More anxious than depressed: prevalence and correlates in a 15-nation study of anxiety disorders in people with type 2 diabetes mellitus

Background

Anxiety disorder, one of the highly disabling, prevalent and common mental disorders, is known to be more prevalent in persons with type 2 diabetes mellitus (T2DM) than the general population, and the comorbid presence of anxiety disorders is known to have an impact on the diabetes outcome and the quality of life. However, the information on the type of anxiety disorder and its prevalence in persons with T2DM is limited.

Aims

To assess the prevalence and correlates of anxiety disorder in people with type 2 diabetes in different countries.

Methods

People aged 18–65 years with diabetes and treated in outpatient settings were recruited in 15 countries and underwent a psychiatric interview with the Mini-International Neuropsychiatric Interview. Demographic and medical record data were collected.

Results

A total of 3170 people with type 2 diabetes (56.2% women; with mean (SD) duration of diabetes 10.01 (7.0) years) participated. The overall prevalence of anxiety disorders in type 2 diabetic persons was 18%; however, 2.8% of the study population had more than one type of anxiety disorder. The most prevalent anxiety disorders were generalised anxiety disorder (8.1%) and panic disorder (5.1%). Female gender, presence of diabetic complications, longer duration of diabetes and poorer glycaemic control (HbA1c levels) were significantly associated with comorbid anxiety disorder. A higher prevalence of anxiety disorders was observed in Ukraine, Saudi Arabia and Argentina with a lower prevalence in Bangladesh and India.

Conclusions

Our international study shows that people with type 2 diabetes have a high prevalence of anxiety disorders, especially women, those with diabetic complications, those with a longer duration of diabetes and poorer glycaemic control. Early identification and appropriate timely care of psychiatric problems of people with type 2 diabetes is warranted.

White matter microstructure alterations in bipolar disorder

Genetic, neuropathological and magnetic resonance imaging findings support the presence of diffuse white matter cytoarchitectural disruption in bipolar disorder. In this study, diffusion-weighted imaging (DWI) was applied to study cortical white matter microstructure organisation in 24 patients with DSM-IV bipolar disorder and 35 matched normal controls. DWI images were obtained using a 1.5 Tesla scanner and apparent diffusion coefficient (ADC) values were determined over regions of interest placed, bilaterally, in the frontal, temporal, parietal, and occipital white matter. Significantly increased ADC values were found in bipolar patients with respect to normal controls in the right temporal lobe, left parietal lobe and bilateral occipital lobes. ADC values did not associate significantly with age or with clinical variables (p>0.05). Diffuse cortical white matter alterations on DWI in bipolar disorder denote widespread disruption of white matter integrity and may be due to altered myelination and/or axonal integrity.

Increased fronto-temporal perfusion in bipolar disorder

OBJECTIVES

Previous imaging reports showed over-activation of fronto-limbic structures in bipolar patients, particularly in response to emotional stimuli. In this study, for the first time, we used perfusion weighted imaging (PWI) to analyze lobar cerebral blood volume (CBV) in bipolar disorder to further explore the vascular component to its pathophysiology.

METHODS

Fourteen patients with DSM-IV bipolar disorder (mean age+/-SD=49.00+/-12.30 years; 6 males, 8 females) and 29 normal controls (mean age+/-SD=45.07+/-10.30 years; 13 males, 16 females) were studied. PWI images were obtained following intravenous injection of paramagnetic contrast agent (Gadolinium-DTPA), with a 1.5 T Siemens magnet using an echo-planar sequence. The contrast of enhancement (CE), was calculated pixel by pixel as the ratio of the maximum signal intensity drop during the passage of contrast agent (Sm) by the baseline pre-bolus signal intensity (So) (CE=Sm/So*100) for frontal, temporal, parietal, and occipital lobes, bilaterally, on two axial images. Higher CE values correspond to lower CBV and viceversa.

RESULTS

Bipolar patients had significantly lower CE values in left frontal and temporal lobes (p=0.01 and p=0.03, respectively) and significantly inverse laterality index for frontal lobe (p=0.017) compared to normal controls. No significant correlations between CE measure and age or clinical variables were found (p>0.05).

CONCLUSION

This study found increased left frontal and temporal CBV in bipolar disorder. Fronto-temporal hyper-perfusion may sustain over-activation of these structures during emotion modulation, which have been observed in patients with bipolar illness.

Assessment of cerebral blood volume in schizophrenia: A magnetic resonance imaging study

Brain atrophy has consistently been observed in schizophrenia, representing a 'gross' evidence of anatomical abnormalities. Reduced cerebral blood volume (CBV) may accompany brain size decrement in schizophrenia, as suggested by prior small SPECT studies. In this study, we non-invasively investigated the hemisphere CBV in a large sample of patients suffering from schizophrenia with perfusion-weighted imaging (PWI). PWI images were obtained, following intravenous injection of paramagnetic contrast agent (Gadolinium-DTPA), for 54 DSM-IV patients with schizophrenia (mean age+/-SD=39.19+/-12.20 years; 34 males, 20 females) and 24 normal controls (mean age+/-SD=44.63+/-10.43 years; 9 males, 15 females) with a 1.5T Siemens magnet using an echo-planar sequence (TR=2160 ms, TE=47 ms, slice thickness=5mm). The contrast of enhancement (CE), a semi-quantitative parameter inversely estimating the CBV, were calculated pixel by pixel as the ratio of the maximum signal intensity drop during the passage of contrast agent (Sm) by the baseline pre-bolus signal intensity (So) (CE=Sm/Sox100) for right and left hemisphere on two axial images. Specifically, higher CE values correspond to lower CBV and viceversa Compared to normal controls, patients with schizophrenia had significantly higher bilateral hemisphere CE values (p=0.02) and inverse CE laterality index (p=0.02). This study showed abnormally reduced and inverse hemisphere CBV in a large population of patients with schizophrenia. Hypothetically, chronic low CBV may sustain neural hypoactivation and concomitant increase of free radicals, ultimately resulting in neuronal loss and cognitive impairments. Thus, altered intracranial hemodynamics may accompany brain atrophy and cognitive deficits, being a crucial factor in the pathophysiology of schizophrenia.

Cortical white-matter microstructure in schizophrenia. Diffusion imaging study

BACKGROUND

Several, although not all, of the previous small diffusion-weighted imaging (DWI) studies have shown cortical white-matter disruption in schizophrenia.

AIMS

To investigate cortical white-matter microstructure with DWI in a large community-based sample of people with schizophrenia.

METHOD

Sixty-eight people with schizophrenia and 64 healthy controls underwent a session of DWI to obtain the apparent diffusion coefficient (ADC) of white-matter water molecules. Regions of interest were placed in cortical lobes.

RESULTS

Compared with controls, the schizophrenia group had significantly greater ADCs in frontal, temporal and occipital white matter (analysis of covariance, P < 0.05).

CONCLUSIONS

Our findings confirm the presence of cortical white-matter microstructure disruption in frontal and temporo-occipital lobes in the largest sample of people with schizophrenia thus for studied with this technique. Future brain imaging studies, together with genetic investigations, should further explore white-matter integrity and genes encoding myelin-related protein expression in people with first-episode schizophrenia and those at high risk of developing the disorder.

Three-dimensional MRI perfusion maps: a step beyond volumetric analysis in mental disorders

A new type of magnetic resonance imaging analysis, based on fusion of three-dimensional reconstructions of time-to-peak parametric maps and high-resolution T1-weighted images, is proposed in order to evaluate the perfusion of selected volumes of interest. Because in recent years a wealth of data have suggested the crucial involvement of vascular alterations in mental diseases, we tested our new method on a restricted sample of schizophrenic patients and matched healthy controls. The perfusion of the whole brain was compared with that of the caudate nucleus by means of intrasubject analysis. As expected, owing to the encephalic vascular pattern, a significantly lower time-to-peak was observed in the caudate nucleus than in the whole brain in all healthy controls, indicating that the suggested method has enough sensitivity to detect subtle perfusion changes even in small volumes of interest. Interestingly, a less uniform pattern was observed in the schizophrenic patients. The latter finding needs to be replicated in an adequate number of subjects. In summary, the three-dimensional analysis method we propose has been shown to be a feasible tool for revealing subtle vascular changes both in normal subjects and in pathological conditions.

Cerebral atrophy and white matter disruption in chronic schizophrenia

Several magnetic resonance imaging (MRI) studies have shown cerebral atrophy in established schizophrenia, although not in all reports. Discrepancies may mostly be due to population and postprocessing differences. Recently, disruption of cortical white matter integrity has also been reported in chronic patients with schizophrenia. In this study we explored tridimensional (3D) cerebral volumes and white matter microstructure in schizophrenia with structural and diffusion magnetic resonance. Twenty-five patients with established schizophrenia and 25 1:1 matched normal controls underwent a session of MRI using a Siemens 1.5T-scanner. 3D brain volume reconstruction was performed with the semi-automatic software Amira (TGS, San Diego, CA), whereas the apparent diffusion coefficients (ADCs) of cortical white matter water molecules were obtained with in-house developed softwares written in MatLab (The Mathworks-Inc., Natick, MA). Compared to controls, patients with schizophrenia had significantly smaller gray matter intracranium and total brain volumes, increased 4th ventricle volumes, and greater temporal and occipital ADCs. Patients treated with typical antipsychotic medication (N = 9) had significantly larger right lateral and 4th ventricles compared to those on atypical antipsychotic drugs. Intracranial volumes significantly inversely correlated with left temporal ADC in patients with schizophrenia. Also, age correlated directly with right, left, and 3rd ventricle volumes and inversely with gray matter intracranium volumes in individuals with schizophrenia. This study confirmed the presence of cortical atrophy in patients with schizophrenia, especially in those on typical antipsychotic drugs, and the existence of white matter disruption. It also suggested that physiological aging effects on brain anatomy may be abnormally pronounced in schizophrenia.

Normal pituitary volumes in chronic schizophrenia

Pituitary volumes were shown to be abnormally large in pre- or first-psychotic episode patients and abnormally reduced in established schizophrenia by magnetic resonance imaging (MRI) studies. We present here the results of the second ever published MRI study exploring pituitary size in a large population of patients with chronic schizophrenia recruited from the geographically defined catchment area of South Verona, Italy. No significant differences for pituitary volumes were reported between 65 subjects with chronic schizophrenia and 65 normal individuals (mean age+/-S.D.=42.31+/-11.44 and 40.54+/-11.12 years). In contrast to Pariante et al. (2004), normal pituitary size was found in our population of chronic schizophrenia. Discrepancies between these two studies may partially be accounted by sample age and gender. Considering increased pituitary volumes in pre- or first-psychotic episode patients, we put forward the hypothesis that pituitary size may normalize or reduce with the progression of the illness as a result of reduced numbers of acute episodes and consequent diminished hypothalamus-pituitary-adrenal axis activity. To better test this hypothesis, future large MRI studies should investigate pituitary volumes in chronic schizophrenia longitudinally, also collecting pituitary hormones and cortisol, and comparing the effects of typical and atypical antipsychotics on pituitary size in a randomized trial.

Investigation of corpus callosum in schizophrenia with diffusion imaging

BACKGROUND

Corpus callosum (CC) is the main white matter commissure between the two cerebral hemispheres. Abnormalities of CC have been shown in schizophrenia patients by magnetic resonance imaging (MRI) studies. We here further investigated CC organization with diffusion imaging (DWI) in a sample of schizophrenia patients recruited from the epidemiologically defined catchment area of South Verona, Italy.

METHODS

Sixty-seven patients with schizophrenia and 70 normal controls were studied. Regions of interests (ROIs), standardized at 5 pixels, were placed in CC on the non-diffusion weighted echoplanar images (b = 0) and were then automatically transferred to the corresponding maps to obtain the apparent diffusion coefficient (ADC) of water molecules.

RESULTS

ADC measures for all callosal subregions in schizophrenia patients were significantly greater compared to normal controls (ANCOVA, p < 0.05). Positive symptoms significantly correlated with anterior callosal ADC measures (partial correlation analyses, p < 0.05).

CONCLUSIONS

These findings support the existence of widespread microstructure disruption of CC in schizophrenia, which may ultimately lead to inter-hemispheric misconnection, and also suggest a specific role of anterior transcallosal disconnectivity in underlying positive symptoms. Future longitudinal MRI studies in high risk and first-episode patients together with neurophysiological tests are indicated to further examine CC anatomical abnormalities and inter-hemispheric transmission in schizophrenia.

Reassessing treatment environments after two decades: client and staff perceptions of an Italian community mental health service environment, then and now

Community-based psychiatric services and programs developed in accordance with the 1978 Italian psychiatric reform have now been in operation for a quarter of a century. The paper presents the results of a study in which three treatment environments of South-Verona, i.e. a general hospital psychiatric ward, a community mental health center (CMHC) and two residential facilities have been investigated using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environment Scale (COPES). Staff and patient ratings have been collected in the three environments thus allowing comparisons between respondents and settings. For the ward and the CMHC, whose staff had already been interviewed almost twenty years before, a comparison between studies was also possible. Results seem to show that original policies, attitudes and staff commitment have successfully survived the passage of time with only minor adjustments and that the single-staff module of South-Verona may have effectively contributed in this respect.