Showing papers in "Acta Psychiatrica Scandinavica in 2016"

Areas of controversy in neuroprogression in bipolar disorder.

Abstract: OBJECTIVE: We aimed to review clinical features and biological underpinnings related to neuroprogression in bipolar disorder (BD). Also, we discussed areas of controversy and future research in the field. METHOD: We systematically reviewed the extant literature pertaining to neuroprogression and BD by searching PubMed and EMBASE for articles published up to March 2016. RESULTS: A total of 114 studies were included. Neuroimaging and clinical evidence from cross-sectional and longitudinal studies show that a subset of patients with BD presents a neuroprogressive course with brain changes and unfavorable outcomes. Risk factors associated with these unfavorable outcomes are number of mood episodes, early trauma, and psychiatric and clinical comorbidity. CONCLUSION: Illness trajectories are largely variable, and illness progression is not a general rule in BD. The number of manic episodes seems to be the clinical marker more robustly associated with neuroprogression in BD. However, the majority of the evidence came from cross-sectional studies that are prone to bias. Longitudinal studies may help to identify signatures of neuroprogression and integrate findings from the field of neuroimaging, neurocognition, and biomarkers.

Placebo-controlled pilot trial testing dose titration and intravenous, intramuscular and subcutaneous routes for ketamine in depression

Abstract: Objective This pilot study assessed the feasibility, efficacy and safety of an individual dose-titration approach, and of the intravenous (IV), intramuscular (IM) and subcutaneous (SC) routes for treating depression with ketamine. Method Fifteen treatment-refractory depressed participants received ketamine or midazolam (control treatment) in a multiple crossover, double-blind study. Ketamine was administered by IV (n = 4), IM (n = 5) or SC (n = 6) injection. Dose titration commenced at 0.1 mg/kg, increasing by 0.1 mg/kg up to 0.5 mg/kg, given in separate treatment sessions separated by ≥1 week, with one placebo control treatment randomly inserted. Mood, psychotomimetic and hemodynamic effects were assessed and plasma ketamine concentrations assayed. Results Twelve participants achieved response and remission criteria, achieved at doses as low as 0.1 mg/kg. All three routes of administration resulted in comparable antidepressant effects. Fewest adverse effects were noted with the SC route. Antidepressant response, adverse effects and ketamine concentrations were dose-related. Conclusion Antidepressant response occurred at a range of doses and at <0.5 mg/kg. The dose-titration approach is a practical method for optimizing the efficacy – side-effects trade-off on an individual patient basis. This pilot study provides preliminary evidence for SC injection as a practical, feasible and efficacious treatment approach.

A systematic review and meta-analysis of the long-term overall outcome of autism spectrum disorders in adolescence and adulthood

Abstract: Objective A systematic review and meta-analysis of studies reporting on the overall outcome in terms of a global measure of adjustment in children with autistic disorders followed up in adolescence and adulthood. Method PubMed, PsycINFO, and EMBASE were systematically searched on 3rd of August 2015. Included studies were analyzed using random-effects models estimating event rates (%) and 95% confidence intervals (95%CI). Results From 4350 records identified in the search, 15 studies covering 12 unique samples and a total of N = 828 individuals with autistic disorders were included in the analyses. An estimated 19.7% (95%CI: 14.2–26.6) had a good outcome, 31.1% (95%CI: 23.2–40.4%) a fair outcome, and 47.7% (95%CI: 36.6–59.0) a poor outcome. The meta-analysis showed strong evidence for heterogeneity. The subtype of childhood autism is a significant moderating factor on the risk of having a poor outcome at follow-up, whereas age at follow-up showed statistically significant but inconsistent associations with outcome status. Conclusion The long-term outcome of almost half of all individuals with autistic disorders is poor. The subtype of autism in childhood may be a predictor for specific long-term outcomes, but in general, little is known about the pathways and predictors.

Understanding auditory verbal hallucinations: a systematic review of current evidence.

Abstract: Objective Auditory verbal hallucinations (AVHs) are core features of psychotic illness and remain significant in predicting poor outcome and risk. There has been a wide range of approaches to understanding these experiences. Method A systematic literature review summarizing different methods of investigation and their results; phenomenology, descriptive psychopathology, psychological, cognitive neurobiology, and neuroimaging. Results A number of 764 papers and texts were screened and 113 reviewed. Phenomenological studies are comparably few in number, and psychopathology remains based on concepts defined in the early 20th century. Psychological models focus on voice content and emotional reaction, and suggest a continuum of AVHs from normal experience. Neuropsychological models include AVHs as misattribution of inner speech, whilst functional neuroimaging studies focus on the spontaneous activity and connectivity of auditory networks. Conclusion There has been a large growth in research on AVHs in recent decades dominated by neurobiological and neuroimaging studies. Future research should include focus on phenomenological aspects and AVHs change over the course of developing illness. Integration between branches of enquiry is needed, and the risk is that without this, models are proposed and investigated that bear scant relevance to the symptom itself.

Suicide attempts in bipolar disorders: comprehensive review of 101 reports

Abstract: Objective Assess reported risk of suicide attempts by patients with bipolar disorder (BD). Method Systematic searching yielded 101 reports from 22 countries (79 937 subjects). We analyzed for risk (%) and incidence rates (%/year) of attempts, comparing sex and diagnostic types, including by meta-analysis. Results Attempt risk averaged 31.1% [CI: 27.9–34.3] of subjects, or 4.24 [3.78–4.70]%/year. In BD-I (43 studies) and BD-II subjects (30 studies), risks (29.9%, 31.4%) and incidence rates (4.01, 4.11%/year) were similar and not different by meta-analysis. Among women vs. men, risks (33.7% vs. 25.5%) and incidence (4.50 vs. 3.21%/year) were greater (also supported by meta-analysis: RR = 1.35 [CI: 1.25–1.45], P < 0.0001). Neither measure was related to reporting year, % women/study, or to onset or current age. Risks were greater with longer exposure, whereas incidence rates decreased with longer time at risk, possibly through ‘dilution’ by longer exposure. Conclusion This systematic update of international experience underscores high risks of suicide attempts among patients with BD (BD-I = BD-II; women > men). Future studies should routinely include exposure times and incidence rates by diagnostic type and sex for those who attempt suicide or not.

Cognitive reserve in bipolar disorder: relation to cognition, psychosocial functioning and quality of life

Abstract: Objective Cognitive reserve (CR) is a concept that was postulated as a protective factor for some clinical symptoms after the observation that there is not a direct relationship between the degree of brain damage and its clinical manifestation. This study aimed to explore the association between CR and the main outcomes in bipolar disorder (BD): cognitive functions, psychosocial functioning and perceived quality of life. Method A sample of 224 euthymic bipolar patients was assessed with a neuropsychological battery, the Functioning Assessment Short Test and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). CR was calculated through three proxies: estimated premorbid Intelligent Quotient, educational level and occupational attainment. Relationships between CR and cognitive functions, psychosocial functioning and quality of life were assessed by multiple linear regression models. Results Higher CR was associated with better cognitive functioning (P < 0.001 in processing speed, working memory, verbal and visual memory, and executive function; P = 0.026 in attention) and better psychosocial functioning (P = 0.008). For quality of life, CR was positively associated with the physical component of the SF-36 (P = 0.016) but negatively associated with the mental component (P = 0.004). Conclusion The results suggest that CR may play an important role in the course and prognosis of bipolar patients and it should be considered in both clinical and research settings related to BD.

Bone mineral density, osteoporosis, and fractures among people with eating disorders: a systematic review and meta-analysis.

Abstract: Objective To provide meta-analytical evidence of bone mineral density (BMD), fractures, and osteoporosis rates in eating disorders (ED) vs. healthy controls (HCs). Method Three independent authors searched major electronic databases from inception till August 2015 for cross-sectional studies reporting BMD in people with ED (anorexia nervosa, (AN); bulimia nervosa, (BN); eating disorders not otherwise specified, (EDNOS)) vs. HCs. Standardized mean differences (SMDs) ±95% and confidence intervals (CIs) were calculated for BMD, and odds ratios (ORs) for osteopenia, osteoporosis, and fractures. Results Overall, 57 studies were eligible, including 21 607 participants (ED = 6485, HCs = 15 122). Compared to HC, AN subjects had significantly lower BMD values at lumbar spine (SMD = −1.51, 95% CI = −1.75, −1.27, studies = 42), total hip (SMD = −1.56, 95%CI = −1.84, −1.28, studies = 23), intertrochanteric region (SMD = −1.80, 95%CI = −2.46, −1.14, studies = 7), trochanteric region (SMD = −1.05, 95%CI = −1.44, −0.66, studies = 7), and femoral neck (SMD = −0.98, 95%CI = −1.12, −0.77, studies = 20). Reduced BMD was moderated by ED illness duration and amenorrhea (P < 0.05). AN was associated with an increased likelihood of osteoporosis (OR = 12.59, 95%CI = 3.30–47.9, P < 0.001, studies = 4) and fractures (OR = 1.84, 95% CI = 1.17–2.89, I2 = 56, studies = 6). No difference in BMD was found between BN and EDNOS vs. HC. Conclusion People with AN have reduced BMD, increased odds of osteoporosis and risk of fractures. Proactive monitoring and interventions are required to ameliorate bone loss in AN.

Regional brain volumes, diffusivity, and metabolite changes after electroconvulsive therapy for severe depression

Abstract: Objective To investigate the role of hippocampal plasticity in the antidepressant effect of electroconvulsive therapy (ECT). Method We used magnetic resonance (MR) imaging including diffusion tensor imaging (DTI) and proton MR spectroscopy (1H-MRS) to investigate hippocampal volume, diffusivity, and metabolite changes in 19 patients receiving ECT for severe depression. Other regions of interest included the amygdala, dorsolateral prefrontal cortex (DLPFC), orbitofrontal cortex, and hypothalamus. Patients received a 3T MR scan before ECT (TP1), 1 week (TP2), and 4 weeks (TP3) after ECT. Results Hippocampal and amygdala volume increased significantly at TP2 and continued to be increased at TP3. DLPFC exhibited a transient volume reduction at TP2. DTI revealed a reduced anisotropy and diffusivity of the hippocampus at TP2. We found no significant post-ECT changes in brain metabolite concentrations, and we were unable to identify a spectral signature at ≈1.30 ppm previously suggested to reflect neurogenesis induced by ECT. None of the brain imaging measures correlated to the clinical response. Conclusion Our findings show that ECT causes a remodeling of brain structures involved in affective regulation, but due to their lack of correlation with the antidepressant effect, this remodeling does not appear to be directly underlying the antidepressant action of ECT.

Public knowledge, attitudes, social distance and reported contact regarding people with mental illness 2009-2015.

Abstract: Objective To investigate whether public knowledge, attitudes, desire for social distance and reported contact in relation to people with mental health problems have improved in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009–2015. Methods Using data from an annual face-to-face survey of a nationally representative sample of adults, we analysed longitudinal trends in the outcomes with regression modelling using standardised scores of the measures overall and by age and gender subgroups. Results There were improvements in all outcomes. The improvement for knowledge was 0.17 standard deviation units in 2015 compared to 2009 (95% CI 0.10, 0.23); for attitudes 0.20 standard deviation units (95% CI 0.14, 0.27) and for social distance 0.17 standard deviation units (95% CI 0.11, 0.24). Survey year for 2015 vs. 2009 was associated with a higher likelihood of reported contact (OR 1.32, 95% CI 1.13, 1.53). Statistically significant interactions between year and age suggest the campaign had more impact on the attitudes of the target age group (25–45) than those aged over 65 or under 25. Women's reported contact with people with mental health problems increased more than did men's. Conclusion The results provide support for the effectiveness of TTC.

Physical activity and depression: a large cross-sectional, population-based study across 36 low- and middle-income countries.

Abstract: Objective Physical activity (PA) is good for health, yet several small-scale studies have suggested that depression is associated with low PA. A paucity of nationally representative studies investigating this relationship exists, particularly in low- and middle-income countries (LMICs). This study explored the global association of PA with depression and its mediating factors. Method Participants from 36 LMICs from the World Health Survey were included. Multivariable logistic regression analyses were undertaken exploring the relationship between PA and depression. Results Across 178 867 people (mean ± SD age = 36.2 ± 13.5 years; 49.9% male), the prevalence of depression and the prevalence of low PA were 6.6% and 16.8% respectively. The prevalence of low PA was significantly higher among those with depression vs. no depression (26.0% vs. 15.8%, P < 0.0001). In the adjusted model, depression was associated with higher odds for low PA (OR = 1.42; 95% CI = 1.24–1.63). Mediation analyses demonstrated that low PA among people with depression was explained by mobility limitations (40.3%), pain and discomfort (35.8%), disruptions in sleep and energy (25.2%), cognition (19.4%) and vision (10.9%). Conclusion Individuals with depression engage in lower levels of PA in LMICs. Future longitudinal research is warranted to better understand the relationships observed.

Qualitative analysis of mental health service users’ reported experiences of discrimination

Abstract: Objective To better understand mental health service users’ experiences of stigma and discrimination in different settings. Method An annual telephone survey of people with a mental health diagnosis conducted to evaluate the Time to Change antistigma campaign in England. Of 985 people who participated in 2013, 84 took part in a qualitative interview which was audio recorded. Of these, 50 interviews were transcribed and thematically analysed to explore accounts of discrimination. We analysed common types of behaviour; motivations ascribed to the discriminators; expectations of what fair treatment would have been; and the impact of discrimination on participants. Results Discrimination was most common in five contexts: welfare benefits, mental health care, physical health care, family and friends. Participants often found it hard to assess whether a behaviour was discriminatory or not. Lack of support, whether by public services or by friends and family, was often experienced as discrimination, reflecting an expectation that positive behaviours and reasonable adjustments should be offered in response to mental health needs. Conclusion The impact of discrimination across different settings was often perceived by participants as aggravating their mental health, and there is thus a need to treat discrimination as a health issue, not just a social justice issue.

The association between biological rhythms, depression, and functioning in bipolar disorder: a large multi-center study.

Abstract: Objective We examined the relationship between biological rhythms and severity of depressive symptoms in subjects with bipolar disorder and the effects of biological rhythms alterations on functional impairment. Method Bipolar patients (n = 260) and healthy controls (n = 191) were recruited from mood disorders programs in three sites (Spain, Brazil, and Canada). Parameters of biological rhythms were measured using the Biological Rhythms Assessment in Neuropsychiatry (BRIAN), an interviewer administered questionnaire that assesses disruptions in sleep, eating patterns, social rhythms, and general activity. Results Multivariate analyses of covariance showed significant intergroup differences after controlling for potential confounders (Pillai's F = 49.367; df = 2, P < 0.001). Depressed patients had the greatest biological rhythms disturbance, followed by patients with subsyndromal symptoms, euthymic patients, and healthy controls. Biological rhythms and HAMD scores were independent predictors of poor functioning (F = 12.841, df = 6, P < 0.001, R2 = 0.443). Conclusion Our study shows a dose-dependent association between the severity of depressive symptoms and degree of biological rhythms disturbance. Biological rhythms disturbance was also an independent predictor of functional impairment. Although the directionality of this relationship remains unknown, our results suggest that stability of biological rhythms should be an important target of acute and long-term management of bipolar disorder and may aid in the improvement of functioning.

Childhood trauma, family history, and their association with mood disorders in early adulthood

Abstract: Objective To assess the prevalence of childhood trauma and types of trauma on mood disorders among young adults in a population-based sample. We further gathered data on family history of mood disorders to test the hypothesis that childhood trauma is a mediating factor for the association between family history of mood disorder and mood disorder in adulthood. Method This is a cross-sectional study, including young adults with bipolar disorder, major depressive disorder, and matched controls without any mood disorder. Childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). The Hicks and Tingley implementation was employed to assess whether trauma is a mediator of the effect of family history on diagnosis of any mood disorder. Results All types of trauma were associated with both major depression and bipolar disorder, with the exception of sexual abuse, which was only associated with bipolar disorder. Moreover, family history of psychiatric illness was also associated with mood disorder in adulthood and with childhood trauma. Using the presence of any mood disorder as the outcome, a third of the effect of having any family history of mood disorder was mediated via childhood trauma. Conclusion This investigation provides further support, in a population-based sample of young adults, of the association between childhood trauma and mood disorders, with sexual abuse being specifically linked with bipolar disorder. The hypothesis that childhood trauma would function as a partial mediator of the association between family history of mood disorder and mood disorder in adulthood was also confirmed.

A grounded theory model for reducing stigma in health professionals in Canada

Abstract: Objective The Mental Health Commission of Canada was formed as a national catalyst for improving the mental health system. One of its initiatives is Opening Minds (OM), whose mandate is to reduce mental health-related stigma. This article reports findings from a qualitative study on antistigma interventions for healthcare providers, which includes a process model articulating key stages and strategies for implementing successful antistigma programmes. Method The study employed a grounded theory methodology. Data collection involved in-depth interviews with programme stakeholders, direct observation of programmes, a review of programme documents, and qualitative feedback from programme participants. Analysis proceeded via the constant comparison method. A model was generated to visually present key findings. Results Twenty-three in-depth interviews were conducted representing 18 different programmes. Eight programmes were observed directly, 48 programme documents were reviewed, and data from 1812 programme participants were reviewed. The analysis led to a four-stage process model for implementing successful antistigma programmes targeting healthcare providers, informed by the basic social process ‘targeting the roots of healthcare provider stigma’. Conclusion The process model developed through this research may function as a tool to help guide the development and implementation of antistigma programmes in healthcare contexts.

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review.

Abstract: Objective A recent meta-analysis showed that breast cancer probably is more common in female patients with schizophrenia than in the general population (effect size = 125, P < 005) Increasing experimental and epidemiological data have alerted researchers to the influence of prolactin (PRL) in mammary carcinogenesis We therefore investigated the possible relationship between antipsychotic-induced hyperprolactinemia (HPRL) and breast cancer risk in female patients with schizophrenia Method A literature search (1950 until January 2015), using the MEDLINE database, was conducted for English-language published clinical trials to identify and synthesize data of the current state of knowledge concerning breast cancer risk (factors) in women with schizophrenia and its (their) relationship between HPRL and antipsychotic medication Results Although an increasing body of evidence supports the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative (with risk ratios ranging from 070 to 19 for premenopausal women and from 076 to 203 for postmenopausal women) Moreover, these studies equally do not take into account the local production of PRL in breast epithelium, although amplification or overexpression of the local autocrine/paracrine PRL loop may be a more important mechanism in tumorigenesis Until now, there is also no conclusive evidence that antipsychotic medication can increase the risk of breast malignancy and mortality Conclusion Other breast risk factors than PRL, such as nulliparity, obesity, diabetes mellitus, and unhealthy lifestyle behaviours (alcohol dependence, smoking, low physical activity), probably are of greater relevance in individual breast cancer cases within the population of female patients with schizophrenia

PANSS-6: a brief rating scale for the measurement of severity in schizophrenia

Abstract: Objective The 30-item Positive and Negative Syndrome Scale (PANSS-30) is the most widely used rating scale in schizophrenia, but too long for clinical use. Shorter PANSS versions have been proposed, including the PANSS-14 and PANSS-8. However, none of these PANSS versions has been validated using the parametric Rasch rating scale model, which evaluates ‘scalability’. Scalability means that each item in a rating scale provides unique information regarding syndrome severity and is a statistical prerequisite for using the total score as a measure of overall severity. Method Based on data from two randomized placebo-controlled trials in schizophrenia, we tested the scalability of PANSS-30, PANSS-14 and PANSS-8 by means of the parametric Rasch rating scale model. Furthermore, we tested whether a scalable PANSS version could separate efficacy of haloperidol and sertindole from placebo. Results Neither PANSS-30, PANSS-14 nor PANSS-8 was scalable. However, PANSS-6, consisting of the items: P1-Delusions, P2-Conceptual disorganization, P3-Hallucinations, N1-Blunted Affect, N4-Social withdrawal, N6-Lack of spontaneity and flow of conversation, was scalable. Furthermore, PANSS-6 captured superior symptom reduction and higher remission rates during treatment with haloperidol and sertindole vs. placebo. Conclusion PANSS-6 is a short schizophrenia severity rating scale that adequately separates antipsychotic efficacy from that of placebo.

Association between depression and anemia in otherwise healthy adults.

Abstract: Objective It remains debated whether anemia is associated with depression, independently of physical health factors. We report a large-scale cross-sectional study examining this association in adults free of chronic disease and medication from the general population. Method Hemoglobin levels were measured among 44 173 healthy participants [63% men; mean [standard deviation] age = 38.4 (11.1) years] from the ‘Investigations Preventives et Cliniques’ (IPC) cohort study. Depression was measured with the Questionnaire of Depression 2nd version, Abridged. Logistic regression analyses were performed to examine the association between anemia and depression, while adjusting for a wide range of sociodemographic characteristics and health-related factors (i.e., sex, age, living status, education level, occupational status, alcohol intake, smoking status, physical activity, and body mass index). Results Depressed participants were significantly more likely to have anemia compared to non-depressed participants, even after adjustment for sociodemographic and health-related variables [odds ratio = 1.36; 95% confidence interval = (1.18; 1.57)]. Anemia prevalence increased with depression severity, suggesting a dose–response relationship (P for trend <0.001). Conclusion In healthy adults from the general population, we found a significant and robust association between depression and anemia. Further studies are needed to assess the longitudinal relationship between both conditions and determine the mechanisms underlying this association.

Brain structural changes in schizoaffective disorder compared to schizophrenia and bipolar disorder.

Abstract: Amann BL, Canales-Rodriguez EJ, Madre M, Radua J, Monte G,Alonso-Lana S, Landin-Romero R, Moreno-Alcazar A,Bonnin CM, Sarro S, Ortiz-Gil J, Gomar JJ, Moro N,Fernandez-Corcuera P, Goikolea JM, Blanch J, Salvador R, Vieta E,McKenna PJ, Pomarol-Clotet E. Brain structural changes inschizoaffective disorder compared to schizophrenia and bipolar disorder.Objective: Brain structural changes in schizoaffective disorder, and howfar they resemble those seen in schizophrenia and bipolar disorder, haveonly been studied to a limited extent.Method: Forty-five patients meeting DSM-IV and RDC criteria forschizoaffective disorder, groups of patients with 45 matchedschizophrenia and bipolar disorder, and 45 matched healthy controlswere examined using voxel-based morphometry (VBM).Results: Analyses comparing each patient group with the healthycontrol subjects found that the patients with schizoaffective disorderand the patients with schizophrenia showed widespread andoverlapping areas of significant volume reduction, but the patients withbipolar disorder did not. A subsequent analysis compared the combinedgroup of patients with the controls followed by extraction of clusters. Inregions where the patients differed significantly from the controls, nosignificant differences in mean volume between patients withschizoaffective disorder and patients with schizophrenia in any of fiveregions of volume reduction were found, but mean volumes in thepatients with bipolar disorder were significantly smaller in three of five.Conclusion: The findings provide evidence that, in terms of structuralgray matter brain abnormality, schizoaffective disorder resemblesschizophrenia more than bipolar disorder.

Changes in newspaper coverage of mental illness from 2008 to 2014 in England.

Abstract: Objective This study evaluates English newspaper coverage of mental health topics between 2008 and 2014 to provide context for the concomitant improvement in public attitudes and seek evidence for changes in coverage. Method Articles in 27 newspapers were retrieved using keyword searches on two randomly chosen days each month in 2008–2014, excluding 2012 due to restricted resources. Content analysis used a structured coding framework. Univariate logistic regression models were used to estimate the odds of each hypothesised element occurring each year compared to 2008. Results There was a substantial increase in the number of articles covering mental health between 2008 and 2014. We found an increase in the proportion of antistigmatising articles which approached significance at P < 0.05 (OR = 1.21, P = 0.056). The decrease in stigmatising articles was not statistically significant (OR = 0.90, P = 0.312). There was a significant decrease in the proportion of articles featuring the stigmatising elements ‘danger to others’ and ‘personal responsibility’, and an increase in ‘hopeless victim’. There was a significant proportionate increase in articles featuring the antistigmatising elements ‘injustice’ and ‘stigma’, but a decrease in ‘sympathetic portrayal of people with mental illness’. Conclusion We found a decrease in articles promoting ideas about dangerousness or mental illness being self-inflicted, but an increase in articles portraying people as incapable. Yet, these findings were not consistent over time.

Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem.

Abstract: Objective Improving quality of life (QoL) is an important objective in the treatment of schizophrenia. The aim of the current study was to examine to what extent resilience, self-esteem, hopelessness, and psychopathology are correlated with QoL. Method We recruited 52 out-patients diagnosed with schizophrenia according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale. The following scales were used in both patients and control subjects: the Berliner Lebensqualitatsprofil, the Resilience Scale, the Rosenberg Self-Esteem Scale, and the Beck Hopelessness Scale to assess QoL, resilience, self-esteem, and hopelessness respectively. Results Patients with schizophrenia presented with significantly less QoL, resilience, self-esteem, and hope compared to healthy control subjects. In patients, QoL correlated moderately with resilience, self-esteem, and hopelessness and weakly with symptoms. With respect to the latter, particularly depression and positive symptoms were negatively correlated with QoL. Conclusion Our results highlight the complex nature of QoL in patients suffering from schizophrenia. They underscore that significant efforts are necessary to enhance resilience and self-esteem and to diminish hopelessness as well as affective and positive symptoms in patients with schizophrenia.

Reduced heart rate variability in schizophrenia and bipolar disorder compared to healthy controls

Abstract: Objective Despite current diagnostic systems distinguishing schizophrenia (SZ) and bipolar disorder (BD) as separate diseases, emerging evidence suggests they share a number of clinical and epidemiological features, such as increased cardiovascular disease (CVD) risk. It is not well understood if poor cardiac autonomic nervous system regulation, which can be indexed non-invasively by the calculation of heart rate variability (HRV), contributes to these common CVD risk factors in both diseases. Method We calculated HRV in 47 patients with SZ, 33 patients with BD and 212 healthy controls. Measures of symptom severity were also collected from the patient groups. Results Heart rate variability was significantly reduced in both these disorders in comparison with the healthy participants; however, there were no HRV differences between disorders. Importantly, these reductions were independent of the medication, age or body mass index effects. There was also preliminary evidence that patients with reduced HRV had increased overall and negative psychosis symptom severity regardless of SZ or BD diagnosis. Conclusion We suggest that HRV may provide a possible biomarker of CVD risk and symptom severity in severe mental illness. Thus, our results highlight the importance of cardiometabolic screening across SZ and bipolar spectrum disorders.

Changes in attitudes, intended behaviour, and mental health literacy in the Swedish population 2009–2014: an evaluation of a national antistigma programme

Abstract: Objective: Public stigma of mental illness is still a major problem where numerous population studies during the last decade have mainly shown no improvements. A Swedish national antistigma campaign has been running 2010–2014. The aim of this study was to investigate changes in public stigma during this period as compared to baseline in 2009. Methods: Yearly population surveys were made between 2009 and 2014 including assessments of mental health literacy, attitudes, and intended future behaviour. Two surveys were made, one including a nationally representative sample and one including a representative sample from three original campaign regions. Multiple regression analyses, also including age, gender, education, and familiarity with mental illness were made to investigate yearly changes in public stigma compared to baseline. Results: Mental health literacy improved significantly in the campaign regions between 2009 and 2014, as did intended future behaviour. Attitudes toward mental illness also improved significantly. Improvements were also shown in the national population surveys, but the time pattern of these compared to that of the original campaign regions indicated that these changes took place mainly after the campaign had been extended to a further five Swedish regions. Conclusion: The results of our surveys suggest that a campaign primarily based on social contact theory and involving people with lived experience of mental illness may, even in a rather short-term perspective, have a significant positive impact on mental health literacy, attitudes, and intentions of social contact with people with mental illness. (Less)

Predictors of the discrepancy between objective and subjective cognition in bipolar disorder: a novel methodology.

Abstract: OBJECTIVE The poor relationship between subjective and objective cognitive impairment in bipolar disorder (BD) is well-established. However, beyond simple correlation, this has not been explored further using a methodology that quantifies the degree and direction of the discrepancy. This study aimed to develop such a methodology to explore clinical characteristics predictive of subjective-objective discrepancy in a large BD patient cohort. METHODS Data from 109 remitted BD patients and 110 healthy controls were pooled from previous studies, including neuropsychological test scores, self-reported cognitive difficulties, and ratings of mood, stress, socio-occupational capacity, and quality of life. Cognitive symptom 'sensitivity' scores were calculated using a novel methodology, with positive scores reflecting disproportionately more subjective complaints than objective impairment and negative values reflecting disproportionately more objective than subjective impairment ('stoicism'). RESULTS More subsyndromal depressive and manic symptoms, hospitalizations, BD type II, and being male positively predicted 'sensitivity', while higher verbal IQ predicted more 'stoicism'. 'Sensitive' patients were characterized by greater socio-occupational difficulties, more perceived stress, and lower quality of life. CONCLUSION Objective neuropsychological assessment seems especially warranted in patients with (residual) mood symptoms, BD type II, chronic illness, and/or high IQ for correct identification of cognitive deficits before commencement of treatments targeting cognition.

Sleep problems in bipolar disorders: more than just insomnia.

Abstract: Objective Sleep problems in bipolar disorder (BD) are common, but reported rates vary from 10% to 80%, depending on definitions, methodologies and management of potential confounding factors. This multicenter study seeks to address these issues and also compares BD cases with Hypersomnia as well as the more commonly investigated Insomnia and No Sleep Problem groups. Method A cross-sectional comparison of sleep profiles in 563 BD I and II individuals who participated in a structured assessment of demographic, clinical, illness history and treatment variables. Results Over 40% cases met criteria for Insomnia and 29% for Hypersomnia. In univariate analysis, Insomnia was associated with BD II depression whilst Hypersomnia was associated with BD I depression or euthymia. After controlling for confounders and covariates, it was demonstrated that Hypersomnia cases were significantly more likely to be younger, have BD I and be prescribed antidepressants whilst Insomnia cases had longer illness durations and were more likely to be prescribed benzodiazepines and hypnotics. Conclusion Whilst Insomnia symptoms are common in BD, Hypersomnia is a significant, frequently underexplored problem. Detailed analyses of large representative clinical samples are critical to extending our knowledge of differences between subgroups defined by sleep profile.

Is it Trauma- or Fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls

Abstract: Objective: The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences. To date, these two models have not been jointly tested in individuals with DID in an empirical manner. Method: This study included matched groups [patients (n = 33) and controls (n = 32)] that were compared on psychological Trauma and Fantasy measures: diagnosed genuine DID (DID-G, n = 17), DID-simulating healthy controls (DID-S, n = 16), individuals with post-traumatic stress disorder (PTSD, n = 16), and healthy controls (HC, n = 16). Additionally, personality-state-dependent measures were obtained for DID-G and DID-S; both neutral personality states (NPS) and trauma-related personality states (TPS) were tested. Conclusion: For Trauma measures, the DID-G group had the highest scores, with TPS higher than NPS, followed by the PTSD, DID-S, and HC groups. The DID-G group was not more fantasy-prone or suggestible and did not generate more false memories. Malingering measures were inconclusive. Evidence consistently supported the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model.

Efficacy of a Danish version of the Cool Kids program: a randomized wait-list controlled trial.

Abstract: Objective The purpose of the study was to evaluate the efficacy of a Danish version of the Cool Kids program, a generic manualized group cognitive-behavioural therapy (CBT) program for anxiety disorders among children and adolescents. Method Children and adolescents (age 7–16) with a primary anxiety disorder diagnosis (n = 109) were randomly allocated to group CBT or a wait-list (WL) control condition at a Danish university clinic. Results Results showed that the Danish version of the Cool Kids program was efficacious with 48.2% free of all anxiety diagnoses at post-treatment, compared with 5.7% in the WL condition, and large effect sizes on self-report measures of child anxiety symptoms rated by child, mother, and father (ηp2 range = 0.18–0.24). Children and adolescents improved further from post-treatment to 3-month follow-up, and this improvement was maintained at 12-month follow-up. Participants with a primary diagnosis of social phobia (SoP) showed less improvement compared with other anxiety diagnoses. Conclusion The study contributes to the evidence base for the Cool Kids program, previously only evaluated by its developers in Australia. Generic group CBT programs may not be the most appropriate treatment for children and adolescents with primary SoP.

Comparative effectiveness and safety of antipsychotic drugs in schizophrenia treatment: a real-world observational study

Abstract: Objective The objective was to compare, in a real-world setting, the risk of mental and physical health events associated with different antipsychotic drugs (clozapine, olanzapine, risperidone, quetiapine and first-generation antipsychotics) in patients with SZ. Methods This is a retrospective cohort study using administrative data. Outcome measures included any mental health event (suicide, hospitalization or emergency visit for mental disorders) and physical health event (death other than suicide, hospitalization or emergency visit for physical disorders). Cox proportional hazard models were used to estimate the hazard ratios of the events associated with the use of the different antipsychotic drugs. Results The cohort included 18 869 adult patients living in the province of Quebec (Canada) with SZ and starting antipsychotic drugs between January 1998 and December 2005. Results show that quetiapine and not using any antipsychotics were associated with an increased risk of mental and physical health events as compared to other drugs. The second finding is the confirmation of better performance of clozapine. The results were robust across sensitivity analyses. Conclusion Both findings call for an international public health and drug agencies surveillance of ‘real-world’ antipsychotic medication to ensure the optimal choices in treatment guidelines for SZ.

Abnormal functional-structural cingulum connectivity in mania: combined functional magnetic resonance imaging-diffusion tensor imaging investigation in different phases of bipolar disorder.

Abstract: Objective The objective of the study was to investigate the relationship between structural connectivity (SC) and functional connectivity (FC) in the cingulum in bipolar disorder (BD) and its various phases. Method We combined resting-state functional magnetic resonance imaging and probabilistic tractographic diffusion tensor imaging to investigate FC and SC of the cingulum and its portions, the SC–FC relationship, and their correlations with clinical and neurocognitive measures on sustained attention in manic (n = 21), depressed (n = 20), and euthymic (n = 20) bipolar patients and healthy controls (HC) (n = 42). Results First, we found decreased FC between the anterior and posterior parts of the cingulum in manic patients when compared to depressed patients and HC. Second, we observed decreased SC of the cingulum bundle, particularly in its anterior part, in manic patients when compared to HC. Finally, alterations in the cingulum FC (but not SC) correlated with clinical severity scores while changes in the cingulum SC (but not FC) were related with neurocognitive deficits in sustained attention in BD. Conclusion We demonstrate for the first time a reduction in FC and concomitantly in SC of the cingulum in mania, which correlated with psychopathological and neurocognitive parameters, respectively, in BD. This supports the central role of cingulum connectivity specifically in mania.

Course of auditory vocal hallucinations in childhood: 11-year follow-up study

Abstract: OBJECTIVE: Childhood auditory vocal hallucinations (AVH) are mostly transient but may predict clinical outcomes. Little is known about their course over time and associations with risk factors, and how this may inform early intervention. Our objective was to assess the 11-year course of AVH, associated psychopathology and risk factors. METHOD: A 5-year (T1) and 11-year (T2) follow-up of a baseline case-control sample (n = 694, of whom 347 with AVH). At T2, online assessment of AVH, other psychotic experiences, psychopathology, trauma and cannabis use was completed by 293 adolescents aged 18-19 years. RESULTS: The AVH 6-year (T1-T2) persistence rate was 18.2%, and the AVH 11-year (T0-T2) persistence rate was 6.2%. AVH at T2 were associated with higher levels of T2 other psychotic experiences, T2 psychopathology and T2 traumatic events, but not with T2 stress or T2 cannabis use. Persistence of AVH (i.e. AVH reported two or three times from T0) was associated with T2 traumatic events and higher risk for post-traumatic stress disorder. CONCLUSION: Auditory vocal hallucinations in early childhood are mostly transitory. AVH in adolescence, especially when persistent, are associated with affective symptoms and environmental risk, particularly traumatic events.

Forty years of structural imaging in psychosis: promises and truth.

Abstract: Objective Since the first study published in the Lancet in 1976, structural neuroimaging has been used in psychosis with the promise of imminent clinical utility. The actual impact of structural neuroimaging in psychosis is still unclear. Method We present here a critical review of studies involving structural magnetic resonance imaging techniques in patients with psychosis published between 1976 and 2015 in selected journals of relevance for the field. For each study, we extracted summary descriptive variables. Additionally, we qualitatively described the main structural findings of each article in summary notes and we employed a biomarker rating system based on quality of evidence (scored 1–4) and effect size (scored 1–4). Results Eighty studies meeting the inclusion criteria were retrieved. The number of studies increased over time, reflecting an increased structural imaging research in psychosis. However, quality of evidence was generally impaired by small samples and unclear biomarker definitions. In particular, there was little attempt of replication of previous findings. The effect sizes ranged from small to modest. No diagnostic or prognostic biomarker for clinical use was identified. Conclusions Structural neuroimaging in psychosis research has not yet delivered on the clinical applications that were envisioned.