Association between psychiatric admissions in patients with schizophrenia and IL-6 plasma levels polygenic score

Schizophrenia diagnosis and admission history were associated with a polygenic score (PGS) for schizophrenia based on a subset of variants that act by modifying the expression of genes whose expression is also modified by antipsychotics. This gene set was enriched in cytokine production. Interleukin-6 (IL-6) is the only cytokine whose plasma levels were associated both with schizophrenia diagnosis and with acute decompensations in the largest meta-analysis. Therefore, we hypothesized that an IL-6 PGS, but not other cytokines PGSs, would be associated with schizophrenia chronicity/psychiatric admissions. Using the IL-6 PGS model from The PGS Catalog, IL-6 PGS was calculated in 427 patients with schizophrenia and data regarding admission history. Association between IL-6 PGS and chronicity, measured as number and duration of psychiatric admissions, or ever readmission was analyzed by multivariate ordinal and logistic regression, respectively. Specificity of results was assessed by analysis of PGSs from the other cytokines at The PGS Catalog with meta-analytic evidence of association with schizophrenia diagnosis or acute decompensations, IL-1RA, IL-4, IL-8, and IL-12. IL-6 PGS was associated with schizophrenia chronicity, explaining 1.51% of variability (OR = 1.29, 95% CI 1.07-1.55, P = 0.007). There was no association with ever readmission. Other cytokines PGSs were not associated with chronicity. Association with IL-6 PGS was independent of association with schizophrenia PGS. Our results provide evidence that genetically regulated higher levels of IL-6 are involved in schizophrenia chronicity, highlighting the relevance of immunity processes for a subgroup of patients.

Efficacy of a Cognitive Behavioral Intervention for the Prevention of Depression in Nonprofessional Caregivers Administered through a Smartphone App: A Randomized Controlled Trial

Due to the limited availability of in-person interventions for caregivers, the development of effective programs that use new technologies to prevent depression is needed. The goal of this research was to assess the efficacy of a cognitive behavioral intervention for the prevention of depression, administered to nonprofessional caregivers through a smartphone application (app). One hundred and seventy-five caregivers were randomly assigned to either an app-based cognitive behavioral intervention (CBIA), the CBIA intervention plus a telephone conference call (CBIA + CC), or an attention control group (ACG). At post-intervention, the incidence of depression was lower in the CBIA and CBIA + CC compared to the ACG (1.7% and 0.0% vs. 7.9%, respectively). The absolute risk, relative risk, and number needed to treat compared to the ACG were 6.2%, 21.6%, and 16 for the CBIA, whilst they were 8%, 0.0%, and 13 for the CBIA + CC. Depressive symptomatology was significantly lower in the CBIA and CBIA + CC compared to the ACG (d = 0.84, Cliff's δ = 0.49; d = 1.56, Cliff's δ = 0.72), as well as in the CBIA + CC compared to the CBIA (d = 0.72, Cliff's δ = 0.44). The prevention of depression was more likely in participants who received the CBIA, and adding the conference call in the CBIA + CC group improved the likelihood of this.

Epidemiological characteristics and hospitalization trajectories prior to suicide in Galicia between 2013 and 2016

INTRODUCTION

Addressing suicide requires an understanding of regional patterns of epidemiology, with health variables being central. However, the clinical profile of people who commit suicide has received little attention. The objectives of this study were to analyze the sociodemographic, clinical, and forensic characteristics of persons who committed suicide in Galicia between 2013 and 2016, analyze suicide mortality rates, and identify trajectories of hospitalizations and associated variables.

MATERIAL AND METHODS

A population study was carried out on the 1354 people who died by suicide in Galicia.

RESULTS

The most common profile was a retired man, 57.9 years old (SD=18.5), from an urban and inner area. 43.6% had been previously hospitalized, 41.6% had been diagnosed with physical disorders, and 26.8% with mental disorders. 48.2% had been prescribed psychiatric medications and 29.6% had received outpatient psychiatric care. The highest prevalence of death by suicide (27.5%) was in 2014, with the predominant method being hanging (59.1%). The average raw rate was 12.3/100,000. Three trajectories of hospitalizations emerged: 94.83% had experienced few hospitalizations; 2.95% an increasing pattern; and 2.22% a decreasing pattern. These trajectories were associated with number of psychiatric appointments, prescription of psychiatric medications, and diagnoses of physical and mental disorders.

CONCLUSIONS

These findings are crucial for detection and prevention.

Association between psychiatric hospitalizations of patients with schizophrenia and polygenic risk scores based on genes with altered expression by antipsychotics

OBJECTIVE

To test whether a schizophrenia polygenic risk score (PRS) based on the subset of polymorphisms that affect brain expression of genes with altered expression by antipsychotics (exprAP PRS) is associated with psychiatric readmission of patients with schizophrenia.

METHODS

The study involved 427 patients with schizophrenia. Genes with altered expression by antipsychotics were extracted from the Comparative Toxigenomics Database. ExprAP PRS was estimated using the clumping and thresholding (p < 0.05) method. Two additional PRS were tested based on subsets of exprAP polymorphisms whose schizophrenia risk allele has the same (unrestored PRS) or opposite (restored PRS) direction of effect on gene expression than antipsychotics. A general SCZ PRS was tested for comparison. Logistic and ordinal regression were used to test for association of each PRS with ever readmission and admission history, an outcome based on length and number of admissions, respectively. Webgestalt was used for Gene Ontology enrichment analysis.

RESULTS

ExprAP PRS was associated with ever readmission (OR = 1.48, 95%CI:1.10-1.97) and admission history (OR = 1.30, 95%CI 1.07-1.57). SCZ PRS (OR = 1.22, 95%CI: 1.01-1.48) and unrestored PRS (OR = 1.26, 95%CI 1.04-1.53) were only associated with admission history. Genes at exprAP PRS were enriched in regulation of cytokine production.

CONCLUSION

Our findings suggest that PRS based on genes with altered expression by antipsychotics may be better predictors of readmission than SCZ PRS, warranting further investigation in larger cohorts of patients. The action of antipsychotics may be related to brain gene expression, mainly in genes involved in immunity.

A polygenic approach to the association between smoking and schizophrenia

Smoking prevalence in schizophrenia is considerably larger than in general population, playing an important role in early mortality. We compared the polygenic contribution to smoking in schizophrenic patients and controls to assess if genetic factors may explain the different prevalence. Polygenic risk scores (PRSs) for smoking initiation and four genetically correlated traits were calculated in 1108 schizophrenic patients (64.4% smokers) and 1584 controls (31.1% smokers). PRSs for smoking initiation, educational attainment, body mass index and age at first birth were associated with smoking in patients and controls, explaining a similar percentage of variance in both groups. Attention-deficit hyperactivity disorder (ADHD) PRS was associated with smoking only in schizophrenia. This association remained significant after adjustment by psychiatric cross-disorder PRS. A PRS combining all the traits was more explanative than smoking initiation PRS alone, indicating that genetic susceptibility to the other traits plays an additional role in smoking behaviour. Smoking initiation PRS was also associated with schizophrenia in the whole sample, but the significance was lost after adjustment for smoking status. This same pattern was observed in the analysis of specific SNPs at the CHRNA5-CHRNA3-CHRNB4 cluster associated with both traits. Overall, the results indicate that the same genetic factors are involved in smoking susceptibility in schizophrenia and in general population and are compatible with smoking acting, directly or indirectly, as a risk factor for schizophrenia that contributes to the high prevalence of smoking in these patients. The contrasting results for ADHD PRS may be related to higher ADHD symptomatology in schizophrenic patients.

Determination of antidepressants and benzodiazepines in paired hair and nail samples

Hair and nails are keratinized matrices that can be used in Toxicology as matrices for the long-term detection of substances. Whereas hair is an established matrix with decades of use in this field, nails have been less studied, especially including a comparison to hair samples. Specifically in the case of antidepressant and benzodiazepine drugs, very few publications analyzing these drugs in nail samples exist as of yet. For this reason, in the present study a method for the detection of 12 antidepressant and benzodiazepine drugs in hair and nail samples was developed. Samples were decontaminated with 3 washes of dichloromethane, and 25 or 30 mg of hair and nails, respectively, were pulverized. Then, the samples were incubated with 1.5 mL water:ACN (50:50, v/v) with horizontal agitation for 90 min. The supernatant was evaporated and reconstituted in 200 µL of methanol and 2 mL of 2% FA in water, submitted to solid phase extraction (SPE) using Oasis MCX cartridges and analyzed by LC-MS/MS. The method was satisfactorily validated in nail and hair samples for the following parameters: linearity, LOD (0.005-0.02 ng/mg), LOQ (0.01-0.02 ng/mg), selectivity, carryover, accuracy, imprecision, matrix effect, extraction efficiency, process efficiency and autosampler stability. Matched fingernail, toenail and hair samples were obtained from 21 patients under treatment with any of the studied drugs and analyzed with the developed method. The most frequently detected drugs were venlafaxine (n = 11), trazodone (n = 6), zolpidem (n = 5), alprazolam (n = 5) and nordiazepam (n = 5). Concentrations in hair, fingernails and toenails, respectively, were 44.31 ng/mg, 8.05-43.35 ng/mg and 7.02-22.69 ng/mg for venlafaxine; 5.40-19.08 ng/mg, 0.13-1.00 ng/mg and 0.42-1.04 ng/mg for trazodone; 13.86 ng/mg, 5.19 ng/mg and 9.11 ng/mg for fluoxetine; 7.42 ng/mg, 1.85 ng/mg and 0.03-2.81 ng/mg for sertraline; 0.40-1.42 ng/mg, 0.12 ng/mg and 0.16 ng/mg for zolpidem; and 0.02-0.11 ng/mg, 0.07-1.07 ng/mg and 0.05 ng/mg for alprazolam for the patients under active treatment. Hair concentrations were higher than nail concentrations for most drugs in patients under active treatment, with the exception of diazepam (n = 1; 0.12 ng/mg in hair and 0.41 ng/mg in fingernails). Fingernail concentrations were lower than toenail concentrations in patients under active treatment in most compared cases. Comparison of fingernails and toenails of a patient with antifungal treatment did not show an observable effect in concentrations.

Predictors of persistence in patients with schizophrenia treated with aripiprazole once-monthly long-acting injection in the Spanish clinical practice: a retrospective, observational study

Background

Poor adherence to antipsychotic drugs is a major problem in schizophrenia management and one of the most important risk factors for relapse and hospitalization. To date, there is little evidence on persistence predictors with long-acting injectable antipsychotics, especially with aripiprazole once-monthly (AOM). This study (NCT03130478) aimed to describe the impact of demographic and clinical characteristics on persistence with AOM treatment in real-world setting.

Methods

This was an observational, retrospective, non-interventional study that included adult patients with schizophrenia who were initiated on AOM during a schizophrenia-related hospitalization. Data were retrospectively collected from patients’ medical records. The primary variable was persistence with AOM, measured as the number of days from AOM initiation up to all-cause AOM discontinuation during the first six months after treatment index.

Results

140 patients were enrolled and 91 fulfilled the selection criteria. Six months after AOM initiation, 65 (71.4%) patients were still receiving AOM treatment, whereas 26 (28.6%) were not. The mean (standard deviation) time to AOM treatment discontinuation in the first six months was 138.1 (6.8) days, with most of the patients discontinuing at the first 28 days. The risk of AOM discontinuation in the first six months increases 1.05-fold annually since schizophrenia diagnosis (p=0.003); moreover, this risk increases 2.86-fold in patients with concomitant schizophrenia medication at AOM initiation compared to patients without concomitant schizophrenia treatments (p=0.02).

Conclusions

Main factors predicting persistence with AOM treatment at six months in clinical practice are fewer years since schizophrenia diagnosis and not receiving concomitant schizophrenia treatments at AOM initiation.

Structure and Functioning of Acute Inpatient Psychiatric Units in Spain: Qualitative Study

Background

As a consequence of the decentralization of health care provision to the different Regions (called Autonomous Communities) in Spain, different health care models and resources have been developed for psychiatric patients. It would be very useful to obtain comprehensive and comparative data on health care models, resources, and activity of acute inpatient psychiatric units (AIPUs) as a key part of mental health systems.

Objective

The aim of this study was to determine the current state of AIPUs in Spain through a national scorecard that allows the current situation to be visualized in terms of resources, processes, and outputs.

Methods

A 104-item online questionnaire was sent to all the AIPUs of the different Regions in Spain. It was divided into 11 sections, including data on the resources, processes, and outputs of the AIPUs plus general data, an indicator dashboard, and good practices.

Results

The questionnaire was completed by 60.0% (117/195) of the AIPUs invited to participate. The information collected has allowed us to obtain a detailed snapshot of the current situation of AIPUs in Spain at the levels of infrastructure and material resources, staffing, organization and activity of the units, coordination with other units, guidelines, processes and protocols used, participation and communication with patients and their families, teaching activity, and research linked to the units.

Conclusions

This project aimed to help understand the general situation of AIPUs in Spain and its different Regions, contribute to enhancing the benchmarking and harmonization among Spanish Regions, and provide data for future comparisons with other countries.

International Registered Report Identifier (IRRID)

RR1-10.2196/26214

Long-Term Effects of a Cognitive Behavioral Conference Call Intervention on Depression in Non-Professional Caregivers

Recent evidence supports the efficacy of conference call cognitive-behavioral interventions in preventing depression in caregivers at post-intervention, but we do not know whether the results are sustained long term. The main objective of this study was to evaluate the long-term efficacy of a cognitive-behavioral intervention administered by telephone conference call in preventing depression in caregivers with elevated depressive symptoms, comparing all components of the intervention versus only the behavioral ones. A randomized controlled trial was conducted using a dismantling strategy. At total of 219 caregivers were randomly assigned to a cognitive-behavioral conference call intervention (CBCC; n = 69), a behavioral-activation conference call intervention (BACC; n = 70), or a usual care control group (CG, n = 80). Information was collected on depressive symptoms and depression at pre-intervention and at 1, 3, 6, 12, and 36 months post-intervention. At 36 months, there was a reduction in depressive symptoms (p < 0.001) and a lower incidence of major depressive episodes in both the CBCC and BACC groups compared to CG (8.7%, 8.6%, and 33.7%, respectively). The results show that a conference call intervention was effective in the long term to prevent depression in caregivers and that the behavioral-activation component was comparable to the complete cognitive-behavioral protocol.

Analysis of the Components of a Cognitive-Behavioral Intervention for the prevention of Depression Administered via Conference Call to Nonprofessional Caregivers: A Randomized Controlled Trial

Effective and accessible interventions for indicated prevention of depression are necessary and lacking, especially for informal caregivers. Although telephone-based interventions could increase the accessibility for caregivers, randomized controlled trials are scarce, with no examination of prevention to date. Moreover, the efficacy of specific therapeutic components in preventive cognitive-behavioral programs is unknown. The main objective of this study was to evaluate the efficacy of a telephone-administered psychological preventive intervention in informal caregivers with high depressive symptoms. A total of 219 caregivers were randomized to a cognitive-behavioral conference call intervention (CBCC, n = 69), a behavioral-activation conference call intervention (BACC, n = 70), or a usual care control group (CG, n = 80). Both interventions consisted of five 90-minute group sessions. At the post-intervention, incidence of depression was lower in CBCC and BACC compared to CG (1.5% and 1.4% vs. 8.8%). Relative risk was 0.17 for the CBCC and 0.16 for the BACC, and the number-needed-to-treat was 14 in both groups. Depressive symptoms were significantly lower in BACC and BACC groups compared to CG (d = 1.16 and 1.29), with no significant differences between CBCC and BACC groups. The conference call intervention was effective in preventing depression and the behavioral-activation component (BACC) was comparable to the CBCC intervention.

Identification of relevant hub genes for early intervention at gene coexpression modules with altered predicted expression in schizophrenia

Genetic risk for schizophrenia is due to the joint effect of multiple genes acting mainly at two different processes, prenatal/perinatal neurodevelopment and adolescence/early adulthood synapse maturation. Identification of important genes at the second process is of relevance for early intervention. The aim of this work was to identify gene co-expression modules with altered expression in schizophrenia during adolescence/early adulthood. To this goal, we predicted frontal cortex gene expression in one discovery sample, the largest GWAS of schizophrenia from the Psychiatric Genomics Consortium, using S-prediXcan, and in one target sample, consisting of 625 schizophrenic patients and 819 controls from Spain, using prediXcan. Prediction models were trained on GTEx frontal cortex expression dataset. In parallel, we identified brain co-expression modules from BrainSpan using WGCNA. Then, we estimated polygenic risk scores based on predicted expression (PE-PRS) for each co-expression module in the target sample, based on PE-PRS model from the discovery sample. This analysis led to the identification of a module with mainly adolescence/adulthood expression whose PE-PRS was significantly associated with schizophrenia. The module was significantly enriched in synaptic processes. Several hub genes at this module are drugabble, according to the drug-gene interaction database, and/or involved in synaptic transmission, such as the voltage-gated ion channels SCN2B and KCNAB2, the calcium calmodulin kinases CAMK2A and CAMK1G, or genes involved in synaptic vesicle cycle, such as DNM1, or SYNGR1. Therefore, identification of this module may be the first step in patient stratification based on biology, as well as in drug design and drug repurposing efforts.

Identification of putative second genetic hits in schizophrenia carriers of high-risk copy number variants and resequencing in additional samples

Copy number variants (CNVs) conferring risk of schizophrenia present incomplete penetrance, suggesting the existence of second genetic hits. Identification of second hits may help to find genes with rare variants of susceptibility to schizophrenia. The aim of this work was to search for second hits of moderate/high risk in schizophrenia carriers of risk CNVs and resequencing of the relevant genes in additional samples. To this end, ten patients with risk CNVs at cytobands 15q11.2, 15q11.2-13.1, 16p11.2, or 16p13.11, were subjected to whole-exome sequencing. Rare single nucleotide variants, defined as those absent from main public databases, were classified according to bioinformatic prediction of pathogenicity by CADD scores. The average number of rare predicted pathogenic variants per sample was 13.6 (SD 2.01). Two genes, BFAR and SYNJ1, presented rare predicted pathogenic variants in more than one sample. Follow-up resequencing of these genes in 432 additional cases and 432 controls identified a significant excess of rare predicted pathogenic variants in case samples at SYNJ1. Taking into account its function in clathrin-mediated synaptic vesicle endocytosis at presynaptic terminals, our results suggest an impairment of this process in schizophrenia.

Cognitive behavioral intervention via a smartphone app for non-professional caregivers with depressive symptoms: study protocol for a randomized controlled trial

Background

Although major depression is a frequent disorder in non-professional caregivers and there are effective psychological interventions to prevent it, caregivers have difficulty accessing them. Interventions for depression applied through an app could improve accessibility; yet, to date, adherence to such interventions has been low. The objectives of this study are to (1) evaluate the efficacy of a cognitive behavioral depression prevention intervention administered through a smartphone app with and without telephone conference calls, (2) analyze the mediators of the change in the incidence of depression and depressive symptoms, and (3) assess adherence and satisfaction with the interventions.

Methods

A randomized controlled clinical trial will be conducted. Caregivers with elevated symptoms will be randomly assigned to a cognitive behavioral intervention administered by a smartphone app (CBIA) group, a CBIA plus telephone conference calls (TCCs) group (CBIA + TCC), or an attention control group. Each condition will consist of approximately 58 participants. Both interventions will be administered in five modules through a smartphone app and the CBIA + TCC group will receive additional TCCs in group format (four sessions of 30 min each). Trained blind assessors will conduct pre-treatment, post-treatment and follow-up assessments at 1, 3, 6, and 12 months.

Discussion

This study will provide evidence of the efficacy of a cognitive behavioral intervention to prevent depression in caregivers with elevated depressive symptoms administered through a smartphone app and the impact of feedback applied through conference calls to increase program adherence and efficacy. If the results were favorable, it would mean that we have developed a more effective, accessible, and clinically useful preventive depression intervention than the currently available ones for many present and future caregivers.

Trial registration

ClinicalTrials.gov: NCT03110991. Registered 5 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2793-2) contains supplementary material, which is available to authorized users.

The role of emotion dysregulation in Conversion Disorder

INTRODUCTION

The role that emotion regulation plays in Conversion Disorders (CD) is not well known. This research deepens in this subject and describes the main differences between a group of conversion patients and a control group on different measures of emotion regulation and other clinical variables.

METHODS

A case-control study was conducted including 43 patients suffering from CD and 42 healthy controls. Both groups went thought two psychiatric interviews and fulfilled 6 questionnaires assessing depression, anxiety, alexithymia, emotion dysregulation, affect intensity, psychoform and somatoform dissociation.

RESULTS

Patients suffering from CD scored significantly higher on all the six questionnaires (p<0.001). Negative reactivity and negative intensity were also higher in patients (p<0.01), while cases and controls did not show any significant differences on positive affectivity and serenity. Anxiety, alexithymia and emotional dysregulation were the most relevant factors (OR=5.85/3.50/3.23 respectively). Anxiety and difficulties in emotion regulation were the most explicative variables for conversion in the regression analysis performed. Within the five factors assessing difficulties in emotion regulation, lack of emotional control and interference in goal directed behaviors were the most relevant. Positive and negative conversion where correlated to different emotional impairments.

CONCLUSIONS

People suffering from CD show several emotional impairments when compared to healthy controls. Emotion dysregulation can be considered a relevant aspect in CD. The existence of specific emotional patterns for different conversion manifestations is suspected.

Emotion regulation strategies in trauma-related disorders: pathways linking neurobiology and clinical manifestations

Emotion regulation impairments with traumatic origins have mainly been studied from posttraumatic stress disorder (PTSD) models by studying cases of adult onset and single-incident trauma exposure. The effects of adverse traumatic experiences, however, go beyond the PTSD. Different authors have proposed that PTSD, borderline personality, dissociative, conversive and somatoform disorders constitute a full spectrum of trauma-related conditions. Therefore, a comprehensive review of the neurobiological findings covering this posttraumatic spectrum is needed in order to develop an all-encompassing model for trauma-related disorders with emotion regulation at its center. The present review has sought to link neurobiology findings concerning cortico-limbic function to the field of emotion regulation. In so doing, trauma-related disorders have been placed in a continuum between under- and over-regulation of affect strategies. Under-regulation of affect was predominant in borderline personality disorder, PTSD with re-experiencing symptoms and positive psychoform and somatoform dissociative symptoms. Over-regulation of affect was more prevalent in somatoform disorders and pathologies characterized by negative psychoform and somatoform symptoms. Throughout this continuum, different combinations between under- and over-regulation of affect strategies were also found.

Hepatocellular carcinoma treatment: ablation and arterial embolization

Percutaneous and endovascular techniques take an important role in the therapeutic management of patients with hepatocarcinoma. Different techniques of percutaneous ablation, especially indicated in tumors up to 2cm diameter offer, at least, similar results to surgical resection. Taking advantage of double hepatic vascularization and exclusive tumor nutrition by the artery, several endovascular techniques of treating the tumor have been developed. Intra-arterial administration of embolizing particles, alone or charged with drug (chemoembolization), will produce ischemia and consequent necrosis with excellent results in selected patients. Certain types of particles may exclusively be carriers of a therapeutic agent when they incorporate a radioisotope that facilitates the direct intratumoral selective irradiation (radioembolization). This technique has demonstrated its efficacy in lesions not susceptible to be treated with other methods and should be considered, together with ablation and chemoembolization, in the therapeutic algorithms of hepatocarcinoma.

Treatment of benign biliary leaks with transhepatic placement of coated self-expanding metallic stents

OBJECTIVES

To analyze the safety and efficacy of percutaneous placement of coated self-expanding metallic stents (SEMS) in patients with biliary leaks.

MATERIAL AND METHODS

This ethics committee at our center approved this study. We retrospectively reviewed all coated SEMS placed between October 2008 and September 2015. We analyzed patient-related factors such as the primary underlying disease, prior hepatic procedures, and clinical outcome. We evaluated the location, the number and type of leak (anastomotic or non-anastomotic), and the characteristics of the interventional procedure (number of stents deployed, location of the stents, technical success, and primary functionality). We recorded the complications registered.

RESULTS

We studied 14 patients (11 men and 3 women). The mean follow-up period was 375.5 days (range 15-1920 days). Leaks were postsurgical in 12 patients. One patient developed an arteriobilioportal fistula. In another, the biliary leak occurred secondary to the rupture of the common bile duct after ERCP. A total of 23 coated SEMS were placed, including 21 Fluency^® stents (Bard, Tempe, AZ, USA) and 2 Wallflex^® stents (Boston Scientific, Galway, Republic of Ireland). The technical success of the procedure was considered total in 11 (78.6%) patients, partial in 2 (14.3%) patients, and null in 1 (7.2%) patient. The clinical outcome was good in 13 of the 14 patients. The mean period of primary functionality of the coated SEMS was 331 days (range 15-1920 days). No major complications were observed in 11 (78.6%) patients.

CONCLUSIONS

Percutaneous placement of coated SEMS for the treatment of benign biliary leaks is safe and efficacious, with a high rate of technical and clinical success and a moderate rate of complications.

Suicide mortality trends in Galicia, Spain and their relationship with economic indicators

BACKGROUND

Recent research has shown an association between unemployment and suicide, but the mediating factors in this relationship are still unknown. In this study, we investigated the effect of unemployment and economic recession on suicide rates in the Spanish region of Galicia between 1975 and 2012 Method. We analysed age-standardised suicide rates in men and women and in four age groups: less than 25 years, 25-45 years, 45-65 years and more than 65 years and performed a joinpoint analysis to determine trend changes throughout 1975-2012 period. Also we analysed the association between suicide, recession and unemployment by means of a temporal trend model with a Generalised Additive Model.

RESULTS

Suicide rates increased from 145 suicides in 1975 to a high in 1993, with 377 deaths by suicide, representing 1.38% of all causes of death, and thereafter they tend to decrease to 335 suicides in 2012. Joinpoint analyses revealed that suicide rates changed differently across sex and age groups. For men, the annual percentage of change (APC) between 1975 and 1988 (CI 95% 1986-1994) was 5.45 (CI 95% = 3.5, -7.2) but from 1988 the APC became negative [-0.66 (CI 95% = -1.3, -0.1)]. For women, APC between 1974 and 1990 (CI 95% 1986-1992) was 4.86 (CI 95% = 3.2, -6.4) and -1.46 subsequently (CI 95% = -2.2, -0.5). Women aged 24 years or less showed stable suicide rates while men from 45-65 years showed two incidence peaks. When we studied the independent correlation between unemployment, recession and suicide, we found a significant association between unemployment and suicide, but not between recession and suicide for both sexes together and for men while for women there was no significant correlation between suicide and unemployment or recession. Finally, when we studied the effect of the interaction between unemployment and recession on suicide we found economic recession and unemployment interacted with regards to suicide rates (F = 5.902; df = 4.167; p = 0.00098) and after adjusting by sex, the effect was confirmed among men (F = 4.827; df = 2.823; p = 0.0087), but not among women (F = 0.001; df = 1.000; p = 0.979).

CONCLUSIONS

Although suicide rates in Galicia are gradually decreasing in the last decades, there are important sex and age differences. Unemployment was related with suicide during economic recession periods according to our results.

Targeted resequencing of regulatory regions at schizophrenia risk loci: Role of rare functional variants at chromatin repressive states

There is mounting evidence that regulatory variation plays an important role in genetic risk for schizophrenia. Here, we specifically search for regulatory variants at risk by sequencing promoter regions of twenty-three genes implied in schizophrenia by copy number variant or genome-wide association studies. After strict quality control, a total of 55,206bp per sample were analyzed in 526 schizophrenia cases and 516 controls from Galicia, NW Spain, using the Applied Biosystems SOLiD System. Variants were filtered based on frequency from public databases, chromatin states from the RoadMap Epigenomics Consortium at tissues relevant for schizophrenia, such as fetal brain, mid-frontal lobe, and angular gyrus, and prediction of functionality from RegulomeDB. The proportion of rare variants at polycomb repressive chromatin state at relevant tissues was higher in cases than in controls. The proportion of rare variants with predicted regulatory role was significantly higher in cases than in controls (P=0.0028, OR=1.93, 95% C.I.=1.23-3.04). Combination of information from both sources led to the identification of an excess of carriers of rare variants with predicted regulatory role located at polycomb repressive chromatin state at relevant tissues in cases versus controls (P=0.0016, OR=19.34, 95% C.I.=2.45-2495.26). The variants are located at two genes affected by the 17q12 copy number variant, LHX1 and HNF1B. These data strongly suggest that a specific epigenetic mechanism, chromatin remodeling by histone modification during early development, may be impaired in a subset of schizophrenia patients, in agreement with previous data.

Excitatory and inhibitory conversive experiences: neurobiological features involving positive and negative conversion symptoms

Previous reviews have focused on neurobiological and physiological mechanisms underlying conversion disorder, but they do not usually distinguish between negative and positive conversion symptoms. Some authors have proposed that different phenomena should underlie both situations and that diverse emotion regulation strategies (under- vs. overregulation of affect) should be related to different internal experiences (excitatory experiences with hyperarousal manifestations vs. inhibitory experiences coexisting with hypoarousal states, respectively). After a careful review of the literature, we conclude that there is not a unique theory comprising all findings. Nevertheless, we have also collected some replicated findings that should be salient. Patients manifesting positive conversion symptoms tended to present with limbic hyperfunction, not sufficiently counteracted by prefrontal control. This leads to underregulation of affect mechanisms, increased emotional reactivity and autonomic hyperarousal. The opposite pattern (with a prefrontal overfunction working as a cognitive brake over the limbic system) has been described during negative conversion manifestations. We also highlight the influence of fronto-limbic circuits over cortico-striato-thalamo-cortical circuits’ regulation, whose horizontal and vertical synchronization has been at the spotlight of the genesis of conversion and dissociative disorders.

Cumulative role of rare and common putative functional genetic variants at NPAS3 in schizophrenia susceptibility

Schizophrenia may be considered a human-specific disorder arisen as a maladaptive by-product of human-specific brain evolution. Therefore, genetic variants involved in susceptibility to schizophrenia may be identified among those genes related to acquisition of human-specific traits. NPAS3, a transcription factor involved in central nervous system development and neurogenesis, seems to be implicated in the evolution of human brain, as it is the human gene with most human-specific accelerated elements (HAEs), i.e., .mammalian conserved regulatory sequences with accelerated evolution in the lineage leading to humans after human-chimpanzee split. We hypothesize that any nucleotide variant at the NPAS3 HAEs may lead to altered susceptibility to schizophrenia. Twenty-one variants at these HAEs detected by the 1000 genomes Project, as well as five additional variants taken from psychiatric genome-wide association studies, were genotyped in 538 schizophrenic patients and 539 controls from Galicia. Analyses at the haplotype level or based on the cumulative role of the variants assuming different susceptibility models did not find any significant association in spite of enough power under several plausible scenarios regarding direction of effect and the specific role of rare and common variants. These results suggest that, contrary to our hypothesis, the special evolution of the NPAS3 HAEs in Homo relaxed the strong constraint on sequence that characterized these regions during mammalian evolution, allowing some sequence changes without any effect on schizophrenia risk.

Resequencing and association analysis of coding regions at twenty candidate genes suggest a role for rare risk variation at AKAP9 and protective variation at NRXN1 in schizophrenia susceptibility

A fraction of genetic risk to develop schizophrenia may be due to low-frequency variants. This multistep study attempted to find low-frequency variants of high effect at coding regions of eleven schizophrenia susceptibility genes supported by genome-wide association studies (GWAS) and nine genes for the DISC1 interactome, a susceptibility gene-set. During the discovery step, a total of 125 kb per sample were resequenced in 153 schizophrenia patients and 153 controls from Galicia (NW Spain), and the cumulative role of low-frequency variants at a gene or at the DISC1 gene-set were analyzed by burden and variance-based tests. Relevant results were meta-analyzed when appropriate data were available. In addition, case-only putative damaging variants were genotyped in a further 419 cases and 398 controls. The discovery step revealed a protective effect of rare missense variants at NRXN1, a result supported by meta-analysis (OR = 0.67, 95% CI: 0.47-0.94, P = 0.021, based on 3848 patients and 3896 controls from six studies). The follow-up step based on case-only putative damaging variants revealed a promising risk variant at AKAP9. This variant, K873R, reached nominal significance after inclusion of 240 additional Spanish controls from databases. The variant, located in an ADCY2 binding region, is absent from large public databases. Interestingly, GWAS revealed an association between common ADCY2 variants and bipolar disorder, a disorder with considerable genetic overlap with schizophrenia. These data suggest a role of rare missense variants at NRXN1 and AKAP9 in schizophrenia susceptibility, probably related to alteration of the excitatory/inhibitory synaptic balance, deserving further investigation.

Role of DISC1 interacting proteins in schizophrenia risk from genome-wide analysis of missense SNPs

A balanced translocation affecting DISC1 cosegregates with several psychiatric disorders, including schizophrenia, in a Scottish family. DISC1 is a hub protein of a network of protein-protein interactions involved in multiple developmental pathways within the brain. Gene set-based analysis has been proposed as an alternative to individual analysis of single nucleotide polymorphisms (SNPs) to get information from genome-wide association studies. In this work, we tested for an overrepresentation of the DISC1 interacting proteins within the top results of our ranked list of genes based on our previous genome-wide association study of missense SNPs in schizophrenia. Our data set consisted of 5100 common missense SNPs genotyped in 476 schizophrenic patients and 447 control subjects from Galicia, NW Spain. We used a modification of the Gene Set Enrichment Analysis adapted for SNPs, as implemented in the GenGen software. The analysis detected an overrepresentation of the DISC1 interacting proteins (permuted P-value=0.0158), indicative of the role of this gene set in schizophrenia risk. We identified seven leading-edge genes, MACF1, UTRN, DST, DISC1, KIF3A, SYNE1, and AKAP9, responsible for the overrepresentation. These genes are involved in neuronal cytoskeleton organization and intracellular transport through the microtubule cytoskeleton, suggesting that these processes may be impaired in schizophrenia.

No evidence that major mtDNA European haplogroups confer risk to schizophrenia

Previous studies suggest that genetic factors could be involved in mitochondrial dysfunction observed in schizophrenia (SZ), some of them claiming a role of mtDNA common variants (mtSNPs) and/or haplogroups (hgs) in developing this disorder. These studies, however, have mainly been undertaken on relatively small cohorts of patients and control individuals and most have not yet been replicated. To further analyze the role of mtSNPs in SZ risk, we have carried out the largest genotyping effort to date using two Spanish case-control samples comprising a total of 942 schizophrenic patients and 1,231 unrelated controls: 454 patients and 616 controls from Santiago de Compostela (Galicia) and 488 patients and 615 controls from Reus (Catalonia). A set of 25 mtSNPs representing main branches of the European mtDNA phylogeny were genotyped in the Galician cohort and a subset of 16 out of these 25 mtSNPs was genotyped in the Catalan cohort. These 16 common variants characterize the most common European branches of the mtDNA phylogeny. We did not observe any positive association of mtSNPs and hgs with SZ. We discuss several deficiencies of previous studies that might explain the false positive nature of previous findings, including the confounding effect of population sub-structure and deficient statistical methodologies. It is unlikely that mtSNPs defining the most common European mtDNA haplogroups are related to SZ.

Association study of nonsynonymous single nucleotide polymorphisms in schizophrenia

BACKGROUND

Genome-wide association studies using several hundred thousand anonymous markers present limited statistical power. Alternatively, association studies restricted to common nonsynonymous single nucleotide polymorphisms (nsSNPs) have the advantage of strongly reducing the multiple testing problem, while increasing the probability of testing functional single nucleotide polymorphisms (SNPs).

METHODS

We performed a case-control association study of common nsSNPs in Galician (northwest Spain) samples using the Affymetrix GeneChip Human 20k cSNP Kit, followed by a replication study of the more promising results. After quality control procedures, the discovery sample consisted of 5100 nsSNPs at minor allele frequency >5% analyzed in 476 schizophrenia patients and 447 control subjects. The replication sample consisted of 4069 cases and 15,128 control subjects of European origin. We also performed multilocus analysis, using aggregated scores of nsSNPs at liberal significance thresholds and cross-validation procedures.

RESULTS

The 5 independent nsSNPs with false discovery rate q ≤ .25, as well as 13 additional nsSNPs at p < .01 and located in functional candidate genes, were genotyped in the replication samples. One SNP, rs13107325, located at the metal ions transporter gene SLC39A8, reached significance in the combined sample after Bonferroni correction (trend test, p = 2.7 × 10(-6), allelic odds ratio = 1.32). This SNP presents minor allele frequency of 5% to 10% in many European populations but is rare outside Europe. We also confirmed the polygenic component of susceptibility.

CONCLUSIONS

Taking into account that another metal ions transporter gene, SLC39A3, is associated to bipolar disorder, our findings reveal a role for brain metal homeostasis in psychosis.

Interaction between COMT haplotypes and cannabis in schizophrenia: a case-only study in two samples from Spain

Cannabis use is one of the environmental factors with more solid evidence contributing to schizophrenia risk, especially in genetically susceptible individuals. One of the genes that may interact with cannabis is COMT, although available data are scarce. Here, we present a case-only study of the putative COMT-cannabis interaction in schizophrenia. Two Spanish samples from Santiago de Compostela and Valencia were screened for cannabis use. One hundred and fifty five individuals from a total of 748 patients were identified as cannabis users. Five SNPs in COMT, defining three common functional haplotypes with different enzymatic activities, were genotyped and analyzed for association at the SNP, haplotype and genotype levels. An association was detected between cannabis use and low activity variants (P<0.01) in the joint analysis and results were consistent between the two samples. Schizophrenic subjects homozygous for the Met allele at rs4680 doubled the probability of lifetime prevalence of cannabis use in comparison to Val homozygous (Mantel-Haenszel OR=2.07, 95% CI: 1.27-3.26, P=0.0031, in the combined sample). These data are in contrast to those from Caspi et al. (Biol. Psychiatry 57 (2005)1117-1127) who found association between schizophrenia/schizophreniform disorder and homozygosity at the high activity Val variant of rs4680. The results of our study are discussed in the context of previous findings, suggesting the involvement of COMT polymorphisms in the association between cannabis use and schizophrenia as well as the existence of additional factors mediating this association. However, further research is needed to confirm the COMT-cannabis interaction.

Heterozygosity at catechol-O-methyltransferase Val158Met and schizophrenia: new data and meta-analysis

Catechol-O-methyltransferase (COMT) has been largely studied in relation to schizophrenia susceptibility. Most studies focused on the functional single nucleotide polymorphism (SNP) rs4680 that causes a substitution of Val by Met at codon 158 of the COMT protein. Recent meta-analyses do not support an association between allelic variants at rs4680 and schizophrenia. However, the putative role of overdominance has not been tested in meta-analyses, despite its biological plausibility. In this work, we tested the overdominant model in two Spanish samples (from Valencia and Santiago de Compostela), representing a total of 762 schizophrenic patients and 1042 controls, and performed a meta-analysis of the available studies under this model. A total of 51 studies comprising 13,894 schizophrenic patients and 16,087 controls were included in the meta-analysis, that revealed a small but significant protective effect for heterozygosity at rs4680 (pooled OR=0.947, P=0.023). Post-hoc analysis on southwestern European samples suggested a stronger effect in these populations (pooled OR=0.813, P=0.0009). Thus, the COMT functional polymorphism rs4680 contributes to schizophrenia genetic susceptibility under an overdominant model, indicating that both too high and too low levels of dopamine (DA) signalling may be risk factors. This effect can be modulated by genetic background.

Testing the antagonistic pleiotropy model of schizophrenia susceptibility by analysis of DAOA, PPP1R1B, and APOL1 genes

Schizophrenia is a common disease associated with reduced fertility. Therefore, the existence of common susceptibility alleles not removed by natural selection may be considered an evolutionary paradox. The antagonistic pleiotropy model, proposed to explain this paradox, states that an allele may be common because of its overall selective advantage, in spite of deleterious effects on specific traits. Recent work on DAOA, PPP1R1B, and APOL1 suggests that these genes present common alleles associated to increase risk of schizophrenia but conferring an overall selective advantage, related to better cognitive performance (DAOA and PPP1R1B) or protection against pathogens (APOL1). To test if these genes fit the antagonistic pleiotropy model, we searched for recent natural selection at these loci applying the long-range haplotype test on data from the HapMap Project; and performed case-control association analysis in a well-powered sample, including 301 schizophrenic patients and 604 controls from Spain. For DAOA and PPP1R1B, we genotyped the Single-nucleotide polymorphisms (SNPs) needed to replicate previous associations, while for APOL1, we genotyped 15 tagSNPs, and seven putative functional SNPs. We did not detect evidence of recent natural selection. Furthermore, we did not find significant associations. Thus, these genes do not fit the antagonistic pleiotropy model.

[Late-onset bipolar disorder following right thalamic injury]

Bipolar disorder occurs in the elderly ages and is frequently associated to a brain injury -cerebrovascular disease. Its diagnosis is based on the finding of an ischemic injury in specific regions of the brain. The case of a 63-year-old male with cardiovascular risk factors, who was admitted due to maniform picture during a two-year long bipolar affective syndrome is presented. The neuroimaging tests showed lacunar infarction in the right thalamus and diffuse foci of ischemia in subcortical white matter having right predominance. Due to the refractoriness to psychodrugs of an endogenomorphic depressive episode, electroconvulsive therapy was prescribed, with normalization of motor component, although without mood stabilization. The therapeutic strategies and the evolution of this form of bipolarity are discussed.

Extensive linkage disequilibrium mapping at HTR2A and DRD3 for schizophrenia susceptibility genes in the Galician population

The serotonin and dopamine neurotransmitter systems are candidate pathways in the development of schizophrenia because of the assumed causal relationship with the observed symptoms as well as effective targeting of the corresponding receptors by antipsychotic drugs. However, genetic association studies have systematically focused on a limited set of genes and single nucleotide polymorphisms (SNPs), including T102C at HTR2A and Ser9Gly at DRD3. Meta-analyses of the associations between these two markers and schizophrenia revealed a true increase in risk, the magnitude of the effect being very low. In the present study we analyzed 260 schizophrenic patients and 354 control subjects from a homogeneous population, the Galician population, using an extensive linkage disequilibrium (LD) mapping approach, genotyping a total of 47 SNPs to test for the existence of additional variants that confer higher risk. We detected nominal significant association with schizophrenia for several haplotype tag SNPs (htSNPs) at HTR2A, although the significance was lost after multiple test corrections. In addition, haplotype analyses involving a sliding window approach, with window size 2 to 4 SNPs, revealed significant differences in frequencies of the DRD3 haplotypes at the 3' half of the gene region. This difference, which remains clearly significant after multiple test corrections (p=0.002, 0.0001, and 0.0025, for window sizes 2, 3, and 4, respectively), was mainly due to over-representation of several rare haplotypes in patients, at the expense of a single common haplotype; this represents interesting evidence of rare haplotypes for susceptibility detected using common htSNPs due to their strong effect.

[Malignant catatonia as paradigm of neuropsychiatric disease]

Catatonia is a large neuropsychiatric syndrome with multiple etiologies (psychiatric disorder, cerebral structural lesion, systemic disease, secondary to drugs and toxic agents) and varied clinical manifestations (cognitive and behavioral disorders, motor and speech disorders and vegetative disorders). The presence of disautonomy means a situation having vital risk, that requires immediate therapeutic intervention. A 22 year old woman was admitted due to a picture of stupor, fever, maintained postures, rigidity, seizures and tachycardia and hypertension episodes; this picture initiated four weeks earlier, with psychotic and affective symptoms and she slowly developed speech and motor activity impairment. Initially, she had been treated with neuroleptics, anticholinergics and antidepressants. The CT, MRI and CSF studies were normal. The EEG revealed diffuse slow waves and right frontotemporal paroxystic activity Laboratory determinations showed elevation of CK, coinciding with the vegetative disorder phase. The picture resolved progressively in two months, after receiving 19 sessions of electroshock therapy. In all the patients, and above all in those who receive neuroleptics, with symptoms suggesting catatonia, the presence of disautonomy should be considered as an alarm situation, which would make it necessary to discontinue the neuroleptics and to adopt special control. Electroshock therapy is the most effective therapeutic option in the situation of malignant catatonia.

Alcohol consumption in a southern European region (Galicia, Spain)

Galicia is a distinct region and an autonomous community of Spain with its own cultural identity. Two-thirds of the 2.7 million inhabitants live in the rural, reservoir of the traditional culture. Alcohol use is deeply rooted in Galician culture, and its abuse constitutes an important public health problem.

OBJECTIVES

To analyze changes in alcohol consumption in the Galician adult population during the two last decades and its sociodemographic correlates, focusing on rural versus urban differences.

METHODS

The principal source of epidemiological information is the Galicia Study of Mental Health of Adult Population, the first household survey representative of the Galician population, in which a sample of 2510 people from the population aged 16 years and older were asked about alcohol consumption in 1985. Data from subsequent surveys are also summarized and interpreted in terms of the sociocultural evolution of Galician society.

RESULTS

The per capita annual rate of alcohol consumption in Galicia was 11,167cc pure alcohol, 40% higher than the national average. Personal and social characteristics associated with high alcohol consumption included: males in their thirties and young females, farmers, and low socioeconomic status. The traditional rural model of drinking in which alcohol is perceived as a daily nourishment still predominates. However, an urban consumer model is quickly growing, especially among young women.

[A preliminary study of low dosage zuclopenthixol depot in Alzheimer's disease]

Persistent psychomotor agitation and psychotic ideation in patients with Alzheimer's disease are normally treated orally with antipsychotic drugs and are occasionally treated with other drugs. Neuroleptics administered intramuscularly at very low doses are an alternative, especially when the patient rejects medicine as a results of his or her anosognosia or of paranoid manifestations. We present the results we obtained after observing the effects of depot zuclopenthixol in six patients with probable Alzheimer's disease (based upon NINCDS-ADRDA criteria). Psychic abnormalities were assessed as per the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS). Possible extrapyramidal side effects were evaluated by means of the Abnormal Involuntary Movement Scale (AIMS). Initially 60 mg (0.3 ml) were administered intramuscularly and successive doses could be modified by +/-20 mg (0.1 ml) according to results seen on the various scales. During the first six weeks of treatment progressive improvement was noted on all three psychic functions scales in all patients. Between the sixth and twelfth weeks improvement continued although without significant change. The AIMS did not show significant changes in the twelve weeks of follow-up. We consider depot zuclopenthixol at low doses as efficacious in treating persistent psychomotor agitation and/or psychotic manifestations of Alzheimer's disease. No undesired side effects were observed in our group after a twelve week follow-up.