrenia.

Executive function in deficit schizophrenia: what do the dimensions of the Wisconsin Card Sorting Test tell us?

Neuropsychological characterization of the schizophrenia deficit syndrome is an unresolved issue. The initial assumption was that patients with deficit syndrome show more definitive impairments on tests sensitive for frontal and parietal functions compared with nondeficit patients,but recent studies failed to confirm this assumption. The fundamental question is whether a more refined delineation of executive dysfunctions is able to yield differences between deficit and nondeficit patients. To investigate this question, we implemented a factor analytic approach to explore potential differences between deficit and nondeficit patients using the Wisconsin Card Sorting Test (WCST). Our paper presents an exploratory factor analysis of the WCST on schizophrenia patients and healthy samples, and a comparison among deficit, non-deficit patients with schizophrenia and control samples using the identified factors. A total of 154 patients with schizophrenia fulfilling the criteria for the deficit syndrome, 121 nondeficit patients, and 130 healthy controls were compared. Factor analysis of the WCST variables using the principal component method resulted in a two-factor solution. Comparison of the diagnostic groups on each of the factors revealed that deficit schizophrenia patients suffer from a more severe degree of impairment on the 'General executive function' factor than nondeficit schizophrenia patients. To our knowledge this is the first study that compared patients with the deficit and non-deficit forms of schizophrenia using WCST factor analytic techniques. Our results provide an insight into the cognitive profile of schizophrenia patients with regard to WCST, which could serve as a framework for future clinical and research endeavors.

Attention deficit hyperactivity disorder (ADHD): gender- and age-related differences in neurocognition

BACKGROUND

Despite the growing recognition that the clinical symptom characteristics associated with attention deficit hyperactivity disorder (ADHD) persist into adulthood in a high proportion of subjects, little is known about the persistence of neurocognitive deficits in ADHD. The objective was twofold: (1) to conduct a meta-analysis of neuropsychological studies to characterize attentional performance in subjects with adult ADHD by examining differences in ADHD versus normal control subjects; and (2) to investigate whether these differences vary as a function of age and gender.

METHOD

Twenty-five neuropsychological studies comparing subjects with adult ADHD and healthy controls were evaluated. Statistical effect size was determined to characterize the difference between ADHD and control subjects. Meta-regression analysis was applied to investigate whether the difference between ADHD and control subjects varied as a function of age and gender across studies.

RESULTS

Tests measuring focused and sustained attention yielded an effect size with medium to large magnitude whereas tests of simple attention resulted in a small to medium effect size in terms of poorer attention functioning of ADHD subjects versus controls. On some of the measures (e.g. Stroop interference), a lower level of attention functioning in the ADHD group versus the controls was associated with male gender.

CONCLUSIONS

Adult ADHD subjects display significantly poorer functioning versus healthy controls on complex but not on simple tasks of attention, and the degree of impairment varies with gender, with males displaying a higher level of impairment.

What will be the Consequences from the Changes in ICD-11/DSM-V for Decision Making in Clinical Psychopharmacotherapy?

The preparations of DSM V/ICD-11 are in progress. The frustrations and limitations engendered by the categorical model in psychiatry led to the suggestion of alternative dimensional models of classification, e.g. to the suggestions for a dimensional view of psychosis. However there are strong arguments for keeping the categorical classification maybe with inclusion of new criteria, such as neurocognitive impairment for schizophrenia and even there are suggestions for new categories such as nonaffective remitting acute psychosis.

Therapeutic indications of drugs are developed by the industry and are approved by regulatory agencies (FDA, EMEA). Indications are linked to diagnostic categories as defined by DSM-IV/ICD-11, e.g. one antipsychotic is indicated for the treatment of both schizophrenia and bipolar disorder, while another is only indicated for the treatment of schizophrenia. These indications are used by the insurance industry to manage financing of drug treatment.

Changes in the criteria of a diagnostic category will result in a revision of approval which may include the obligation for new studies. Generic companies are now an important part of the major pharmaceutical markets, however many of them do not have the capacity to launch clinical studies, which may lead to the withdrawal of marketing authorization of important drugs. Clinical studies seem to be unavoidable for licensing recently available drugs for the new diagnostic categories of DSM V/ICD 11. The introduction of diagnostic categories by a dimensional approach may lead to “double book keeping”: a dimensional diagnosis used for the medical practice and a categorical one for the insurance.

How to Interpret Efficacy and Safety Data of Antidepressive Drugs and Placebo Response Rates?

During the process of drug development, the sponsoring pharmaceutical manufacturers conduct numerous clinical trials to demonstrate the therapeutic efficacy and safety of new antidepressive agents. These trials are required to provide ‘substantial evidence of effectiveness’ in accordance to terms and conditions codified by law. Accordingly, the design and conduct of clinical studies of new antidepressants are strongly impacted by the need to comply with scientific standards as well as by regulatory requirements for approval. Regulatory requirements are typically published in standard ‘Guidance documents’, but in practice the ‘one size fits all’ approach has room for interpretation for specific indications and clinical trials. Detailed statistical criteria applied for the regulatory evaluation of individual drug trials are typically not available in the standard medical literature, but are accessable via the FDA's Summary Basis of Approval Documents (SBAs). This presentation will examine SBA materials and published scientific literature to gain insight into factors that were considered for the establishment of substantial evidence of effectiveness from a statistical perspective. Specifically, the presentation will investigate critical elements considered for the evaluation of results of controlled trials of new antidepressive agents. Such elements include the measurement of relevant clinical outcomes, definition of endpoints, effect sizes, multiple inferences, and principal trial design choices such as placebo- or active-controlled trials. In addition, the presentation will review the contribution of placebo response to the frequent negative results in antidepressant clinical trials, and discusses the implicatons of this knowledge of the placebo response for future trials and clinical practice.

Detection of colon wall outer boundary and segmentation of the colon wall based on level set methods

Virtual colonoscopy (VC) has become a more prevalent and accepted method to diagnosis colorectal cancer. An essential element to detecting cancerous polyps using VC in conjunction with computer-aided detection is the accurate segmentation of the colon wall. While the inner boundary of the colon wall, the lumen-mucosal boundary, has often been the focus of previous colon segmentation work, detection of the outer wall, the serosal tissue boundary, allows for the segmentation of the colon wall, which is useful in determining both potential polyps, muscular hypertrophy and diverticulitis of the colon. Unfortunately, automatic determination of the outer colon wall position often is difficult due to the low contrast between CT attenuation values of the colon wall and the surrounding fat tissue. We have developed a level set based method to determine from a CT colonography (CTC) scan the location of the colon serosal tissue boundary. After determining this location, the algorithm segments the entire colon wall at subvoxel accurate precision. The algorithm has been validated on several CTC datasets.

Psychiatry in selected countries of Central and Eastern Europe: an overview of the current situation

OBJECTIVE

To review the current status of psychiatry in selected countries of Central and Eastern Europe: Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Russia, Slovakia, and Slovenia.

METHOD

A group of psychiatrists from the region evaluated the status of psychiatry at the end of 2004 based on data from their countries and information available on WHO homepages.

RESULTS

There is a shift from traditional in-patient facilities towards out-patient and community services as evidenced by a decreasing number of hospital beds. Economic pressures affect the financing of psychiatric services, and reimbursement for novel psychotropics. Political changes were followed by updated legislation. Psychiatric training, pre-, postgraduate and continuous medical education, are gradually being transformed. Scientific output as measured by publications in peer-reviewed journals has been significantly lower than in the West.

CONCLUSION

The major changes in the period of transition documented in the review pose new challenges for psychiatry.

Prescribing for inpatients with schizophrenia: an international multi-center comparative study

BACKGROUND

This study compares prescription practices for acute inpatients with schizophrenia among six academic departments located in China, Japan, Hungary, and the U.S.

METHODS

Prescription data for a sample of 429 inpatients from six academic departments were collected on a randomly chosen census day. All patients met criteria for schizophrenia according to DSM-IV and had a length of illness of at least two years.

RESULTS

While patients at the different centers varied in their demographic and clinical characteristics, i. e., age, sex, and length of illness, a great variation in prescription patterns for antipsychotic and other psychotropic drugs among centers was observed even within the same country for all the variables studied (i. e., number and dose antipsychotics, atypical and depot antipsychotics, other psychotropic drugs, multiple antipsychotics, and daily dose) except antidepressant use. In most cases these differences persisted even after adjusting for demographic and clinical characteristics (age, sex, and length of illness) of the subjects. Antipsychotics were usually prescribed in divided daily doses in combination with one or more other psychotropic drugs, including anticholinergics, anticonvulsants, benzodiazepines, and non-benzodiazepine hypnotics. Anticholinergic use was more common with typical antipsychotics. Rates of atypical antipsychotic drug use were lowest in the Japanese center. The Japanese center had by far the highest mean daily dose of antipsychotics.

CONCLUSIONS

The results indicate that prescription patterns in different centers do not follow any specific guidelines for the treatment of schizophrenia. The results also confirm previous findings that prescribing practices for schizophrenia vary greatly among centers and countries. A common prescribing pattern found was the use of atypical antipsychotic drugs in combination with psychotropic drugs, such as anticholinergics, hypnotics, anticonvulsants, and benzodiazepines, administered in multiple daily doses.

Direct Evidence of Ionic Fluxes Across Ion-Selective Membranes: A Scanning Electrochemical Microscopic and Potentiometric Study

Scanning electrochemical microscopy (SECM) supplemented with potentiometric measurements was used to follow the time-dependent buildup of a steady-state diffusion layer at the aqueous-phase boundary of lead ion-selective electrodes (ISEs). Differential pulse voltammetry is adapted to SECM for probing the local concentration profiles at the sample side of solvent polymeric membranes. Major factors affecting the membrane transport-related surface concentrations were identified from SECM data and the potentiometric transients obtained under different experimental conditions (inner filling solution composition, membrane thickness, surface pretreatment). The amperometrically determined surface concentrations correlated well with the lower detection limits of the lead ion-selective electrodes.

Prevalence of subthreshold forms of psychiatric disorders in persons making suicide attempts in Hungary

BACKGROUND

Suicide and suicide attempts have been associated to psychiatric illnesses; however, little is known about the role in suicide risk of those symptoms that do not meet the full criteria for a DSM-IV disorder. The aim of this study was to examine the prevalence of subthreshold psychiatric disorders among suicide attempters in Hungary.

METHODS

Using a modified structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses and their subthreshold forms defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 140 consecutive suicide attempters, aged 18-65 years.

RESULTS

Eighty-three-point-six percent of the attempters had one or more current threshold diagnoses on Axis I and in addition more than three-quarters (78.6%) of the subjects had at least one subthreshold diagnosis. Six-point-four percent of the subjects (N = 9) had neither subthreshold nor threshold diagnoses at the time of their suicide attempts. Ten percent of the subjects (N = 14), not meeting the full criteria for any DSM-IV diagnoses, had at least one subthreshold diagnosis. In 68.6% of the subjects (N = 96), both subthreshold and threshold disorders were diagnosed at the time of their suicide attempts. The number of subthreshold and threshold diagnoses were positively and significantly related (chi2 = 5.12, df = 1, P < 0.05). Sixty-three-point-six percent of the individuals received two or more current threshold diagnoses on Axis I and 44.3% of the individuals (N = 62) had two or more subthreshold diagnoses at the time of their suicide attempts.

LIMITATIONS

The subthreshold definitions in this study included only those forms of the disorders which required the same duration as the criteria DSM-IV disorder with fewer symptoms. Conclusions - Suicide attempts showed a very high prevalence of subthreshold disorders besides psychiatric disorders meeting the full criteria required according to the DSM-IV. Subthreshold forms of mental disorders need to be taken into account in suicide prevention.

Dynamics of phosphatidylinositol 4,5-bisphosphate in actin-rich structures

Phosphatidylinositol 4,5-bisphosphate (PI(4,5)P(2)) is known to regulate a wide range of molecular targets and cellular processes, from ion channels to actin polymerization [1] [2] [3] [4] [5] [6]. Recent studies have used the phospholipase C-delta1 (PLC-delta1) pleckstrin-homology (PH) domain fused to green fluorescent protein (GFP) as a detector for PI(4,5)P(2) in vivo [7] [8] [9] [10]. Although these studies demonstrated that PI(4,5)P(2) is concentrated in the plasma membrane, its association with actin-containing structures was not reported. In the present study, fluorescence imaging of living NIH-3T3 fibroblasts expressing the PLC-delta1 PH domain linked to enhanced green fluorescent protein (PH-EGFP) reveals intense, non-uniform fluorescence in distinct structures at the cell periphery. Corresponding fluorescence and phase-contrast imaging over time shows that these fluorescent structures correlate with dynamic, phase-dense features identified as ruffles and with microvillus-like protrusions from the cell's dorsal surface. Imaging of fixed and permeabilized cells shows co-localization of PH-EGFP with F-actin in ruffles, but not with vinculin in focal adhesions. The selective concentration of the PH-EGFP fusion protein in highly dynamic regions of the plasma membrane that are rich in F-actin supports the hypothesis that localized synthesis and lateral segregation of PI(4,5)P(2) spatially restricts actin polymerization and thereby affects cell spreading and retraction.

[Pharmacotherapy of anxiety disorders]

The pharmacotherapy of anxiety disorders has revolutionary changed in the last few years. This ICD-10 based review of the literature provides help for general practitioners and other specialists in the short and long term treatment of anxiety as well as in the discontinuation of pharmacologic treatment. The author describes the use of high potency benzodiazepines, selective serotonin reuptake inhibitors and 5 HT1A partial agonists and summarizes the disadvantages of some older drugs still in use for the treatment of anxiety disorders.

Haloperidol blood levels and clinical effects

This study explored the relationships between plasma levels and the clinical effects of haloperidol in 176 acutely exacerbated schizophrenic or schizoaffective patients. After a single-blind placebo period of 1 week (period 1), they entered the double-blind period 2 randomly assigned to one of three plasma levels of haloperidol: low (2 to 13 ng/mL), medium (13.1 to 24 ng/mL), or high (24.1 to 35 ng/mL). Patients whose conditions did not improve in period 2 continued on one of the three haloperidol levels (period 3). Periods 2 and 3 lasted 6 weeks each. Only minor differences in clinical responses were noted among the three levels of haloperidol. These results imply that low or moderate doses of neuroleptics are appropriate for many acutely psychotic patients.

The concept of the neuroleptic threshold: an update

The authors review the development and the controversies of the neuroleptic threshold theory. According to this theory, the minimum effective antipsychotic dose of a neuroleptic ("threshold dose") correlates with the appearance of "fine motor" symptoms (micrography) as opposed to the appearance of manifest or "coarse motor" extrapyramidal side effects. About half of the acutely exacerbated schizophrenic patients respond to threshold doses, but no predictors are known to characterize the responders. The neuroleptic threshold doses were found to be low, and the low dose treatment strategy is supported by the results of current PET and neuroleptic plasma level studies.

Relationship between the Brief Psychiatric Rating Scale and the Scale for the Assessment of Negative Symptoms: a study of their correlation and redundancy

Because overlapping psychometric scales are used frequently in psychiatric research, examination of the relationship between scales has become increasingly important. The concept of relationship is the focus of this article. By way of illustration, the Brief Psychiatric Rating Scale (BPRS) and the Scale for the Assessment of Negative Symptoms (SANS) were compared for correlation and redundancy. Since these scales are frequently represented by derived summary variables (e.g., factors, total scores), it is also important to assess the effect of such representation on measures of relationship. The SANS and the BPRS were found to be highly intercorrelated. Nevertheless, the individual items and the subscale scores of the SANS contain information independent from the BPRS: the best BPRS predictor variates can explain only approximately half of the total variance of the SANS. When the SANS, however, is represented by a single variable (composite score), it becomes highly redundant with the anergia factor of the BPRS.

The measurement of subjective experience in schizophrenia: the Subjective Deficit Syndrome Scale

The systematic assessment of subjective experience independently from its impact on schizophrenic's behavior is neglected in most structured interviews and symptoms rating scales. However, subjective complaints may predict outcome functioning, medication compliance, and future psychotic episodes and better reflects patients' well-being than does behavioral assessment. We demonstrate the reliability of the Subjective Deficit Syndrome Scale and the considerable prevalence of subjective complaints in 166 acute and chronic inpatients and outpatients. Complaints were correlated with global measures of psychopathology in acute but not chronic patients. They were not correlated with negative symptoms or neurological side effects. Some overlap was observed with measures of depression, although most patients denied depressed mood. We conclude that subjective deficits are prevalent in schizophrenia, that they can be reliably assessed, and that they constitute an independent, clinically important dimension of the disease.

Electrodermally differentiated subgroups of anxiety patients. I. Automatic and vigilance characteristics

A total of 32 anxiety patients (agoraphobia, panic syndrome, generalized anxiety syndrome) selected according to the DSM-III criteria were compared with 16 controls to determine distinguishing features of autonomic response patterns to a sequence of verbal and acoustic stimuli. In addition sensorimotor tasks were performed. The anxiety patients were classified into electrodermally stabile and labile subgroups on the basis of two reliably measurable psychophysiological parameters: the rate of electrodermal habituation to neutral stimuli and non-specific electrodermal activity. The electrodermally labile anxiety group was characterized by a high degree of variability in respiratory and pulse rate during the autonomic activation procedure. Within the control group the electrodermally labile subjects were characterized by a significantly higher pulse rate during the entire autonomic activation procedure. The reduced habituation capacity of the labile subgroup of anxiety patients compared to the controls was reflected in both retarded habituation and long durations of electrodermal responses to all verbal stimuli. This group also tolerated monotony; their performance did not drop during the 256 sensorimotor reaction time tasks and even exceeded the performance of the control group by the end of the test. The stabile anxiety subgroup had a significantly longer reaction time in all reaction time tasks than the labile subgroup of anxiety patients.

Types of complaints in psychiatric and internal medical patients

A follow-up study was made in groups of female neurotic, depressive, periodic catatonic, hypertonic, hyperthyreotic patients and normal control subjects using self-rating questionnaires to assess disposition, depressivity, neuroticism and subclinical symptoms. The subclinical symptoms scale (Sub-S) was elaborated on the basis of Huber's pure defect. We found that the experience (Sub-Exp) and behavior characteristics (Sub-Be) of the Sub-S form two separate subconstructs. The Sub-Exp belongs to the neuroticism factor and the Sub-Be can be evaluated as a subclinical appearance of manifest psychopathological behavior symptoms. The 'general disposition' construct is divided into subconstructs and shows contextual variants. It is proposed to use different methods for assessing it in the different problem areas simultaneously.