Current guidelines on management of first-episode mania recommend augmenting with Valproate or other mood-stabilisers if antipsychotic proves ineffective.

To study if timing of starting mood-stabiliser augmentation would influence recovery outcomes in first-episode mania with psychosis.

To study how ‘time to start augmentation’ is related to ‘time to recovery’ and ‘hospital stay’

11 patients with first-episode mania with psychosis (FEM-P) presenting to a specialist early-intervention service in South London, part of naturalistic study of 150 cases of first-episode psychosis. Patients interviewed using the standard rating scales. Other details of treatment obtained from systematic review of case-notes covering 18 months. Operational criteria defined recovery. Correlation and regression analysis carried out to test hypotheses using SPSS-19. Set of predictor variables such as age, DUP, type of antipsychotic, substance misuse used in regression.

All 11 patients started on atypical-antipsychotic (Olanzapine 5, Risperidone 6). 9 patients required augmentation with Valproate, with a mean time of 74 days (s.d.=91) to start augmentation. The mean time to first recovery was 86 days (s.d.=39). Regression analysis with ‘time to recovery’ as dependant variable and ‘time to start augmentation’ as covariate with other predictor variables yielded significant relationship (F=9.2, t=3.1, p=0.02, CI 0.07-0.56). Also time to ‘start augmentation’ showed correlation at trend-level with ‘hospital stay’ (mean= 40, s.d.= 40.3) (Pearson correlation =0.57, p=0.09).

When there is insufficient response with antipsychotic in treatment of FEM-P, augmentation with mood-stabiliser such as Valproate without delay can shorten time to recovery and hospital stay.

Le changement d’antipsychotique (AP) chez des patients atteints de schizophrénie peut parfois augmenter leur risque de rechute [1]. Cette étude de base de données-patients en vraie vie compare le risque de rechute lors de la substitution de la rispéridone injectable à action prolongée (RIAP) par le palmitate de palipéridone injectable à action prolongée [PP] versus une substitution par AP oral.

Les rechutes (hospitalisations et consultations aux Urgences) faisant suite à une substitution de la RIAP par le PP ou par un AP oral ont été évaluées à partir des données-patients de la base de données Truven MarketScan Multi-State Medicaid. Les deux groupes ont été ensuite équilibrés 1:1 à l’aide de la méthode Propensity Score Matching (PSM) [2].

Cent quatre-vingt-huit patients ont été substitués de la RIAP par le PP et 131 patients ont été substitués de la RIAP par un AP oral. Le modèle PSM a permis d’équilibrer les deux groupes (1:1) à partir de 5 variables (âge, nombre de médicaments concomitants, nombre de consultations antérieures en ambulatoire, nombre de consultations liées à leur schizophrénie et nombre de jours sous traitement antipsychotique). La cohorte finale était composée de 109 patients substitués par du PP et 109 patients substitués par un AP oral. Les patients substitués de la RIAP par le PP par rapport à ceux substitués par un AP oral ont connu moins d’hospitalisations (26 vs 32) avec un délai avant hospitalisation plus long (moyenne = 70 vs 47 jours), sont restés plus longtemps sous traitement (moyenne = 239 vs 122 jours) et présentaient un risque plus faible de rechute (risque relatif = 0,54 ; p = 0,024).

Cette étude de base de données-patients en vraie vie suggère que la substitution de la RIAP par le PP est associée à un risque de rechute plus faible et à une poursuite du traitement plus longue en comparaison à un AP oral.

Borderline personality disorder (BPD) is associated with aberrant processing of emotional facial expressions and emotional memory which may contribute to patients’ interpersonal difficulties. However, findings are conflicting and warrant further investigation.

To clarify whether patients with BPD show deficits in facial expression recognition and self-referent incidental memory.

To examine facial expression recognition and/or in emotional categorization and recall of self-referent personality characteristics in a cohort of female patients with BPD in comparison with healthy controls.

14 patients and 11 healthy controls were given a facial expression recognition task and a self-referent emotional categorization and recall task using positive and negative personality characteristics; both tasks were from the Emotional Test Battery (P1Vital, Oxford).

BPD patients showed general impairment of facial expression recognition as reflected by increased response latency (F(1,23)=4.58, p=0.043). Examination of each emotion across different intensity levels revealed specific reduction in the sensitivity to happy expressions (F(1,23)=4.74, p=0.040). Patients also demonstrated reduced categorization accuracy for positive versus negative self-referent words (F(1,23)=5.15, p=0.033) and generally increased response latency on this task relative to controls (F(1,23)=4.46, p=0.046). This was associated with subsequent reduction in overall recall of these self-referent words in patients versus controls (F(1,23)=7.69, p=0.011).

These preliminary findings highlight deficits in facial expression recognition and emotional categorization and recall as potential biomarkers of BPD, which may contribute to patients interpersonal difficulties.

The aim of the study was to compare P50 suppression, prepulse inhibition (PPI) and antisaccade (AS) measures in first episode and chronic schizophrenia patients to assess the predictive validity and progressive changes of selected parameters.

Unmedicated first-episode (15 subjects) and chronic (15 subjects) schizophrenia patients participated in the study. The patients’ symptomatology was rated with the Positive and Negative Syndrome Scale (PANSS). Control group included 21 healthy subjects.

P50 suppression and acoustic startle prepulse inhibition (PPI) were estimated according to standard protocols (Olincy et al., 2010; Calkins et al., 2007). In AS task subjects had to look as quickly as possible at the horizontal mirror position of the peripheral target. Saccade and contingent negative variation (CNV) parameters were evaluated.

Higher PANSS scales values were found in chronic patients compared to first episode ones. Both patients’ groups displayed significantly reduced P50 suppression (p<0,001) and prepulse inhibition deficit at 60 ms lead interval (p<0,05) compared to controls. Patients of both groups exhibited increase in the correct AS latency and larger number of errors in AS task compared to controls (p<0,05). The pronounced decline of CNV amplitude in frontal regions was found in chronic patients only (Group x Area interaction, p<0,05).

Results of the study corroborate the evidences of P50, PPI and AS measures predicting validity. The CNV analysis revealed pronounced prefrontal cortex dysfunction in chronic patients only. These data are compatible with the hypothesis of progressive brain changes in schizophrenia.

Évaluer la tolérance, la sécurité d’emploi et la réponse à un traitement par le palmitate de palipéridone (PP) administré en doses mensuelles flexibles dans un sous-groupe de patients adultes atteints de schizophrénie, non-aigus mais symptomatiques, après échec d’un traitement par aripiprazole oral.

Étude internationale multicentrique, ouverte, prospective de 6 mois.

Changement du score total de PANSS, de CGI-S et CGI-C, du fonctionnement personnel et social (Personal and Social Performance Scale [PSP]), des symptômes extrapyramidaux (Extrapyramidal Symptom Rating Scale [ESRS]) et événements indésirables (EIs).

Quarante-six patients (73,9 % d’hommes, âge moyen 34,4 ± 9,4 ans, 78,3 % souffrant de schizophrénie paranoïde) ont été étudiés. La principale raison de la substitution d’aripiprazole oral (dose moyenne de 22,7 ± 10,7 mg/jour) par le PP était « le choix du patient » (39,1 %) ; 67,4 % des patients ont terminé l’étude à 6 mois. Le score total moyen de PANSS a diminué de 74,7 ± 14,9 à l’inclusion à 62,6 ± 16,5 lors de la dernière observation (soit une variation moyenne de −12,2 ± 16,7 points ; IC 95 % [−17,1 ; −7,2] ; p < 0,0001). Chez 52,2 % des patients, l’amélioration du score total de PANSS a été ≥ 20 % ; le pourcentage de patients considérés légèrement malades ou moins selon les critères de la CGI-S est passé de 23,9 % à 56,5 %. Au total, 75,5 % des patients ont été jugés améliorés à la CGI-C par rapport au traitement antérieur par aripiprazole. Le score de l’échelle de fonctionnement PSP s’est amélioré de 58,9 ± 13,4 à 62,9 ± 15,2 (p = 0,041). Les EIs touchant ≥ 5 % des patients étaient : anxiété (n = 6), douleur au site d’injection, bronchite, insomnie, akathisie (n = 4 chacun) et augmentation du poids, dépression et douleur aux extrémités (n = 3 chacun). Les symptômes extrapyramidaux selon ESRS se sont améliorés de façon significative depuis l’inclusion jusqu’à 6 mois chez les patients ayant terminé l’étude (−1,4 ± 2,7 ; p < 0,006).

L’utilisation de doses flexibles de PP a permis une amélioration symptomatologique et fonctionnelle cliniquement significative chez des patients atteints de schizophrénie, non-aigus et en échec de traitement par aripiprazole oral. Le PP a été bien toléré avec une diminution des symptômes extrapyramidaux.

Un échec de traitement peut entraîner diverses conséquences à la fois pour le patient souffrant de schizophrénie mais aussi en terme de santé publique (arrêt du traitement, hospitalisation, addiction, arrestation/incarcération) [1–3]. Cette étude a comparé en vraie vie, les délais avant échec au traitement des patients souffrant de schizophrénie ayant des antécédents d’incarcération, traités soit par palmitate de paliperidone (PP) ou par des antipsychotiques oraux (APO).

Paliperidone Research In Demonstrating Effectiveness (PRIDE) est une étude en ouvert, prospective, randomisée, d’une durée de 15 mois, comparant le PP une fois par mois aux APO chez des sujets atteints de schizophrénie, avec des antécédents d’incarcération (NCT01157351). Les sujets ont été randomisés (1:1) en deux groupes :

– PP à doses flexibles (78–234 mg) administrées une fois par mois ou à ;

– l’un des 7 APO couramment prescrits par l’investigateur.

Le critère de jugement principal était le délai avant échec du traitement (défini comme arrestation/incarcération, hospitalisation, suicide, arrêt du traitement ou supplémentation par manque d’efficacité ou mauvaise tolérance et/ou besoin d’intensifier les soins psychiatriques) évalué par la méthode de Kaplan-Meier.

Un total de 450 sujets ont été inclus (sexe masculin = 86,3 %). Le délai avant échec du traitement était significativement plus long avec le PP par rapport aux APO (médiane = 416 vs 226 jours avant arrêt du traitement ou supplémentation ; Rapport de risque [IC95 %] = 1,43 [1,09, 1,88] ; p = 0,011). Les taux d’échecs du traitement étaient de 39,8 % avec le PP et de 53,7 % avec les APO. Des résultats similaires ont été observés pour le délai avant hospitalisation ou arrestation/incarcération (médiane ≥ 450 vs 274 jours ; rapport de risque [IC95 %] = 1,43 [1,06, 1,93] ; p = 0,019). Les événements indésirables les plus fréquents (PP vs APO, ≥ 10 %) étaient : douleur au site d’injection (18,6 % vs 0 %) ; insomnie (16,8 % vs 11,5 %) ; prise de poids (11,9 % vs 6,0 %) ; akathisie (11,1 % vs 6,9 %) ; anxiété (10,6 % vs 7,3 %).

Le traitement mensuel par PP injectable retarde significativement le délai de survenue d’un large éventail de conséquences négatives de la schizophrénie en vie réelle.

The classification of psychiatric illnesses was essentially based on stage theory, the idea that a given illness progressed from stage to stage. This was in contrast to the Kraepelinian scheme of classifying illnesses – with the exception of manic-depressive illness – on the basis of current phenomenology. According to the previous stage theories such as Zeller, Magnan and Griesinger, a major illness would typically begin with a mood picture (mania or melancholia), transition into psychosis (Verrücktheit, délire), then transition again in dementia. This illness course tended to be life-long, the order of the stages invariant (rarely was psychosis seen as the primary disorder, or did dementia yield to yet another stage). These concepts would be innovative in terms of the DSM system, which recognizes stage theory only in bipolar disorder.

To clarify the nature of linear illness pictures (‘stage theory’) in a psychiatric presentation.

To revive a traditional psychiatric concept of the linear illness entity (‘stage theory’) in the interest of improved diagnosis and treatment

An analysis of the large past psychiatric literature in French, German, Italian, and English

The illness courses of many past patients do seem to have unfolded in stages.

Stage theory stemmed from senior clinicians of vast experience, whose ideas were are not entitled patronizingly to dismiss. The DSM system is now under assault and it may be time to reassess the usefulness of stage theory.

Suicide is a leading cause of death and suffering worldwide, mental disorder being a major risk factor for it. Recent data suggest that the underlying temperament may be more important as a risk factor than the exact psychiatric diagnosis.

A cross-sectional non-interventional study of 79 patients with DSM-IV major depressive episode (58 females, 21 males; aged 19–66 years), evaluated by M.I.N.I. Their temperament was assessed through the self-rated TEMPS-A. Patients were distributed into four groups: 1) fMDE - first major depressive episode (n=16); 2) RMD - recurrent major depression: at least 5 years duration of illness, no previous (hypo)manic/mixed episodes, and no first-degree relatives with bipolar disorder (n=23); 3) BDI - MDE with at least one previous manic episode (n=19); 4) BDII – two or more MDE with at least one previous hypomanic episode (n=21).

No significant intergroup differences in the level of suicidal risk measured by the M.I.N.I. No gender difference in the M.I.N.I. risk for suicide, however, female gender was associated with a higher number of previous suicide attempts (p=0.001). The fMDE group had higher mean score for hyperthymic temperament, and the RMD group had higher mean score for anxious temperament. After controlling for the diagnosis and gender, a significant positive correlation was found between level of suicidal risk and mean score for depressive, cyclothymic, and irritable temperament (p<0.05), while the correlation was negative for hyperthymic temperament (p=0.001).

We suggest that hyperthymic temperament is a protective factor against suicide in patients with affective disorders.

A series of meta-analyses points to the benefits of different psychotherapy approaches in the treatment of persons with schizophrenia such as psycho-educational family interventions or cognitive behaviour therapy for psychosis. However, the advantages of these specific psychotherapeutic interventions as compared to non-specific supportive interventions are moderate. This challenges the validity of the presumed specific therapeutic ingredients.

To analyse the significance of specific therapeutic ingredients of evidence-based psychotherapy approaches for schizophrenia all efficacy studies with component control designs were identified by systematic electronic searches. Subsequently, moderator analyses of the standardized weighted effect sizes differences between psychotherapy approaches with different therapeutic components were performed. The effect size differences were integrated by transforming them into weighted mean point-biserial correlations between single therapeutic components and outcome variables. Furthermore, studies relating common factors such as therapeutic alliance or self-efficacy expectations of patients with outcome were searched, and weighted mean Pearson's correlations between common factors and outcome variables were calculated.

The findings indicate that specific therapeutic components such as psycho-education, cognitive restructuring or skills training represent key therapeutic ingredients of evidence-based psychotherapy for schizophrenia. However, also common factors such as positive therapeutic relationship, changing expectations for self-efficacy or successful mastery efforts are associated with positive outcomes.

There is an urgent need to dismantle the actual therapeutically active components in order to promote the targeted, personalized and, thereby, efficient implementation of evidence-based psychotherapy approaches for persons with schizophrenia in routine care.

Schizophrenia is an aetiologically complex disorder associated with significant familial risk. It is marked also by reductions in whole brain, grey and possibly white matter volumes. How these pathological abnormalities are influenced by schizophrenia's genetic and environmental risk remains uncertain.

We investigated the relationship between familial and environmental risk on brain volume in twin pairs varying in their zygosity and concordance for schizophrenia, and healthy control twins, using a variety of complementary imaging strategies. These included region of interest and automated tissue segmentation volumes and voxel based morphometry.

We found that whole brain, grey, white, frontal and right hippocampal volumes were smaller in probands with schizophrenia compared to healthy controls. Well co-twins from MZ discordant pairs showed a trend towards lower white matter volume compared to the healthy controls. Well co-twins from DZ discordant pairs had smaller hippocampal volumes compared to the healthy controls. The patients with schizophrenia and their well co-twins from MZ discordant pairs differed in the superior frontal cortex using both region of interest and VBM techniques. Lower birth weight and hypoxia were both associated with lower whole brain volumes, and with lower white and grey matter volumes respectively.

Our data suggest that total brain and grey matter volume reductions in schizophrenia, possibly focused in part in the frontal cortex, are related primarily to unique environmental factors, including perinatal complications. The white matter and local hippocampal volume reductions suggest an additional vulnerability to genetic risk effects.

As the part of mental health reform in whole Bosnia and Herzegovina (BH) main attention has been given to rehabilitation of people with severe mental diseases. One of important ways to improve better outcomes for those patients is model of case management.

Whole CMHC team in Health Center Prijedor is educated for certificated case managers in period 2012 - 2013. During the well organized training provided by the Mental Health Project in BH we included two young persons with psychosis in case management together with their families.

To show overall improvement in patients who are involved in case management in our CMHC.

Three months follow up of the Plan of Care and Treatment made by case managers and two patients with psychosis in CMHC Prijedor (1 male and 1 female) using the following instruments: BPRS, AVON-My view, HoNOS, SQLS, Overall Risk Assessment, Specific Risk Assessment. Also, home visits by case manager and regular visits in CMHC were included.

The tree months follow up shows improvement in reduction of symptoms, higher self confidence and self esteem, lower self neglect (as the risk which was found in both patients. In last six months both patients had any crisis or hospitalization. It is established better relation with family and case managers. One patient found temporary job and both patients involved in local user organization.

Case management has proven to be efficient in daily practice as the best way of connection between patients, case managers, other professionals, family and community in general.