Structural Changes Induced by Resveratrol in Monounsaturated and Polyunsaturated Phosphatidylcholine-Enriched Model Membranes

Resveratrol (Resv) is considered to exert a beneficial impact due to its radical scavenger, anti-microbial and anti-inflammatory properties through several mechanisms that could include its interaction with the cell plasma membrane. To address this issue, we investigated the influence of Resv on membrane lipid order and organization in large unilamellar vesicles composed of different lipids and ratios. The studied lipid membrane models were composed of phosphatidylcholine (PC) species (either palmitoyl-docosahexaenoyl phosphatidylcholine (PDPC) or palmitoyl-oleoyl phosphatidylcholine (POPC)), sphingomyelin (SM) and cholesterol (Chol). This study found that the addition of Resv resulted in complex membrane reorganization depending on the degree of fatty acid unsaturation at the sn-2 position, and the Lipid/Resv and SM/Chol ratios. Resv rigidified POPC-containing membranes and increased liquid-ordered (Lo) domain formation in 40/40/20 POPC/SM/Chol mixtures as this increase was lower at a 33/33/34 ratio. In contrast, Resv interacted with PDPC/SM/Chol mixtures in a bimodal manner by fluidizing/rigidifying the membranes in a dose-dependent way. Lo domain formation upon Resv addition occurred via the following bimodal mode of action: Lo domain size increased at low Resv concentrations; then, Lo domain size decreased at higher ones. To account for the variable effect of Resv, we suggest that it may act as a "spacer" at low doses, with a transition to a more "filler" position in the lipid bulk. We hypothesize that one of the roles of Resv is to tune the lipid order and organization of cell plasma membranes, which is closely linked to important cell functions such as membrane sorting and trafficking.

How can we improve the care of patients with schizophrenia in the real-world? A population-based cohort study of 456,003 patients

An important step to improve outcomes for patients with schizophrenia is to understand treatment patterns in routine practice. The aim of the current study was to describe the long-term management of patients with schizophrenia treated with antipsychotics (APs) in real-world practice. This population-based study included adults with schizophrenia and who had received ≥3 deliveries of an AP from 2012-2017, identified using a National Health Data System. Primary endpoints were real-life prescription patterns, patient characteristics, healthcare utilization, comorbidities and mortality. Of the 456,003 patients included, 96% received oral APs, 17.5% first-generation long-acting injectable APs (LAIs), and 16.1% second generation LAIs. Persistence rates at 24 months after treatment initiation were 23.9% (oral APs), 11.5% (first-generation LAIs) and 20.8% (second-generation LAIs). Median persistence of oral APs, first-generation LAIs and second-generation LAIs was 5.0, 3.3, and 6.1 months, respectively. Overall, 62.1% of patients were administered anxiolytics, 45.7% antidepressants and 28.5% anticonvulsants, these treatments being more frequently prescribed in women and patients aged ≥50 years. Dyslipidemia was the most frequent metabolic comorbidity (16.2%) but lipid monitoring was insufficient (median of one occasion). Metabolic comorbidities were more frequent in women. Standardized patient mortality remained consistently high between 2013 and 2015 (3.3-3.7 times higher than the general French population) with a loss of life expectancy of 17 years for men and 8 years for women. Cancer (20.2%) and cardiovascular diseases (17.2%) were the main causes of mortality, and suicide was responsible for 25.4% of deaths among 18-34-year-olds. These results highlight future priorities for care of schizophrenia patients. The global persistence of APs used in this population was low, whereas rates of psychiatric hospitalization remain high. More focus on specific populations is needed, such as patients aged >50 years to prevent metabolic disturbances and 18-34-year-olds to reduce suicide rates.

Real-world effectiveness of long-acting injectable antipsychotic treatments in a nationwide cohort of 12,373 patients with schizophrenia-spectrum disorders

This mirror-image study aimed to evaluate the real-life effectiveness of long-acting injectable antipsychotics (LAI) in schizophrenia. Patients with schizophrenia initiating LAIs January 2015-December 2016 were enrolled from the French National Health Data System (SNDS). Standardized mean differences (SMD > 0.1 deemed clinically significant) were calculated for psychiatric healthcare resource utilization measures assessed one year before (during oral AP treatment) and one year after LAI initiation. LAI effectiveness was analyzed overall and by age group, gender and compliance to oral AP, defined as exposure to an AP for at least 80% of the year before LAI initiation. 12,373 patients were included. LAIs were more frequently initiated in men (58.1%), young (18-34 years, 42.0%) and non-compliant (63.7%) patients. LAI initiation was effective in reducing the number and duration of psychiatric hospitalizations and psychiatric emergency department (ED) admissions in non-compliant patients (SMD = -0.19, -0.26 and -0.12, respectively), but not in compliant patients. First-generation LAIs, paliperidone and aripiprazole LAIs reduced psychiatric hospitalizations (SMD = -0.20, -0.24, -0.21, respectively) and ED admissions (SMD = -0.15, -0.13, -0.15, respectively). No differences in effectiveness were found for age or gender. In compliant patients, only aripiprazole LAI reduced the number of psychiatric hospitalizations (SMD = -0.13). Risperidone and paliperidone LAIs increased hospitalization duration (SMD = 0.15 and 0.18, respectively). The prescription of LAIs (except risperidone) should be recommended in all non-compliant patients, even in women and patients aged 35 or older. The lower frequency of administration of LAIs than of oral APs may improve compliance and hence reduce the risk of relapse. Aripiprazole LAI may represent a treatment of choice for compliant patients that should be further investigated.

Impact of Truncated Oxidized Phosphatidylcholines on Phospholipase A2 Activity in Mono- and Polyunsaturated Biomimetic Vesicles

The interplay between inflammatory and redox processes is a ubiquitous and critical phenomenon in cell biology that involves numerous biological factors. Among them, secretory phospholipases A₂ (sPLA₂) that catalyze the hydrolysis of the sn-2 ester bond of phospholipids are key players. They can interact or be modulated by the presence of truncated oxidized phosphatidylcholines (OxPCs) produced under oxidative stress from phosphatidylcholine (PC) species. The present study examined this important, but rarely considered, sPLA₂ modulation induced by the changes in biophysical properties of PC vesicles comprising various OxPC ratios in mono- or poly-unsaturated PCs. Being the most physiologically active OxPCs, 1-palmitoyl-2-(5'-oxo-valeroyl)-sn-glycero-3-phosphocholine (POVPC) and 1-palmitoyl-2-glutaryl-sn-glycero-3-phosphocholine (PGPC) have been selected for our study. Using fluorescence spectroscopy methods, we compared the effect of OxPCs on the lipid order as well as sPLA₂ activity in large unilamellar vesicles (LUVs) made of the heteroacid PC, either monounsaturated [1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine (POPC)], or polyunsaturated [1-palmitoyl-2-docosahexaenoyl-sn-glycero-3-phosphocholine (PDPC)] at a physiological temperature. The effect of OxPCs on vesicle size was also assessed in both the mono- and polyunsaturated PC matrices. Results: OxPCs decrease the membrane lipid order of POPC and PDPC mixtures with PGPC inducing a much larger decrease in comparison with POVPC, indicative that the difference takes place at the glycerol level. Compared with POPC, PDPC was able to inhibit sPLA₂ activity showing a protective effect of PDPC against enzyme hydrolysis. Furthermore, sPLA₂ activity on its PC substrates was modulated by the OxPC membrane content. POVPC down-regulated sPLA₂ activity, suggesting anti-inflammatory properties of this truncated oxidized lipid. Interestingly, PGPC had a dual and opposite effect, either inhibitory or enhancing on sPLA₂ activity, depending on the protocol of lipid mixing. This difference may result from the chemical properties of the shortened sn-2-acyl chain residues (aldehyde group for POVPC, and carboxyl for PGPC), being, respectively, zwitterionic or anionic under hydration at physiological conditions.

The impact of lipid polyunsaturation on the physical and mechanical properties of lipid membranes

The lipid composition of cellular membranes and the balance between the different lipid components can be impacted by aging, certain pathologies, specific diets and other factors. This is the case in a subgroup of individuals with psychiatric disorders, such as schizophrenia, where cell membranes of patients have been shown to be deprived in polyunsaturated fatty acids (PUFAs), not only in brain areas where the target receptors are expressed but also in peripheral tissues. This PUFA deprivation thus represents a biomarker of such disorders that might impact not only the interaction of antipsychotic medications with these membranes but also the activation and signaling of the targeted receptors embedded in the lipid membrane. Therefore, it is crucial to understand how PUFAs levels alterations modulate the different physical properties of membranes. In this paper, several biophysical approaches were combined (Laurdan fluorescence spectroscopy, atomic force microscopy, differential scanning calorimetry, molecular modeling) to characterize membrane properties such as fluidity, elasticity and thickness in PUFA-enriched cell membranes and lipid model systems reflecting the PUFA imbalance observed in some diseases. The impact of both the number of unsaturations and their position along the chain on the above properties was investigated. Briefly, data revealed that PUFA presence in membranes increases membrane fluidity, elasticity and flexibility and decreases its thickness and order parameter. Both the level of unsaturation and their position affect these membrane properties.

Higher stress response and altered quality of life in schizophrenia patients with low membrane levels of docosahexaenoic acid

Schizophrenia is a severe, chronic, and heterogeneous mental disorder that affects approximately 1% of the world population. Ongoing research aims at clustering schizophrenia heterogeneity into various "biotypes" to identify subgroups of individuals displaying homogeneous symptoms, etiopathogenesis, prognosis, and treatment response. The present study is in line with this approach and focuses on a biotype partly characterized by a specific membrane lipid composition. We have examined clinical and biological data of patients with stabilized schizophrenia, including the fatty acid content of their erythrocyte membranes, in particular the omega-3 docosahexaenoic acid (DHA). Two groups of patients of similar size were identified: the DHA- group (N = 19) with a lower proportion of membrane DHA as compared to the norm in the general population, and the DHAn group (N = 18) with a normal proportion of DHA. Compared to DHAn, DHA- patients had a higher number of hospitalizations and a lower quality of life in terms of perceived health and physical health. They also exhibited significant higher interleukin-6 and cortisol blood levels. These results emphasize the importance of measuring membrane lipid and immunoinflammatory biomarkers in stabilized patients to identify a specific subgroup and optimize non-pharmacological interventions. It could also guide future research aimed at proposing specific pharmacological treatments.

Fifty years of experience with loxapine for the rapid non-coercive tranquilization of acute behavioral disturbances in schizophrenia patients, and beyond

INTRODUCTION

Acute behavioral disturbances in psychosis, including agitation, comprise a heterogeneous group of manifestations varying in intensity and duration they last for. They require rapid, non-coercive treatments ranging from verbal de-escalation to the calming effect of pharmacological agents. The treatment goals are reduction of patient suffering and prevention of disease deterioration. Stabilizing rather than sedating is preferred to ensure improved compliance and a stronger therapeutic alliance. Furthermore, animal pharmacology and clinical studies on agitation reveal the robust calming and anxiolytic properties of loxapine.

AREAS COVERED

This review covers the pharmacological and clinical history of loxapine along with research developments. It emphasizes the advantages of its multiple formulations ranging from injectable forms and tablets to orally inhaled forms to attain rapid and fine-tuned tranquilization.

EXPERT OPINION

Rapid tranquillization is achieved within 2-6 hours using liquid orally-consumed loxapine, and within an hour or less with its IM or orally inhaled forms. Loxapine has been adopted in the management of a wide range of acute disturbances, such as agitation in psychosis. In the context of personalized medicine, key cellular and molecular elements of the schizophrenia phenotype were recently shown to be improved with loxapine.

Place of the partial dopamine receptor agonist aripiprazole in the management of schizophrenia in adults: a Delphi consensus study

BACKGROUND

Aripiprazole is a second-generation antipsychotic, efficacious in patients with schizophrenia during acute episodes. Due to its pharmacological profile, aripiprazole may be of interest in patients with specific clinical profiles who have not been studied extensively in randomised clinical trials.

OBJECTIVES

To capture experience with aripiprazole in everyday psychiatric practice using the Delphi method in order to inform decision-making on the use of aripiprazole for the treatment of patients with schizophrenia in clinical situations where robust evidence from clinical trials is lacking.

METHODS

The scope of the survey was defined as the management of schizophrenia in adults. A systematic literature review was performed to identify the different clinical situations in which aripiprazole has been studied, and to describe the level of clinical evidence. Clinical profiles to include in the Delphi survey were selected if there was a clear interest in terms of medical need but uncertainty over the efficacy of aripiprazole. For each clinical profile retained, five to seven specific statements were generated and included in a questionnaire. The final 41-item questionnaire was proposed to a panel of 406 French psychiatrists with experience in the treatment of schizophrenia. Panellists rated their level of agreement using a Likert scale. A second round of voting on eleven items was organised to clarify points for which a consensus was not obtained in the first round.

RESULTS

Five clinical profiles were identified in the literature review (persistent negative symptoms, pregnancy, cognitive dysfunction, addictive comorbidity and clozapine resistance). Sixty-two psychiatrists participated in the first round of the Delphi survey and 33 in the second round. A consensus was obtained for 11 out of 41 items in the first round and for 9/11 items in the second round. According to the panellists' clinical experience, aripiprazole can be used as maintenance treatment for pregnant women, is relevant to preserve cognitive function and can be considered an option in patients with a comorbid addictive disorder or with persistent negative symptoms.

CONCLUSION

These findings may help physicians in choosing relevant ways to use aripiprazole and highlight areas where more research is needed to widen the evidence base.

Nature and determinants of social actions during a mass shooting

Reactions to danger have been depicted as antisocial but research has shown that supportive behaviors (e.g., helping injured others, giving information or reassuring others) prevail in life-threatening circumstances. Why is it so? Previous accounts have put the emphasis on the role of psychosocial factors, such as the maintenance of social norms or the degree of identification between hostages. Other determinants, such as the possibility to escape and distance to danger may also greatly contribute to shaping people’s reactions to deadly danger. To examine the role of those specific physical constraints, we interviewed 32 survivors of the attacks at ‘Le Bataclan’ (on the evening of 13-11-2015 in Paris, France). Consistent with previous findings, supportive behaviors were frequently reported. We also found that impossibility to egress, minimal protection from danger and interpersonal closeness with other crowd members were associated with higher report of supportive behaviors. As we delved into the motives behind reported supportive behaviors, we found that they were mostly described as manifesting cooperative (benefits for both interactants) or altruistic (benefits for other(s) at cost for oneself) tendencies, rather than individualistic (benefits for oneself at cost for other(s)) ones. Our results show that supportive behaviors occur during mass shootings, particularly if people cannot escape, are under minimal protection from the danger, and feel interpersonal closeness with others. Crucially, supportive behaviors underpin a diversity of motives. This last finding calls for a clear-cut distinction between the social strategies people use when exposed to deadly danger, and the psychological motivations underlying them.

Tissue damage from neutrophil-induced oxidative stress in COVID-19

In this Comment article, Becker and colleagues consider how the excessive release of reactive oxygen species by neutrophils may perpetuate red blood cell dysfunction, thrombosis and tissue damage in severe cases of COVID-19.

The effects of education in psychiatry on attitudes towards antidepressants in nursing students: A cross-sectional study

BACKGROUND

Stigma associated with depression and antidepressants is strong among the general population but also among patients and health professionals.

OBJECTIVES

This cross-sectional study is aimed at: 1) evaluating the knowledge and attitude towards antidepressant by nursing student; 2) exploring the association between instruction in psychiatry and representation of depression and antidepressants.

PARTICIPANTS

2037 undergraduate students from 10 French nursing schools were invited to participate in 2017, 1475 (73%) completed the questionnaire.

METHODS

The self-report questionnaire included the Drug Attitude Inventory (DAI) and questions about representation on depression and antidepressant. Four groups of students were built: 1) pre-teaching group (PT) as a reference group, 2) clinical training in psychiatry (CT), 3) receiving mental health theoretical education (TE), 4) receiving both (CT + TE).

RESULTS

The mean (standard deviation) DAI score was negative: -1.9 (±4.4) with only 40% of the nursing students conveying a positive attitude towards antidepressant. A combination of CT and TE was associated with a more positive attitude towards antidepressant in comparison with the PT condition. The CT + TE group was more prone to view antidepressants as effective and safe.

CONCLUSION

There is strong stigma against depression/antidepressants among nursing student. Education combined with clinical experiences in psychiatry improved these representations.

[Membrane lipids in schizophrenia and early phases of psychosis: Potential biomarkers and therapeutic targets?]

The various roles of membrane lipids in human health has urged researchers to study their impact in neuropsychiatric diseases, especially in schizophrenia spectrum disorders and more recently in early stages of psychosis. The progress in mass spectrometry technologies now allows a more comprehensive analysis of phospholipids (PL) and their fatty acid (FA) molecular species. FA are defined by a carbon chain of variable length and are said to be unsaturated when their chain has one or more carbon-carbon double bonds. The PL are composed of a hydrophilic polar head with a phosphoric acid group and an hydrophobic part with FAs; they encompass glycerophospholipids and sphingolipids. The plasma membrane is a complex and dynamic structure consisting of a lipid bilayer composed of an outer layer and an inner layer of specific lipid composition. The permanent remodeling of membrane lipids involves phospholipases especially the phospholipase A2. Seventy percent of the brain consists of lipids from different classes and molecular species. Most of the brain lipids are composed of polyunsaturated fatty acid (PUFA)-enriched diacyl classes where omega-3 and omega-6 molecular species predominate. The balance between omega-3 and omega-6 is important for the neurodevelopment. PUFA are also involved in neurogenesis and neurotransmission. Sphingomyelin (SM) is a sphingolipid that influences inflammation, cell proliferation and lipid rafts formation. It is an important component of myelin sheaths of white matter and therefore is involved in cerebral connectivity. In rat models, deficiency in omega-3 causes abnormalities in dopaminergic neurotransmission, impacts on the functioning of some receptors (including cannabinoids CB1, glutamatergic N-methyl-D-aspartate receptor, NMDA), and increases sensitivity to hallucinogens. In contrast, omega-3 supplementation improves cognitive function and prevents psychotic-like behavior in some animal models for schizophrenia. It also reduces oxidative stress and prevents demyelination. The historical membrane hypothesis of schizophrenia has led to explore the lipids abnormality in this disorder. This hypothesis was initially based on the observation of an abnormal membrane prostaglandin production in schizophrenia caused by a membrane arachidonic acid deficiency. It has evolved emphasizing the various PUFA membrane's roles in particular regarding oxidative stress, inflammation and regulation of the NMDA receptors. In patients with mental disorders, low omega-3 index is more frequent than in the general population. This lipid abnormality could lead to myelination abnormalities and cognitive deficits observed in patients. It could also participate in oxidative stress abnormalities and inflammation reported in schizophrenia. On the other hand, low omega-3 index deficit was reported to be associated with an increased cardiovascular risk, and omega-3 supplementation may also have a positive cardiovascular impact in psychiatric patients, even more than in the general population. The presence of membrane lipid abnormalities is also found in patients during the first psychotic episode (FEP). The omega-3 supplementation improved the recovery rate and prevented the loss of gray matter in FEP. In patients at ultra-high risk to develop a psychotic disorder (UHR), omega-3 supplementation has been associated with a reduction of the rate of conversion to psychosis and with metabolic changes, such as decreased activity of phospholipase A2. However, this study has not as yet been replicated. Not all patients exhibit lipid abnormalities. Several studies, including studies from our team, have found a bimodal distribution of lipids in patients with schizophrenia. But some studies have found differences (in PUFA) in the acute phase whereas our studies (on phospholipids) are in chronic phases. It will be interesting to study in more depth the links between these two parameters. Furthermore, we identified a subgroup which was identified with a deficit in sphingomyelin and PUFA whereas others have found an increase of sphingomyelin. Individuals with this abnormal lipid cluster had more cognitive impairments and more severe clinical symptoms. Because the niacin test is an indirect reflection of arachidonic acid levels, it has been proposed to identify a subset of patients with membrane lipids anomalies. Niacin test response is influenced by several factors related to lipid metabolism, including cannabis use and phospholipase A2 activity. Despite progress, the function and impact of membrane lipids are still poorly understood in schizophrenia. They could serve as biomarkers for identifying biological subgroups among patients with schizophrenia. In UHR patients, their predictive value on the conversion to psychosis should be tested. Omega-3 supplementation could be a promising treatment thanks to its good tolerance and acceptability. It could be more appropriate for patients with PUFA anomalies in a more personalized medical approach.

Factors Associated With a Higher Score of Burnout in a Population of 860 French Psychiatrists

Burnout rates are estimated to be twice as high among healthcare professionals as in the general working population, and studies indicate rising incidence. The present study aimed to identify the contextual factors associated with self-reported burnout rates among French psychiatrists. A total of 860 French or French-speaking psychiatrists completed an online questionnaire when they registered for a major psychiatric conference. The Copenhagen Burnout Inventory, a validated scale that independently appraises personal, work- and patient-related dimensions, was used to assess the degree of perceived burnout. Respondents were divided into lower risk and higher risk groups. The latter contained the 25% of individuals who scored the highest on each of the three dimensions of the CBI scale. Univariate analysis showed that private practice was associated with lower levels of risk on the personal and work-related dimensions. Working for the public sector and long hours were both associated with a higher score on the work-related dimension. Interestingly, none of the variables we investigated, except from poor atmosphere at work, correlated with the patient-related dimension. Among public-sector psychiatrists, female gender, longer hours, and more consultations per week were associated with a higher score on the work-related dimension. Working four or more night shifts per month was significantly associated with a higher score of burnout risk on all three dimensions. Private- and public-sector practitioners who mainly treated patients with schizophrenia had a higher score of burnout risk. Multivariate analysis showed that a poor atmosphere at work, longer hours, and working four or more night shifts were significantly associated with higher score of burnout risk. A nonreassuring working environment and more stressors while treating patients each had a possibly negative impact. Although this study only examined the factors that distinguish between clinicians with the lowest versus highest CBI burnout risk scores, it opens up important avenues for research and development of programs to reduce burnout risk within the French healthcare system.

Social cognition in post-traumatic stress disorder: A systematic review

OBJECTIVES

Post-traumatic stress disorder (PTSD) is a common psychiatric condition. Patients with PTSD have marked symptoms that significantly impair their social and emotional abilities, and numerous studies have explored this issue. We hypothesized that impairment of social cognition takes part in functional disability of individuals with PTSD.

METHODS

We conducted a systematic review by querying PubMed database for the titles of articles published up to February 2018 with the terms [PTSD] [Post traumatic disorder] AND [Emotion recognition] OR [Facial expression of emotion] OR [Facial expression perception] OR [Empathy] OR [Affective empathy] OR [Mentalizing] OR [Social cognition] OR [Theory of Mind] OR [Mental state attribution] OR [Cognitive empathy] OR [Emotional empathy] OR [Social behaviour deficits].

RESULTS

Our results suggest that affective and cognitive aspect of theory of mind is comprehensively disturbed in patients with PTSD, showing a significant impairment in their ability to predict what others feel, think, or believe. They could also be massively altered in their perception of basic emotional expressions whether it is an expression of threat or happiness. Their affective empathy appears to be systematically disturbed and correlated to verbal and/or physical aggressive behaviour.

CONCLUSIONS

Social cognition is disturbed in PTSD and should be regarded as an important symptom. Damages in social cognition seem to take part in the functional disability of people with PTSD. We highlight the interest of a systematic assessment of social cognition in the care of patients with PTSD and suggest which tests could be the most relevant for this evaluation.

PRACTITIONER POINTS

•PTSD is no longer regarded as a subtype of anxiety disorder, but as part of a new category in the DSM-5. In clinical practice, symptoms tied to alterations in arousal and reactivity - such as irritability and vigilance - and to the disturbance of cognition and mood, are particularly closely correlated with poorer quality of life. Impaired social cognition clearly impacts the functional disability of people with PTSD. There are potential benefits of individualized cognitive remediation based on empathy and the emotional component of ToM (cognitive remediation, cognitive-behavioural therapy, therapeutic education, etc.) in PTSD people.

An update on the anxiolytic and neuroprotective properties of etifoxine: from brain GABA modulation to a whole-body mode of action

Treating the signs and symptoms of anxiety is an everyday challenge in clinical practice. When choosing between treatment options, anxiety needs to be understood in the situational, psychiatric, and biological context in which it arises. Etifoxine, a non-benzodiazepine anxiolytic drug belonging to the benzoxazine class, is an effective treatment for anxiety in response to a stressful situation. In the present review, we focused on several aspects of the cerebral and somatic biological mechanisms involved in anxiety and investigated the extent to which etifoxine's mode of action can explain its anxiolytic activity. Its two mechanisms of action are the modulation of GABAergic neurotransmission and neurosteroid synthesis. Recent data suggest that the molecule possesses neuroprotective, neuroplastic, and anti-inflammatory properties. Etifoxine was first shown to be an effective anxiolytic in patients in clinical studies comparing it with clobazam, sulpiride, and placebo. Randomized controlled studies have demonstrated its anxiolytic efficacy in patients with adjustment disorders (ADs) with anxiety, showing it to be superior to buspirone and comparable to lorazepam and phenazepam, with a greater number of markedly improved responders and a better therapeutic index. Etifoxine's noninferiority to alprazolam has also been demonstrated in a comparative trial. Significantly less rebound anxiety was observed after abrupt cessation of etifoxine compared with lorazepam or alprazolam. Consistent with this finding, etifoxine appears to have a very low dependence potential. Unlike lorazepam, it has no effect on psychomotor performance, vigilance, or free recall. Severe adverse events are in general rare. Skin and subcutaneous disorders are the most frequently reported, but these generally resolve after drug cessation. Taken together, its dual mechanisms of action in anxiety and the positive data yielded by clinical trials support the use of etifoxine for treating the anxiety signs and symptoms of individuals with ADs.

[Organic and psychiatric intricacy: The complex psychiatric disorder concept, paraclinical investigations]

The purpose of this article is to describe complex psychiatric disorders, to recall "minimal classical" explorations in psychiatry, to describe the concept of "complex psychiatric disorders" and to propose a systematized method of exploration. Some organic diseases are well known for their links with psychiatric disorders (manic syndrome and hyperthyroidism, depressive syndrome and corticotropic insufficiency, anxiety disorder and heart disease, etc.). Many other neurological, autoimmune, metabolic, paraneoplastic or endocrine pathologies can have essentially psycho-behavioral manifestations before being neurological or systemic. A large number of factors (nutritional, toxic, immunological, etc.), often ignored, influence the links between organicity and psychiatric pathologies. It is necessary to optimize the medical management of these patients in whom the psychiatric diagnosis masks a curable organo-psychiatric cause.

Membrane lipidomics in schizophrenia patients: a correlational study with clinical and cognitive manifestations

Schizophrenia is a severe mental condition in which several lipid abnormalities-either structural or metabolic-have been described. We tested the hypothesis that an abnormality in membrane lipid composition may contribute to aberrant dopamine signaling, and thereby symptoms and cognitive impairment, in schizophrenia (SCZ) patients. Antipsychotic-medicated and clinically stable SCZ outpatients (n=74) were compared with matched healthy subjects (HC, n=40). A lipidomic analysis was performed in red blood cell (RBC) membranes examining the major phospholipid (PL) classes and their associated fatty acids (FAs). Clinical manifestations were examined using the positive and negative syndrome scale (PANSS). Cognitive function was assessed using the Continuous Performance Test, Salience Attribution Test and Wisconsin Card Sorting Test. Sphingomyelin (SM) percentage was the lipid abnormality most robustly associated with a schizophrenia diagnosis. Two groups of patients were defined. The first group (SCZ c/SM-) is characterized by a low SM membrane content. In this group, all other PL classes, plasmalogen and key polyunsaturated FAs known to be involved in brain function, were significantly modified, identifying a very specific membrane lipid cluster. The second patient group (SCZ c/SM+) was similar to HCs in terms of RBC membrane SM composition. Compared with SCZ c/SM+, SCZ c/SM- patients were characterized by significantly more severe PANSS total, positive, disorganized/cognitive and excited psychopathology. Cognitive performance was also significantly poorer in this subgroup. These data show that a specific RBC membrane lipid cluster is associated with clinical and cognitive manifestations of dopamine dysfunction in schizophrenia patients. We speculate that this membrane lipid abnormality influences presynaptic dopamine signaling.

Phospholipase A2-Induced Remodeling Processes on Liquid-Ordered/Liquid-Disordered Membranes Containing Docosahexaenoic or Oleic Acid: A Comparison Study

Vesicle cycling, which is an important biological event, involves the interplay between membrane lipids and proteins, among which the enzyme phospholipase A2 (PLA2) plays a critical role. The capacity of PLA2 to trigger the budding and fission of liquid-ordered (L(o)) domains has been examined in palmitoyl-docosahexaenoylphosphatidylcholine (PDPC) and palmitoyl-oleoylphosphatidylcholine (POPC)/sphingomyelin/cholesterol membranes. They both exhibited a L(o)/liquid-disordered (L(d)) phase separation. We demonstrated that PLA2 was able to trigger budding in PDPC-containing vesicles but not POPC ones. The enzymatic activity, line tension, and elasticity of the membrane surrounding the L(o) domains are critical for budding. The higher line tension of Lo domains in PDPC mixtures was assigned to the greater difference in order parameters of the coexisting phases. The higher amount of lysophosphatidylcholine generated by PLA2 in the PDPC-containing mixtures led to a less-rigid membrane, compared to POPC. The more elastic L(d) membranes in PDPC mixtures exert a lower counteracting force against the L(o) domain bending.

Attitudes négatives aux antidépresseurs au cours de la prise en charge des épisodes dépressifs : l’autre « French Paradox » ?

Introduction

Alors que la majorité des traitements antidépresseurs prescrits en France durent moins de 28 jours , moins de 2 % des travaux étudiant le traitement pharmacologique des troubles de l’humeur explorent les facteurs métapsychologiques associés à l’adhésion . Quelles sont les attitudes aux antidépresseurs des patients observants et demandeurs de soins ?

Objectif

L’objectif de cette étude était d’évaluer les attitudes aux antidépresseurs chez :

Méthode

Les attitudes aux antidépresseurs étaient évaluées en utilisant la version courte du Drug Attitude Inventory (DAI-10), chez 98 patients : 40 hospitalisés de leur plein gré en psychiatrie et 58 venant chercher une prescription d’antidépresseur en officine.

Résultats

L’âge moyen de l’échantillon était de 43 ans, avec 69 % de femmes. Dans l’échantillon hospitalier, la médiane du DAI était de 3,5 (échelle de –10 à +10). Trente pour cent des patients avaient une attitude négative à l’antidépresseur prescrit, dont 10 % de l’échantillon ne connaissait pas le nom. Il s’agissait de la première prescription d’antidépresseur pour 30 % des patients. Dans le volet ambulatoire, la médiane du DAI n’était que faiblement plus positive (4), et 10 % des sujets avaient une attitude négative à l’antidépresseur qu’ils venaient chercher. Vingt pour cent des sujets déclaraient ne pas avoir de suivi de son trouble dépressif.

Discussion

Cette étude naturalistique met en relief l’ambivalence des patients face aux antidépresseurs. Tandis qu’un comportement montre un engagement fort dans les soins (être hospitalisé en milieu spécialisé, aller chercher une prescription au long cours), les connaissances sur les troubles les justifiant et les croyances envers les thérapeutiques prescrites restent précaires .

Conclusion

Cette ambivalence, reflet des attitudes de la société face à nos médicaments, pourrait être mieux explorée en pratique clinique quotidienne.

Docosahexaenoic acid promotes micron scale liquid-ordered domains. A comparison study of docosahexaenoic versus oleic acid containing phosphatidylcholine in raft-like mixtures

The understanding of the functional role of the lipid diversity in biological membranes is a major challenge. Lipid models have been developed to address this issue by using lipid mixtures generating liquid-ordered (Lo)/liquid-disordered (Ld) immiscibility. The present study examined mixtures comprising Egg sphingomyelin (SM), cholesterol (chol) and phosphatidylcholine (PC) either containing docosahexaenoic (PDPC) or oleic acid (POPC). The mixtures were examined in terms of their capability to induce phase separation at the micron- and nano-scales. Fluorescence microscopy, electron spin resonance (ESR), X-ray diffraction (XRD) and calorimetry methods were used to analyze the lateral organization of the mixtures. Fluorescence microscopy of giant vesicles could show that the temperature of the micron-scale Lo/Ld miscibility is higher for PDPC than for POPC ternary mixtures. At 37°C, no micron-scale Lo/Ld phase separation could be identified in the POPC containing mixtures while it was evident for PDPC. In contrast, a phase separation was distinguished for both PC mixtures by ESR and XRD, indicative that PDPC and POPC mixtures differed in micron vs nano domain organization. Compared to POPC, the higher line tension of the Lo domains observed in PDPC mixtures is assumed to result from the higher difference in Lo/Ld order parameter rather than hydrophobic mismatch.

Anxiety disorders and GABA neurotransmission: a disturbance of modulation

Lines of evidence coming from many branches of neuroscience indicate that anxiety disorders arise from a dysfunction in the modulation of brain circuits which regulate emotional responses to potentially threatening stimuli. The concept of anxiety disorders as a disturbance of emotional response regulation is a useful one as it allows anxiety to be explained in terms of a more general model of aberrant salience and also because it identifies avenues for developing psychological, behavioral, and pharmacological strategies for the treatment of anxiety disorder. These circuits involve bottom-up activity from the amygdala, indicating the presence of potentially threatening stimuli, and top-down control mechanisms originating in the prefrontal cortex, signaling the emotional salience of stimuli. Understanding the factors that control cortical mechanisms may open the way to identification of more effective cognitive behavioral strategies for managing anxiety disorders. The brain circuits in the amygdala are thought to comprise inhibitory networks of γ-aminobutyric acid-ergic (GABAergic) interneurons and this neurotransmitter thus plays a key role in the modulation of anxiety responses both in the normal and pathological state. The presence of allosteric sites on the GABAA receptor allows the level of inhibition of neurons in the amygdala to be regulated with exquisite precision, and these sites are the molecular targets of the principal classes of anxiolytic drugs. Changes in the levels of endogenous modulators of these allosteric sites as well as changes in the subunit composition of the GABAA receptor may represent mechanisms whereby the level of neuronal inhibition is downregulated in pathological anxiety states. Neurosteroids are synthesized in the brain and act as allosteric modulators of the GABAA receptor. Since their synthesis is itself regulated by stress and by anxiogenic stimuli, targeting the neurosteroid-GABAA receptor axis represents an attractive target for the modulation of anxiety.

Revisiting loxapine: a systematic review

Loxapine is an antipsychotic used in psychiatry for over 40 years with a well-established profile. Loxapine is a dibenzoxazepine tricyclic antipsychotic agent, available for oral, intramuscular and inhalatory administration. In the light of the recent approval by the regulatory agencies of inhaled loxapine for use in the acute treatment of mild-to-moderate agitation in adults affected with schizophrenia or bipolar disorder, this article aims to critically review the available literature on loxapine, irrespective of its formulation. This review examines the efficacy and tolerability of the various formulations of loxapine in the treatment of agitation and aggression in patients affected with schizophrenia, bipolar disorder and other psychiatric conditions. A comprehensive and systematic literature search of PubMed/MEDLINE was conducted, and relevant pharmacodynamic and pharmacokinetic data was included. The findings from the literature were critically reviewed and synthesized. The available data suggests that the antipsychotic efficacy of loxapine is similar to the efficacy of other typical or atypical antipsychotics, with an adverse effects profile comparable to that of the typical antipsychotics at high doses for chronic treatment. As an acute treatment in agitation associated with schizophrenia or bipolar disorder, inhaled loxapine was developed as an innovative and rapid option which appears to be efficacious and tolerable.

Adhésion et représentations des antidépresseurs chez des patients hospitalisés pour épisode dépressif majeur

Introduction

La non-adhésion diminue largement l’efficacité des antidépresseurs [1,2], dont la représentation évolue dans un contexte particulièrement défiant et médiatiquement tendu.

Objectif

L’objectif de cette étude est de :

– évaluer l’adhésion aux antidépresseurs chez des patients hospitalisés pour épisode dépressif majeur ;

– explorer les représentations que les patients ont des antidépresseurs et de la dépression, ainsi que la perception de la stigmatisation aux troubles mentaux ;

– analyser la relation entre les attitudes face aux antidépresseurs et des paramètres sociodémographiques et cliniques.

Méthode

L’adhérence était évaluée chez 40 patients en utilisant la version courte du Drug Attitude Inventory (DAI-10), complétée par un questionnaire mesurant les connaissances, craintes, impact des média et stigmatisation liés aux antidépresseurs. Des entretiens d’investigation étaient ensuite menés à l’aide de celui-ci.

Résultats

L’âge moyen de l’échantillon est de 43 ans, dont 27 % d’homme. Il s’agit d’un premier épisode pour 40 % des patients. La médiane du DAI est de 3,5 (échelle de −10 à +10), et 30 % des patients ne sont pas adhérents. Les hommes de l’échantillon ont une plus mauvaise représentation des antidépresseurs (−2 VS 4 ; U de Mann-Whitney = 90,50 ; p = 0,0035). Soixante-dix pour cent des patients ont des craintes par rapport à leur antidépresseur (prise de poids et dépendance au premier rang). Vingt pour cent des patients n’ont pas dit à leur entourage qu’ils prenaient des médicaments contre la dépression.

Discussion

Une intervention à de multiples niveaux pourrait augmenter les connaissances des patients ainsi que de l’opinion publique [3]. Une collaboration spécifique entre journalistes et psychiatres permettrait une meilleure connaissance et une diffusion plus représentative des enjeux de santé mentale dans les média [4]. Des actions de santé publique et initiatives citoyennes pourraient aussi être profitables aux patients.

Conclusion

L’adhérence aux antidépresseurs peut largement être améliorée, la stigmatisation restant une barrière aux traitements et à la prise en charge.

Évaluation de l’intérêt d’un Serious game chez des patients souffrant de troubles bipolaires inclus dans un programme de psychoéducation

Introduction

La psychoéducation du trouble bipolaire favorise l’adhésion thérapeutique et le maintien de l’euthymie à 2 ans [1]. Au terme d’un tel programme, les patients peuvent avoir besoin d’aide pour perpétuer la mise en place des apprentissages concernant l’observance thérapeutique, les routines de vie quotidienne, l’évitement des toxiques et le repérage des prodromes thymiques. Le Serious Game BIPOLIFE®, jeu centré sur un avatar souffrant de trouble bipolaire évoluant dans des situations de la vie courante, s’articule aussi autour de ces cibles.

Objectifs

Évaluer la qualité de l’observance thérapeutique par la Medication Adherence Rating Scale (MARS) [2], les indicateurs de routine de vie et de recours aux soins psychiatriques à 1 et 4 mois de la dernière séance de psychoéducation chez les patients utilisant BIPOLIFE® vs. suivi habituel.

Méthodologie

Étude pilote multicentrique randomisée contrôlée à 2 bras (durée : 24 mois) incluant des sujets euthymiques (score de dépression MADRS ≤ 12 et de manie YMRS ≤ 8 depuis 3 mois), bénéficiant d’un programme de psychoéducation. Les patients du groupe « intervention » se connecteront au site BIPOLIFE®, de manière hebdomadaire, pendant un mois (durée de connexion libre). À l’inclusion (dernière séance de psychoéducation), 1 et 4 mois, seront évalués l’attitude vis-à-vis du traitement, la qualité du sommeil, l’indice de masse corporelle, le périmètre ombilical, la consommation de toxiques, le fonctionnement psychosocial et le recours aux soins psychiatriques.

Perspectives

Proposer BIPOLIFE® en add-on de la psychoéducation pour renforcer les compétences acquises lors du programme et le maintien de l’euthymie.

[Treatment practices in the management of patients with bipolar disorder in France. The TEMPPO study]

TEMPPO is an observational, cross-sectional and multicentre study, initiated in the French metropolitan territory in 2009. Set up from a random sample of 135 psychiatrists, it has observed the procedures for therapeutic management of a population (n=619) of their outpatients (respectively 197 and 422 in public and private practice) with bipolar disorder type I or II disorders (DSM-IV). The patients who were followed were mostly very sick. Every patient received a pharmacological treatment. The prescription included at least one mood stabilizer or an antipsychotic (71 % atypical) in 78 % and 56 % of cases respectively. Treatment regimen changes were frequent (61 % of patients had at least one change in treatment during the last 12 months). A single molecule by therapeutic class was generally prescribed. The presence of an antipsychotic in combination therapy was often associated with the severity or difficulty of care of the patient (mixed states, severity of the global functioning impairment, manic states, high number of hospitalizations and history of suicide attempt). The combination of two antipsychotics is found only in the difficult situations of manic states. Patients with severe depressive phase are those who benefit from the combination mood stabilizer+antipsychotic+antidepressant (16 % of the sample). In this study, the prescription of antidepressants significantly differs from recommendations for good prescribing practices. Indeed antidepressants were commonly prescribed in mixed-phase (63 %), particularly as a monotherapy in 5 % of cases. It was also found in patients in euthymic phase (48 %), manic phase (12 %) and hypomanic phase (29 %). The prescription of atypical antipsychotics (monotherapy or combination) is now fully established in the management of all phases of the disease. The importance of non-pharmacological treatment is acknowledged by psychiatrists and proposed whether a psychotherapeutic support, information about the disease and/or lifestyle changes. The data collected in this study allowed to demonstrate that the participant psychiatrists have a pharmacological management of patients with bipolar disorder mostly in line with national and international guidelines.

The use of amisulpride in the treatment of acute psychosis

The management of acute episodes in schizophrenia is frequently initiated in the psychiatric emergency department and requires rapid intervention to relieve distress and psychiatric symptoms. Both non-pharmacological and pharmacological interventions are needed to calm the patient and prevent potential harm to the patient or others. Treatment is a step-by-step process including management of behavioral symptomatology, diagnosis of potential organic causes, and evaluation of potential substance abuse. Better care is delivered if predefined standard operating procedures are adopted systematically. The ultimate goal of treatment is to establish a therapeutic alliance with the patient. Atypical antipsychotics given orally are recommended as a first-line treatment. As the treatment endpoint is calmness rather than sleep, a non-sedative antipsychotic agent is usually preferred. Drug tolerance is a major issue for the patient. Amisulpride is an effective atypical antipsychotic agent in this context. The optimal dose is 800 mg/day, which is effective on positive and negative symptoms and can be given from the first day with a low risk of extrapyramidal symptoms. Since drug-drug interactions are limited, agitation and anxiety may be controlled by short-term adjunctive therapy with benzodiazepines. In conclusion, amisulpride is an appropriate first-line treatment for the management of acute psychosis.

The interaction of antipsychotic drugs with lipids and subsequent lipid reorganization investigated using biophysical methods

The interaction of antipsychotic drugs (AP) with lipids and the subsequent lipid reorganization on model membranes was assessed using a combination of several complementary biophysical approaches (calorimetry, plasmon resonance, fluorescence microscopy, X-ray diffraction and molecular modeling). The effect of haloperidol (HAL), risperidone (RIS), and 9-OH-risperidone (9-OH-RIS) was examined on single lipid and mixtures comprising lipids of biological origin. All APs interact with lipids and induced membrane reorganization. APs showed higher affinity for sphingomyelin than for phosphatidylcholine. Cholesterol increased AP affinity for the lipid bilayer and led to the following AP ranking regarding affinity and structural changes: RIS >9-OH-RIS >HAL. Liquid-ordered domain formation and bilayer thickness were differentially altered by AP addition. Docking calculations helped understanding the observed differences between the APs and offer a representation of their conformation in the lipid bilayer. Present results indicate that AP drugs may change membrane compartmentalization which could differentially modulate the signaling cascade of the dopamine D2 receptor for which APs are ligands.

Antipsychotic medication, functional outcome and quality of life in schizophrenia: focus on amisulpride

BACKGROUND

Restoration of quality of life is considered as the ultimate treatment goal in the management of schizophrenia and is important for destigmatising the disease. However, few studies, including the most recent, have collected quality of life data prospectively or evaluated the relationship of treatment with quality of life.

SCOPE

Amisulpride is an atypical antipsychotic drug which has been described to have potency in improving negative symptoms of chronic schizophrenia and whose use is associated with a relatively low rate of emergence of extrapyramidal side-effects. These properties may contribute to a beneficial effect on quality of life. A systematic literature review of functional outcome in clinical trials with amisulpride was performed in order to assess the effect of this drug on quality of life and social functioning in patients. The Medline database was searched for all studies of amisulpride in schizophrenia which reported functional and quality of life outcomes up until 30 September 2009.

FINDINGS

Only one dedicated study assessing functional outcome or quality of life as a primary outcome criterion was identified. This demonstrated significant improvement in subjective well-being in patients with schizophrenia initiating treatment with amisulpride, and a correlation between this improvement and amelioration of psychopathology. In addition, functional outcome rating scales were used as secondary outcome measures in eight randomised clinical trials, and two naturalistic observational studies. Amisulpride treatment was associated with improvement in functional outcome, with effect sizes that were comparable between studies. Improvements in functional outcome are consistently greater than those observed in patients treated with haloperidol and similar in magnitude to those seen with three other atypical antipsychotics, namely olanzapine, ziprasidone and risperidone. A patient-reported outcome measure was used in only one comparative study, and demonstrated perception of a superior benefit with amisulpride compared to haloperidol. These findings could to some extent be replicated in several large naturalistic studies under standard conditions of care.

CONCLUSIONS

The data from studies on functional outcome and subjective well-being provide consistent information supporting the use of amisulpride for the treatment of schizophrenia in order to improve social functioning, integration into the community and autonomy, which are critical for the overall quality of life of patients with schizophrenia.

Abnormal transbilayer distribution of phospholipids in red blood cell membranes in schizophrenia

Abnormalities in membrane lipids have been repeatedly reported in patients with schizophrenia. These abnormalities include decreased phosphatidylethanolamine (PE) and n-3 and n-6 polyunsaturated fatty acids in peripheral and brain cell membranes. The present study investigates the hypothesis of an overrepresentation of PE in the external leaflet of the red blood cell (RBC) membrane in patients with schizophrenia. The assumption was that this modification of PE asymmetrical distribution could explain the reported lipid membrane abnormalities. Phosphatidylethanolamine located in the external leaflet was specifically labeled in RBC membranes from 65 medicated patients with schizophrenia and 38 healthy controls. Labeled (external) and non-labeled (internal) PE and their respective fatty acid composition were analyzed by mass spectrometry. A significant increase in the percentage of external leaflet PE was found in RBC membranes in 63.1% of the patients. In this subgroup, a significant depletion of n-3 and n-6 polyunsaturated fatty acids from internally located PE was also observed. Age, sex and antipsychotic treatment were not associated with the transbilayer membrane distribution of PE. Potential mechanisms underlying these abnormalities may involve membrane phospholipid transporters or degradative enzymes involved in phospholipid metabolism. The anomaly described could characterize a subgroup among patients with schizophrenia.

Liquid-liquid immiscibility under non-equilibrium conditions in a model membrane: an X-ray synchrotron study

Several non-random lipid mixtures have been proposed as models of lipid plasma membrane, as they mimic the ability of biomembranes to form lateral domains. Biological membranes are characterised by a succession of localised transient steady-state lipid organisations rather than stable equilibria. This suggests that several quasi at-equilibrium lipid organisations may exist at different times in the same local patch of membranes. Identification of the conditions which can mimic heterogeneous dynamic membrane states in a lipid membrane model is a challenge. This is of particular importance as the lateral organisation of lipids mixtures in fully equilibrated samples may differ from the arrangement found in quasi at-equilibrium conditions. To address this issue, we have performed a real-time synchrotron X-ray diffraction study in ternary mixtures of egg-phosphatidylcholine/egg-sphingomyelin and cholesterol using a 0.5 degrees C/15 s step within a 20-50-20 degrees C thermal cycle. In the present study, all ternary mixtures displayed lamellar phase separation. A d-spacing value was observed reversibly during the heating and cooling scan for each of the two coexisting phases. In mixtures with a cholesterol concentration from 20 to 50 mol%, a liquid-ordered (Lo) and liquid-disordered (Ld) phase separation was observed in the 20-50 degrees C thermal range. These results are discussed in terms of a specific interaction between lipid molecular aggregates.

Modification of membrane heterogeneity by antipsychotic drugs: an X-ray diffraction comparative study

Lipid mixtures are used to mimic biological membranes as they allow characterization of lipid lateral domains defined by their specific lipid molecular organization. Therapeutic agents such as antipsychotic drugs (AP) that may interact with lipids arrangement are likely to modify membrane biological properties. The present study describes the effect of 2 typical and 5 atypical antipsychotic drugs on an aqueous co-dispersion of a lipid mixture made of egg phosphatidylcholine (PC)/brain sphingomyelin (SM)/cholesterol (1/1/1 mol/mol/mol). Lamellar liquid-ordered (Lo) and liquid-disordered (Ld) phase coexistence was identified in the control and antipsychotic-added mixtures at 37 degrees C using synchrotron small-angle X-ray scattering methods (XRD). Intensity of the Bragg peaks was used to generate electron density profiles (EDP) allowing bilayer thickness calculation. All antipsychotic except from amisulpride induced a Lo phase bilayer thickness (d(pp)) decrease. Chlorpromazine, haloperidol, amisulpride and 9-0H-risperidone induced a Ld d(pp) increase while ziprazidone, risperidone and clozapine induced a Ld d(pp) decrease, indicating that antipsychotic atypicality is not associated with a specific d(pp) modification on our lipid model mixture. Results are discussed in terms of competition of antipsychotic compounds with cholesterol and mode of reorganization of lateral domains. A pharmacological relevance of these changes is also discussed.

A positron emission tomography (PET) study of cerebral dopamine D2 and serotonine 5-HT2A receptor occupancy in patients treated with cyamemazine (Tercian)

RATIONALE

Cyamemazine (Tercian) is an antipsychotic drug with anxiolytic properties. Recently, an in vitro study showed that cyamemazine possesses high affinity for serotonin 5-HT(2A) receptors, which was fourfold higher than its affinity for dopamine D(2) receptors (Hameg et al. 2003).

OBJECTIVES

The aim of this study is to confirm these previous data in vivo in patients treated with clinically relevant doses of Tercian.

METHODS

Eight patients received 37.5, 75, 150 or 300 mg/day of Tercian depending on their symptomatology. Dopamine D(2) and serotonin 5-HT(2A) receptor occupancies (RO) were assessed at steady-state plasma levels of cyamemazine with positron emission tomography (PET), using [(11)C]raclopride and [(11)C]N-methyl-spiperone, respectively. The effective plasma level of the drug leading to 50% of receptor occupancy was estimated by fitting RO with plasma levels of cyamemazine at the time of the PET scan.

RESULTS

Cyamemazine induced near saturation of 5-HT(2A) receptors (RO=62.1-98.2%) in the frontal cortex even at low plasma levels of the drug. On the contrary, occupancy of striatal D(2) receptors increased with plasma levels, and no saturation was obtained even at high plasma levels (RO=25.2-74.9%). The effective plasma level of cyamemazine leading to 50% of D(2) receptor occupancy was fourfold higher than that for 5-HT(2A) receptors. Accordingly, individual 5-HT(2A)/D(2) RO ratios ranged from 1.26 to 2.68. No patients presented relevant increased prolactin levels, and only mild extrapyramidal side effects were noticed on Simpson and Angus Scale.

CONCLUSION

This in vivo binding study conducted in patients confirms previous in vitro findings indicating that cyamemazine has a higher affinity for serotonin 5-HT(2A) receptors compared to dopamine D(2) receptors. In the dose range 37.5-300 mg, levels of dopamine D(2) occupancy remained below the level for motor side effects observed with typical antipsychotics and is likely to explain the low propensity of the drug to induce extrapyramidal side effects.

The generic alternative in schizophrenia: opportunity or threat?

Pharmacological treatment of schizophrenia often requires careful dosage titration to achieve satisfactory symptom control whilst minimising the risk of adverse effects. Relapses requiring hospitalisation are an important potential source of additional cost for the health service and any inadequate symptom control increases the indirect costs of schizophrenia relating to, for example, the need for sheltered accommodation or intensive social services support. The availability of generic drugs is widely regarded as an opportunity to reduce expenditure on drug costs and deploy limited resources more widely and effectively. However, generic drugs may differ from branded drugs in their formulation and may not show precise bioequivalence with the branded product. This may have consequences for the pharmacokinetic profile of the generic drug. A higher maximum plasma concentration (C(max)) could lead to increased or emergent adverse effects, whereas a decreased absorption or minimum plasma concentration (C(min)) may result in a reduced therapeutic effect. For example, plasma levels of clozapine are critical to therapeutic response. Symptom aggravation occurred in approximately 10% of patients switched from branded to generic clozapine in a small, randomised, crossover study. Patients with schizophrenia may also show suspicion and hostility regarding their treatment. This may result in unwillingness to take an unfamiliar medication and decreased compliance, thus increasing the risk of a relapse. Thus, great care should be taken by psychiatrists when switching patients with schizophrenia from branded to generic antipsychotic drugs; this entails monitoring clinical outcome closely and adjusting the treatment in case of symptom aggravation or emergence of adverse effects.

Effects of stress and etifoxine on pentobarbital-induced loss of righting reflex in Balb/cByJ and C57BL/6J mice

We hypothesized that functional changes in the GABAergic system induced by stress would differ between two inbred mouse strains BALB/cByJ and C57BL/6J. We compared the effects of restraint stress and of the anxiolytic drug etifoxine (EFX) on the duration of pentobarbital-induced loss of righting reflex (hypnotic effect) in the two strains. Naive BALB/cByJ mice were less sensitive than naive C57BL/6J mice to the hypnotic effect of pentobarbital. C57BL/6J mice exhibited a shortening in the duration of pentobarbital-induced hypnosis following stress whereas stress had no effect in BALB/cByJ mice. EFX reversed the shortening of pentobarbital-induced hypnosis elicited by stress in C57BL/6J and shortened the duration of pentobarbital-induced hypnosis after stress in BALB/cByJ mice. Alterations in the GABAergic function in BALB/cByJ mice could be corrected by EFX, an enhancer of GABAergic transmission.

Reduction of extracellular dopamine and metabolite concentrations in rat striatum by low doses of acute cyamemazine

The low incidence of extrapyramidal effects with atypical neuroleptics has been ascribed to their 5-HT(2A)- and 5-HT(2C)-serotonin receptor antagonistic properties. On the other hand, the acute increase in striatal dopamine release by submaximal dopamine D(2) autoreceptor blockade can be respectively reduced and increased by 5-HT(2A)- and 5-HT(2C)-antagonists. Cyamemazine is a neuroleptic D(2)- and 5-HT(2A)-receptor antagonist, with small antagonistic activity at 5-HT(2C) receptors and low incidence of extrapyramidal side effects. Therefore, submaximal cyamemazine was tested in rats for its acute action on the extracellular concentrations of dopamine and dopamine metabolites (DOPAC: 3,4,dihydroxyphenylacetic acid and HVA: 4-hydroxy-3-methoxy-phenyl-acetic acid) in the corpus striatum. The serotonin metabolite 5-HIAA (5-hydroxy-indole-acetic acid) was measured in parallel. Rats prepared for microdialysis (striatum) were intraperitoneally given cyamemazine 1 mg/kg, 5 mg/kg or vehicle ( n=4 in each group). Dopamine, DOPAC, HVA and 5-HIAA concentrations in perfusates under basal conditions and after stimulation by high K(+) were measured by HPLC coupled to electrochemical detection. Cyamemazine 1 mg/kg significantly reduced extracellular concentrations of basal dopamine (-77%), DOPAC (-54%), HVA (-54%) and 5-HIAA (-65%). No such effects were seen with the dose of cyamemazine 5 mg/kg or for K(+)-evoked dopamine release. In conclusion, submaximal cyamemazine can acutely reduce basal dopamine release and metabolism in the rat striatum. Such unusual action can be explained by the original pharmacological profile of cyamemazine (potent D(2)- and 5-HT(2A)-antagonist, with small antagonistic activity at 5-HT(2C) receptors). Further experiments are required to explain the low incidence of extrapyramidal side actions with cyamemazine.

Affinity of cyamemazine, an anxiolytic antipsychotic drug, for human recombinant dopamine vs. serotonin receptor subtypes

Animal studies indicate that the anxiolytic properties of the antipsychotic agent cyamemazine may result from blockade of serotonin 5-HT(2C) receptors and to a lesser extent from blockade of serotonin 5-HT(3) receptors. Here, we used human recombinant receptors to determine the relative affinity of cyamemazine for serotonin and dopamine receptor subtypes. In addition, cyamemazine was tested in other brain receptor types and subtypes which are considered to mediate central nervous systems effects of drugs. Hence, cyamemazine affinity was determined in human recombinant receptors expressed in CHO cells (hD(2), hD(3), and hD(4.4) receptors, h5-HT(1A), h5-HT(2A), h5-HT(2C), and h5-HT(7), and hM(1), hM(2), hM(3), hM(4), and hM(5) receptors), L-cells (hD(1) receptor), and HEK-293 cells (h5-HT(3) receptors) or natively present in N1E-115 cells (5-HT(3) receptors) or in rat cerebral cortex (non-specific alpha(1)- and alpha(2)-adrenoceptors, GABA(A) and GABA(B) receptors, H(3) histamine receptors), and guinea-pig cerebellum (H(1) central and H(2) histamine receptors) membranes. Similarly to atypical antipsychotics, cyamemazine exhibited high affinity for: (i) h5-HT(2A) receptors (K(i)=1.5+/-0.7 nM, mean+/-SEM, N=3) and this was four times higher than for hD(2) receptors (K(i)=5.8+/-0.8 nM), (ii) h5-HT(2C) receptors (K(i)=11.8+/-2.2nM), and (iii) 5-HT(7) receptors (K(i)=22 nM). Conversely, cyamemazine exhibited very low affinity for h5-HT(3) receptors (K(i)=2.9+/-0.4 microM). In conclusion, similarly to atypical antipsychotic agents, cyamemazine, possesses high affinity for h5-HT(2A), h5-HT(2C), and h5-HT(7) receptors, a feature which can explain its low propensity to cause extrapyramidal adverse reactions in clinical practice. The high affinity for h5-HT(2C) receptors, but not for h5-HT(3) receptors, can account for the anxiolytic activity of cyamemazine in human subjects.

[Drug users attending at hospital emergency rooms. Changes in sociodemographic features, health care, referral attitudes and impact of substitution therapy, between 1993 and 1998]

The purpose of this work was to assess changes observed between 1993 and 1998 relative to drug users seen at hospital emergency rooms. We retrospectively reviewed our medical files for two periods, 1993-1995 and 1996-1998, i.e. before and after routine institution of substitution therapy with buprenorphine and methadone. A predefined grid was used to select files. All patients whose file indicated drug use, irrespective of the reason for consultation, were eligible for inclusion. Overall demographic features were: mean age 29 years, men 74%, known address 60%, indication of medical coverage 29%, institutional transportation 70%, heroine abusers 53%, injecting drug users 65%, associated acute alcohol intoxication 27%. There was a significant decline in the incidence of drug abusers during the second period (2.42% versus 3.44%) with no difference for age, sex, or area of residence. Documentation of medical coverage improved. There was no change in the hour of arrival, more than 50% arrived outside regular hospital hours but a higher proportion arrived during the weekend, indicating some access difficulty. Our results are in agreement with the OFDT data on product use: reduction in the use of heroine and significant increase in the use of cocaine, alcohol consumption remaining unchanged. Among the 63 patients seen during the second period, 31.7% stated they were taking substitution therapy, indicating this population has access to treatment. There was no statistical difference for diagnosis, but certain trends were observed: acute intoxication with loss of consciousness leading to emergency squad transfer to the emergency room remained the most common situation, rate of trauma was unchanged at approximately 10%, as was the rate of post-IV abscesses; there was a 3-fold reduction in request for drugs and a 2-fold rise in public intoxication. These data help better define management conditions for drug users attending emergency rooms.

What is the schizophrenic patients' level of information about their disease and their treatment?

Improved compliance with antipsychotic medication is a major issue in schizophrenic management. For this purpose educational programs have been used, but up to now, little or no information has been gathered or published in France concerning schizophrenic patients' opinion on information they have about their disease and their treatment. Thus we conducted a survey in concert with 78 psychiatrists from the French psychiatric health service. From this cross sectional survey we assessed 336 outpatients (male: 72%; mean age: 36 +/- 10.4 years) with schizophrenia according to the DSM IV (paranoid sub type: 57%, disorganized: 12%, catatonic: 1%, undifferentiated: 12%, residual: 18%). The mean duration of the illness was 11.6 years (sd: 8.5) and the mean duration of the follow up with the same psychiatrist was 5.4 years (sd: 5.1). Patients completed a questionnaire which assessed their level of information on mental illness and treatment. The diagnosis of schizophrenia has been told to their patients by 39% of the psychiatrists, and treatment has been explained to the patients by 96% of the practitioners. Results indicate less than half of the patients (45%) felt ill, only 46% thought they knew their illness well or very well (nevertheless only 31% of them named spontaneously the diagnosis of schizophrenia or psychosis), and 61% considered that they had been given sufficient information. Most of the patients (79%) were persuaded that their treatment was useful, and 75% of patients were completely satisfied with their treatment. Surprisingly 92% reported taking their medication regularly. Most patients think that a high level of information about their illness (74%) and treatment (79%) help them to cope better with their schizophrenia. Analysis performed according to patients characteristics indicated that paranoid patients felt more ill (p = 0.035) than others, thought to know less about their illness (p = 0.0065), and were less satisfied with their treatment (p = 0.04) and their level of information (p = 0.03). Patients with a duration of their illness longer than 10 years were more convinced of the utility of their treatment (p = 0.02) and had debated more on the choice of their treatment with their psychiatrist (p = 0.047). Patients older than 35 years were more satisfied with their information (p = 0.002). More patients with atypical antipsychotics accepted to take their treatment on a regular basis (p = 0.035) compared to patients under classical neuroleptics. This survey underlines that mental health consumers' opinions can be obtained even in the field of schizophrenia, and argues in favour of further such investigations. It also highlights the need for educational programs on schizophrenia and antipsychotic medications.

[What information do patients with schizophrenia have about their illness and treatment?]

Improved compliance with antipsychotic medication is a major issue in schizophrenic management. For this purpose educational programs have been used, but up to now, little or no information has been gathered or published in France concerning schizophrenic patients' opinion on information they have about their disease and their treatment. Thus we conducted a survey in concert with 78 psychiatrists from the French psychiatric health service. From this cross sectional survey we assessed 336 outpatients (male: 72%; mean age: 36 +/- 10.4 years) with schizophrenia according to the DSM IV (paranoid sub type: 57%, disorganized: 12%, catatonic: 1%, undifferentiated: 12%, residual: 18%). The mean duration of the illness was 11.6 years (sd: 8.5) and the mean duration of the follow up with the same psychiatrist was 5.4 years (sd: 5.1). Patients completed a questionnaire which assessed their level of information on mental illness and treatment. The diagnosis of schizophrenia has been told to their patients by 39% of the psychiatrists, and treatment has been explained to the patients by 96% of the practitioners. Results indicate less than half of the patients (45%) felt ill, only 46% thought they knew their illness well or very well (nevertheless only 31% of them named spontaneously the diagnosis of schizophrenia or psychosis), and 61% considered that they had been given sufficient information. Most of the patients (79%) were persuaded that their treatment was useful, and 75% of patient were completely satisfied with their treatment. Surprisingly 92% reported taking their medication regularly. Most patients think that a high level of information about their illness (74%) and treatment (79%) help them to cope better with their schizophrenia. Analysis performed according to patients characteristics indicated that paranoid patients felt more ill (p = 0.035) than others, thought to know less about their illness (p = 0.0065), and were less satisfied with their treatment (p = 0.04) and their level of information (p = 0.03). Patients with a duration of their illness longer than 10 years were more convinced of the utility of their treatment (p = 0.02) and had debated more on the choice of their treatment with their psychiatrist (p = 0.047). Patients older than 35 years were more satisfied with their information (p = 0.002). More patients with atypical antipsychotics accepted to take their treatment on a regular basis (p = 0.035) compared to patients under classical neuroleptics. This survey underlines that mental health consumers' opinions can be obtained even in the field of schizophrenia, and argues in favour of further such investigations. It also highlights the need for educational programs on schizophrenia and antipsychotic medications.

[When and how to stop anxiolytic drugs]

The anxiolytics withdrawal constitutes a frequently desirable therapeutic situation in which it is necessary to integrate clinical data related to the disorder for which they were prescribed as well as the pharmacological and psychological aspects. Personality features and emotional environment of the patient are to be considered. This withdrawal follows a first step in which the anxiolytics were initially prescribed. This situation happens in medicine in multiple clinical situations. However, because of the phenomena of tolerance and dependence but also according to the efficacy of the anti-depressants in most anxiety disorders, benzodiazepines are described in France as over-prescribed molecules. General rules of prescription are a prelude to a good withdrawal process. This last must always be prevented especially when the dosage is high occurring after a long duration treatment. A good guideline for the initial prescription is a good ticket to anticipate the withdrawal time.

[Dysthymic disorders]

Long lasting, low intensity depressive episodes have been diversely integrated according to the classifications types or the psychodynamic points of view. The concept of anxious persistent lasting depression, neurotic depressive states, neurotic depression ... have been unified into the dysthymic disorder category of the DSM classification. This concept unification have been a topic of dispute considering that dysthymic disorder was a restrictive, heterogeneous an extensively comorbid diagnosis. Nevertheless the definition of this category offers the opportunity to place the notions of temperament, personality, adjustment disorder. Including dysthymic disorders as a category inside of the mood disorders classification suggests the interest of using an antidepressive medication in presence of chronic depressive states not included in the major depressive disorder category.

[Is the anxious patient dependent?]

To answer the question: is the anxious a dependant person, it is necessary to define to what extend behaviour depends on pathology. The difficulty in answering this question relies on the fact that these two phenomenons interact with each other. The comorbidity analysis allows a descriptive point of view. It shows a higher incidence of these troubles when occurring together, compared to a general population. Nevertheless, the comorbidity approach does not give any information on the nature of the links between anxiety and dependence. The causality models depend on the theory they use. Furthermore, unity between anxiety and dependence disorders does not exist; it is then certainly a mistake to consider their link in a unique way. Three main hypothesis are usually used. The neurobiology point of view supposes a link between brain structures, neurofunctioning, anxiety and dependence disorders. Some authors suggest a general addictive propensity of brain functioning, especially in cases of anxiety disorders. Lastly, the psychopathological analysis can be useful in the understanding of dependence behaviour in case of anxiety.