Psychiatric and neurological symptoms in schizophrenia and substance use disorder patients treated for 12-weeks with quetiapine

Contexte Autant dans une population schizophrène que non schizophrène, l‘abus de substance a pour conséquence la manifestation de symptômes psychiatriques et neurologiques. Dans les présentes études cas-témoins, nous avons examiné les différences initiales ainsi que les changements suite au traitement de 12 semaines à la quetiapine au niveau de la sévérité de la toxicomanie et des symptômes psychiatriques et neurologiques chez 3 groupes distincts. Ces 3 groupes sont: des patients schizophrènes avec une toxicomanie (double diagnostic: DD), des patients schizophrènes sans toxicomanie concomittante (SCZ) et finalement, des toxicomanes non schizophrènes (SUD). Parallèlement, afin de nous aider à interpréter nos résultats, nous avons mené deux revues systématiques: la première regardait l‘effet d‘antipsychotiques dans le traitement de troubles d‘abus/dépendance chez des personnes atteintes ou non de psychoses, la deuxième comparait l‘efficacité de la quetiapine et sa relation dose-réponse parmi différents désordres psychiatriques. Méthodes Pour nos études cas-témoins, l‘ensemble des symptômes psychiatriques et neurologiques ont été évalués via l‘Échelle du syndrome positif et négatif (PANSS), l‘Échelle de dépression de Calgary, l‘Échelle des symptômes extrapyramidaux (ESRS) ainsi qu‘avec l‘Échelle d‘akathisie de Barnes. Résultats À la suite du traitement de 12 semaines avec la quetiapine, les groupes SCZ et DD recevaient des doses de quetiapine significativement plus élevées (moyenne = 554 et 478 mg par jour, respectivement) par rapport au groupe SUD (moyenne = 150 mg par jour). Aussi, nous avons observé chez ces mêmes patients SUD une plus importante baisse du montant d‘argent dépensé par semaine en alcool et autres drogues, ainsi qu‘une nette amélioration de la sévérité de la toxicomanie comparativement aux patients DD. Par conséquent, à la fin de l‘essai de 12 semaines, il n‘y avait pas de différence significative dans l‘argent dépensé en alcool et drogues entre les deux groupes de toxicomanes iv or, les patients DD présentait, comme au point de départ, un score de toxicomanie plus sévère que les SUD. Étonnamment, aux points initial et final de l‘étude, le groupe DD souffrait de plus de symptômes parkinsoniens et de dépression que le groupe SCZ. Par ailleurs, nous avons trouvé qu‘initiallement, les patients SUD présentaient significativement plus d‘akathisie, mais qu‘en cours de traitement, cette akathisie reliée à l‘abus/dépendance de cannabis s‘est nettement améliorée en comparaison aux patients SCZ. Enfin, les patients SUD ont bénéficié d‘une plus grande diminution de leurs symptômes positifs que les 2 groupes atteints de schizophrénie. Conclusions Bref, l‘ensemble de nos résultats fait montre d‘une vulnérabilité accentuée par les effets négatifs de l‘alcool et autres drogues dans une population de patients schizophrènes. Également, ces résultats suggèrent que l‘abus de substance en combinaison avec les états de manque miment certains symptômes retrouvés en schizophrénie. De futures études seront nécessaires afin de déterminer le rôle spécifique qu‘a joué la quetiapine dans ces améliorations.

ESPECTRA: Searching the Bipolar Spectrum in Eating Disorder patients

Background: Bipolar Disorder (BD) is a chronic, recurrent and highly prevalent illness. Despite the need for correct diagnosis to allow proper treatment, studies have shown that reaching a diagnosis can take up to ten years due to the lack of recognition of the broader presentations of BD. Frequent comorbidities with other psychiatric disorders are a major cause of misdiagnosis and warrant thorough evaluation. Methods/Design: ESPECTRA (Occurrence of Bipolar Spectrum Disorders in Eating Disorder Patients) is a single-site cross-sectional study involving a comparison group, designed to evaluate the prevalence of bipolar spectrum in an eating disorder sample. Women aged 18-45 years will be evaluated using the SCID-P and Zurich criteria for diagnosis and the HAM-D, YOUNG, SCI-MOODS, HCL-32, BIS-11, BSQ, WHOQoL and EAS instruments for rating symptoms and measuring clinical correlates. Discussion: The classificatory systems in psychiatry are based on categorical models that have been criticized for simplifying the diagnosis and leading to an increase in comorbidities. Some dimensional approaches have been proposed aimed at improving the validity and reliability of psychiatric disorder assessments, especially in conditions with high rates of comorbidity such as BD and Eating Disorder (ED). The Bipolar Spectrum (BS) remains under-recognized in clinical practice and its definition is not well established in current diagnostic guidelines. Broader evaluation of psychiatric disorders combining categorical and dimensional views could contribute to a more realistic understanding of comorbidities and help toward establishing a prognosis.

Depression in Parkinson`s disease: Convergence from voxel-based morphometry and functional magnetic resonance imaging in the limbic thalamus

Depression is the most frequent psychiatric disorder in Parkinson`s disease (PD). Although evidence Suggests that depression in PD is related to the degenerative process that underlies the disease, further studies are necessary to better understand the neural basis of depression in this population of patients. In order to investigate neuronal alterations underlying the depression in PD, we studied thirty-six patients with idiopathic PD. Twenty of these patients had the diagnosis of major depression disorder and sixteen did not. The two groups were matched for PD motor severity according to Unified Parkinson Disease Rating Scale (UPDRS). First we conducted a functional magnetic resonance imaging (fMRI) using an event-related parametric emotional perception paradigm with test retest design. Our results showed decreased activation in the left mediodorsal (MD) thalamus and in medial prefrontall cortex in PD patients with depression compared to those without depression. Based upon these results and the increased neuron count in MD thalamus found in previous studies, we conducted a region of interest (ROI) guided voxel-based morphometry (VBM) study comparing the thalamic volume. Our results showed an increased volume in mediodorsal thalamic nuclei bilaterally. Converging morphological changes and functional emotional processing in mediodorsal thalamus highlight the importance of limbic thalamus in PD depression. In addition this data supports the link between neurodegenerative alterations and mood regulation. (C) 2009 Elsevier Inc. All rights reserved.

Lower N-Acetyl-Aspartate Levels in Prefrontal Cortices in Pediatric Bipolar Disorder: A (1)H Magnetic Resonance Spectroscopy Study

Objective: The few studies applying single-voxel(1)H spectroscopy in children and adolescents with bipolar disorder (BD) have reported low N-acetyl-aspartate (NAA) levels in the dorsolateral prefrontal cortex (DLPFC), and high myo-inositol / phosphocreatine plus creatine (PCr+Cr) ratios in the anterior cingulate. The aim of this study was to evaluate NAA, glycerophosphocholine plus phosphocholine (GPC+PC) and PCr+Cr in various frontal cortical areas in children and adolescents with BD. We hypothesized that NAA levels within the prefrontal cortex are lower in BD patients than in healthy controls, indicating neurodevelopmental alterations in the former. Method: We studied 43 pediatric patients with DSM-IV BD (19 female, mean age 13.2 +/- 2.9 years) and 38 healthy controls (79 female, mean age 13.9 +/- 2.7 years). We conducted multivoxel in vivo (1)H spectroscopy measurements at 1.5 Tesla using a long echo time of 272 ms to obtain bilateral metabolite levels from the medial prefrontal cortex (MPFC), DLPFC (white and gray matter), cingulate (anterior and posterior), and occipital lobes. We used the nonparametric Mann-Whitney U test to compare neurochemical levels between groups. Results: In pediatric BD patients, NAA and GPC+PC levels in the bilateral MPFC, and PCr+Cr levels in the left MPFC were lower than those seen in the controls. In the left DLPFC white matter, levels of NAA and PCr+Cr were also lower in BD patients than in controls. Conclusions: Lower NAA and PCr+Cr levels in the PFC of children and adolescents with BD may be indicative of abnormal dendritic arborization and neuropil, suggesting neurodevelopmental abnormalities. J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(1):85-94.

Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative

Context: There is limited information on the prevalence and correlates of bipolar spectrum disorder in international population-based studies using common methods. Objectives: To describe the prevalence, impact, patterns of comorbidity, and patterns of service utilization for bipolar spectrum disorder (BPS) in the World Health Organization World Mental Health Survey Initiative. Design, Setting, and Participants: Crosssectional, face-to-face, household surveys of 61 392 community adults in 11 countries in the Americas, Europe, and Asia assessed with the World Mental Health version of the World Health Organization Composite International Diagnostic Interview, version 3.0, a fully structured, lay-administered psychiatric diagnostic interview. Main Outcome Measures: Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) disorders, severity, and treatment. Results: The aggregate lifetime prevalences were 0.6% for bipolar type I disorder (BP-I), 0.4% for BP-II, 1.4% for subthreshold BP, and 2.4% for BPS. Twelve-month prevalences were 0.4% for BP-I, 0.3% for BP-II, 0.8% for subthreshold BP, and 1.5% for BPS. Severity of both manic and depressive symptoms as well as suicidal behavior increased monotonically from subthreshold BP to BP-I. By contrast, role impairment was similar across BP subtypes. Symptom severity was greater for depressive episodes than manic episodes, with approximately 74.0% of respondents with depression and 50.9% of respondents with mania reporting severe role impairment. Three-quarters of those with BPS met criteria for at least 1 other disorder, with anxiety disorders (particularly panic attacks) being the most common comorbid condition. Less than half of those with lifetime BPS received mental health treatment, particularly in low-income countries, where only 25.2% reported contact with the mental health system. Conclusions: Despite cross-site variation in the prevalence rates of BPS, the severity, impact, and patterns of comorbidity were remarkably similar internationally. The uniform increases in clinical correlates, suicidal behavior, and comorbidity across each diagnostic category provide evidence for the validity of the concept of BPS. Treatment needs for BPS are often unmet, particularly in low-income countries.

A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: The relevance of the placebo effect and psychological symptoms

Background: Little is known about the treatment of depression in older patients with heart failure. This Study was developed to investigate the effectiveness of antidepressant treatment for major depressive disorder (MDD) in the elderly with heart failure. Methods: We enrolled 72 older outpatients with ejection fraction < 50 and diagnosed with MDD by the structured clinical interview for DSM-IV. Thirty-seven patients, 19 on citalopram and 18 on placebo, initiated an 8-week double-blind treatment phase. Measurements were performed with the 31-item Hamilton Rating Scale for Depression (Ham-D-31), the Montgomery-Asberg rating scale (MADRS) and the Systematic Assessment for Treatment Emergent Effects (SAFTEE). A psychiatrist followed up the patients weekly, performing a consultation for about 20 min to field complaints after the measurements. Results: A trend toward superiority of citalopram over placebo in reducing depression was observed in MADRS scores (15.05 + 9.74 vs 9.44 + 9.25, P = .082) but not on HAM-D scores. The depressive symptomatology significantly decreased in both groups (P < .001). The high rate of placebo response during the double-blind phase (56.3%) led us to conclude the study at the interim analysis with 37 patients. Conclusion: Citalopram treatment of MDD in older patients with heart failure is well-tolerated with low rates of side effects, but was not significantly more effective than placebo in the treatment of depression. Weekly psychiatric follow-up including counseling may contribute to the improvement of depression in this population. Scales weighted on psychological symptoms such as the MADRS are possibly better suited to measure depression severity and improvement in patients with heart failure. (C) 2009 Elsevier Inc. All rights reserved.

Study of the psychometric qualities of the Brief Social Phobia Scale (BSPS) in Brazilian university students

Purpose: To perform a psychometric analysis of the Brazilian version of the Brief Social Phobia Scale (BSPS). Materials and methods: Hundred and seventy-eight university students of both genders aged on average 21.2 years and identified as Social Anxiety Disorder (SAD) cases and non-cases was studied, with the structured clinical interview for DSM-IV being used as a parameter. The different instruments were applied in an individual manner in the presence of a rater and of an observer. Results: The BSPS showed adequate internal consistency (0.48-0.88) and concurrent and divergent validity with the Beck Anxiety Inventory (BAI) (0.21-0.62), Social Phobia Inventory (0.24-0.82) and Self Statements During Public Speaking Scale (SSPS) (0.23-0.31). Discriminative validity revealed a sensitivity of 0.88-0.90 and a specificity of 0.81(0.83 for cut-off notes of 18/19. Factorial analysis demonstrated the presence of six factors that jointly explained 71.79% of data variance. Construct validity indicated some limits of the scale regarding the diagnosis of SAD. Inter-rater reliability was strong (0.86-1.00, p < 0.001). Conclusions: The BSPS is adequate for use with university students, although further studies in different cultures, samples and contexts are still necessary. (C) 2009 Elsevier Masson SAS. All rights reserved.

Sobrecarga vivenciada por familiares cuidadores de pacientes esquizofrénicos e sua relação com a depressão

RESUMO: A partir da desinstitucionalização psiquiátrica, a ênfase nas políticas públicas de saúde mental passou para os serviços comunitários e para períodos mais curtos de hospitalização. As famílias, então, tornaram-se as principais provedoras de cuidados cotidianos e de apoio aos pacientes. As dificuldades e o despreparo em assumir este novo papel têm gerado um sentimento de sobrecarga nos familiares, o que pode afetar sua saúde física e mental. Vários estudos investigaram as consequências de se tornar um cuidador de um paciente psiquiátrico, mas poucos pesquisaram o impacto na saúde mental desses cuidadores. A presente pesquisa investigou a relação entre a sobrecarga e a saúde mental dos familiares cuidadores de pacientes psiquiátricos. Participaram deste estudo 74 familiares cuidadores de pacientes com diagnóstico de esquizofrenia, atendidos no ambulatório do Serviço de Referência em Saúde Mental, da cidade de Divinópolis, MG. Os familiares participaram de uma entrevista estruturada. Nela foram aplicadas a Escala de Avaliação da Sobrecarga dos Familiares de Pacientes Psiquiátricos (FBIS-BR) e, para avaliar a saúde mental dos cuidadores, a Escala de Depressão de Beck (BDI). Foram realizadas análises estatísticas descritivas, univariadas e multivariadas. Os resultados mostraram que a maioria dos cuidadores era do sexo feminino (78,40%), pais (62,20%) e com idade média de 59,14 anos. Os cuidadores apresentaram uma média de sobrecarga global objetiva de 2,05 (DP ± 0,54), em uma escala de 1 a 5 pontos, e uma média de sobrecarga global subjetiva de 2,44 (DP ± 0,71), em uma escala de 1 a 4 pontos. Os resultados da escala BDI mostraram que 42 cuidadores poderiam ser classificados com depressão mínima (56,80%), 17 com depressão leve (23,00%), 7 com depressão moderada (9,50%) e 8 com depressão grave (10,80%). Foram encontradas correlações positivas significativas entre o grau de sobrecarga global e das subescalas e o nível de depressão. As análises multivariadas mostraram que o principal preditor de depressão dos cuidadores foi a sobrecarga global subjetiva. Outros preditores foram a obrecarga objetiva das rotinas diárias e da supervisão dos comportamentos problemáticos dos pacientes e a sobrecarga subjetiva das preocupações com o paciente. As informações levantadas mostraram o impacto do papel de cuidador na saúde mental dos familiares e apontaram para a necessidade de uma maior atenção, por parte dos gestores e profissionais da área, aos cuidadores de pacientes psiquiátricos.----------ABSTRACT: The emphasis in public policy on mental health was transferred to community services and for shorter periods of hospitalization from the psychiatric deinstitutionalization. Then the families become the first provider of daily care and support to patients. The difficulties and unprepared to assume this new role has generated a sense of overload in the relatives, which can affect your physical and mental health. Several studies have investigated the consequences of becoming a caregiver of a psychiatric patient, but few scholars have researched the impact on the mental health of caregivers. The present study has investigated the relationship between overload and mental health of family caregivers of psychiatric patients. The study included 74 family caregivers of patients with schizophrenia and outpatient clinic of the Department of Mental Health Reference, in Divinópolis, Minas Gerais, Brazil. The Rating Scale Burden of Relatives of Psychiatric Patients and the scale of Beck Depression Inventory (BDI) to assess the mental health of caregivers were applied in the interview. Descriptive statistics and univariate and multivariate analysis have performed. The results showed that the majority of caregivers were female (78.40%), parents (62.20%) and mean age of 59.14 years. The caregivers had an average burden overall objective of 2.05 (± 0.54) on a scale of 1 to 5 points, and a subjective global average burden of 2.44 (± 0.71) in a scale of 1 to 4 points. The results of the BDI showed that 42 caregivers could be classified with minimal depression (56.80%), 17 with mild depression (23.00%), 7 with moderate depression (9.50%) and 8 with severe depression (10 80%). Significant positive correlations were found between the degree of overloading and global subscales and depression levels. Multivariate analysis showed that the main predictor of caregivers' depression was the global subjective burden. Other predictors were the objective burden of daily routines and supervision of problem behaviors of patients and subjective burden of the concerns about patient. The resulting information showed the impact of caregiver role in the mental health of relatives and pointed to the need for higher attention of managers and professionals to caregivers of psychiatric patients.

Psicopatologia obsessivo-compulsiva na distonia focal primária : aspectos neuropsiquiátricos de uma doença do movimento

RESUMO: pela contracção involuntária de grupos musculares de extensão variável, originando movimentos involuntários e posturas anómalas, por vezes dolorosas. O tratamento convencional consiste em injecções localizadas de toxina botulínica, podendo, em casos refractários, estar indicado o tratamento por estimulação cerebral profunda. A neurobiologia da distonia focal primária permanece incompletamente compreendida. Os estudos de neuro-imagem estrutural e funcional revelam alterações subtis da anatomia e funcionamento do estriado e das vias cortico-basais, com destaque para o aumento do volume, da actividade metabólica e da neuroplasticidade do putamen e de áreas corticais motoras, pré-motoras e sensitivas. O conjunto destas alterações aponta para uma disrupção da regulação inibitória de programas motores automáticos sustentados pelo estriado e pelas vias ortico-subcorticais. Nos últimos anos tem crescido o interesse pelas manifestações psiquiátricas e cognitivas da distonia (estas últimas muito pouco estudadas). Tem despertado particular interesse a possível associação entre distonia focal primária e perturbação obsessivo-compulsiva (POC), cuja neurobiologia parece notavelmente sobreponível à da distonia primária. Com efeito, os estudos de neuro-imagem estrutural e funcional na POC revelam consistentemente aumento do volume e actividade do estriado e do córtex órbito-frontal, apontando mais uma vez para uma disfunção do controlo inibitório, no estriado, de programas comportamentais e cognitivos automáticos. Objectivos: 1. Explorar a prevalência e intensidade de psicopatologia em geral, e de psicopatologia obsessivo-compulsiva em particular, numa amostra de indivíduos com distonia focal primária; 2. Explorar a ocorrência, natureza e intensidade de alterações do funcionamento cognitivo numa amostra de indivíduos com distonia focal primária; 3. Investigar a associação entre a gravidade da distonia focal, a intensidade da psicopatologia, e a intensidade das alterações cognitivas. Metodologia: Estudo de tipo transversal, caso-controlo, observacional e descritivo, com objectivos puramente exploratórios. Casos: 45 indivíduos com distonia focal primária (15 casos de blefaroespasmo, 15 de cãibra do escrivão, 15 de distonia cervical espasmódica), recrutados através da Associação Portuguesa de Distonia. Critérios de inclusão: idade = 18; distonia focal primária pura (excluindo casos de distonia psicogénica possível ou provável de acordo com os critérios de Fahn e Williams); Metabolismo do cobre e Ressonância Magnética Nuclear sem alterações. Controlos doentes: 46 casos consecutivos recrutados a partir da consulta externa do Hospital Egas Moniz: 15 doentes com espasmo hemifacial, 14 com espondilartropatia cervical, 17 com síndrome do canal cárpico. Controlos saudáveis: 30 voluntários. Critérios de exclusão para todos os grupos: Mini-Mental State Examination patológico, tratamento actual com anti-colinérgicos, antipsicóticos, inibidores selectivos da recaptação da serotonina, antidepressivos tri- ou tetracíclicos. Avaliação: Avaliação neurológica: história e exame médico e neurológico completos. Cotação da gravidade da distonia com a Unified Dystonia Rating Scale. Avaliação psicopatológica: Symptom Check-List-90-Revised; entrevista psiquiátrica de 60 minutos incluindo a Mini-International Neuropsychiatric Interview (MINI), versão 4.4 (validada em Português), complementada com os módulos da MINI Plus versão 5.0.0 para depressão ao longo da vida e dependência/ abuso do álcool e outras substâncias ao longo da vida; Yale-Brown Obsessive-Compulsive Symptom Checklist e a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Avaliação neuropsicológica: Wisconsin Card Sorting Test (WCST; flexibilidade cognitiva); Teste de Stroop (inibição de resposta); Block Assembly Test (capacidade visuo-construtiva); Teste de Retenção Visual de Benton (memória de trabalho visuo-espacial). Análise estatística:os dados foram analisados com a aplicação informática SPSS for Windows, versão 13. Para a comparação de proporções utilizaram-se o teste do Chi-quadrado e o teste de Fisher. Para a comparação de variáveis quantitativas entre dois grupos utilizou-se o teste t de Student ou o teste U de Mann-Whitney (teste de Wilcoxon no caso de amostras emparelhadas). Para comparações de médias entre três grupos recorreu-se à Análise de Variância a um factor (variáveis de intervalo e de rácio), ou ao teste de Kruskal-Wallis (variáveis ordinais). Para o estudo da associação entre variáveis foram utilizados os coeficientes de correlação de Pearson ou de Spearman, a análise de correlações canónicas, a análise de trajectórias e a regressão logística. Adoptou-se um Alpha de 0.05. Resultados: Os doentes com distonia focal primária apresentaram uma pontuação média na Y- -BOCS significativamente superior à dos dois grupos de controlo. Em 24.4% dos doentes com distonia a pontuação na Y-BOCS foi superior a 16. Estes doentes eram predominantemente mulheres, tinham uma maior duração média da doença e referiam predominantemente sintomas obsessivo-compulsivos (SOC) de contaminação e lavagem. Os dois grupos com doença crónica apresentaram pontuações médias superiores às dos indivíduos saudáveis nas escalas de ansiedade, somatização e psicopatologia geral. Os doentes com distonia tratados com toxina botulínica apresentaram pontuações inferiores às dos doentes não tratados nas escalas de ansiedade generalizada, fobia, somatização e depressão, mas não na Y-BOCS. Sessenta por cento dos doentes com distonia apresentavam pelo menos um diagnóstico psiquiátrico actual ou pregresso. O risco de apresentar um diagnóstico psiquiátrico actual era menor nos doentes tratados com toxina botulínica, aumentando com a gravidade da doença. A prevalência de POC foi 8,3% e a de depressão major 37,7%. No WCST e na Prova de Benton, os doentes com distonia focal primária demonstraram um desempenho inferior ao de ambos os grupos de controlo, cometendo sobretudo erros perseverativos. Os doentes com distonia e pontuação na Y-BOCS > 16 cometeram mais erros e respostas perseverativas no WCST do que os restantes doentes com distonia. As análises de correlações e de trajectórias revelaram que nos doentes com distonia a gravidade da distonia foi, juntamente com a idade e a escolaridade, o factor que mais interagiu com o desempenho cognitivo. Discussão: o nosso estudo é o primeiro a descrever, nos mesmos doentes com distonia focal primária, SOC significativos e alterações cognitivas. Os nossos resultados confirmam a hipótese de uma associação clínica específica entre distonia focal primária e psicopatologia obsessivo-compulsiva. Confirmam igualmente que a distonia focal primária está associada a um maior risco de desenvolver morbilidade psiquiátrica ansiosa e depressiva. O tratamento com toxina botulínica reduz este risco, mas não influencia os SOC. Entre os doentes com distonia, os que têm SOC significativos poderão diconstituir um grupo particular com maior duração da doença (mas não uma maior gravidade), predomínio do sexo feminino e predomínio de SOC de contaminação e limpeza. Em termos cognitivos, os indivíduos com distonia focal primária apresentam défices significativos de flexibilidade cognitiva (particularmente acentuados nos doentes com SOC significativos) e de memória de trabalho visuo-espacial. Estes últimos devem-se essencialmente a um défice executivo e não a uma incapacidade visuo-construtiva ou visuo-perceptiva. A disfunção cognitiva não é explicável pela psicopatologia depressiva nem pela incapacidade motora, já que os controlos com doença periférica crónica tiveram um desempenho superior ao dos doentes com distonia. No seu conjunto os nossos resultados sugerem que os SOC que ocorrem na distonia focal primária constituem uma das manifestações clínicas da neurobiologia desta doença do movimento. O predomínio de sintomas relacionados com higiene e o perfil disexecutivo de alterações cognitivas–perseveração e dificuldades executivas de memória de trabalho visuo-espacial – apontam para a via cortico-basal dorso-lateral e para as áreas corticais que lhe estão associadas como estando implicadas na tripla associação entre sintomas motores, obsessivo-compulsivos e cognitivos. Conclusões: A distonia focal primária é um síndrome neuropsiquiátrico complexo com importantes manifestações não motoras, nomeadamente compromisso cognitivo do tipo disexecutivo e sintomas obsessivo-compulsivos. Clinicamente estas manifestações representam necessidades de tratamento que vão muito para além da simples incapacidade motora, devendo ser activamente exploradas e tratadas.-------------- ABSTRACT: Introduction: primary focal dystonia is an idiopathic movement disorder that manifests as involuntary, sustained contraction of muscular groups, leading to abnormal and often painful postures of the affected body part. Treatment is symptomatic, usually with local intramuscular injections of botulinum toxin. The neurobiology of primary focal dystonia remains unclear. Structural and functional neuroimaging studies have revealed subtle changes in striatal and cortical-basal pathway anatomy and function. The most consistent findings involve increased volume and metabolic activity of the putamen and of motor, pre-motor and somato-sensitive cortical areas. As a whole, these changes have been interpreted as reflecting a failure of striatal inhibitory control over automatic motor programs sustained by cortical-basal pathways. The last years have witnessed an increasing interest for the possible non-motor – mainly psychiatric and cognitive – manifestations of primary focal dystonia. The possible association of primary focal dystonia with obsessive-compulsive disorder (OCD) has raised particular interest. The neurobiology of the two disorders has indeed remarkable similarities: structural and functional neuroimaging studies in OCD have revealed increased volume and metabolic activity of the striatum and orbital-frontal cortex, again pointing to a disruption of inhibitory control of automatic cognitive and behavioural programs by the striatum. Objectives: 1. To explore the prevalence and severity of psychopathology – with a special emphasis on obsessive-compulsive symptoms (OCS) – in a sample of patients with primary focal dystonia;2. To explore the nature and severity of possible cognitive dysfunction in a sample of patients with primary focal dystonia; 3. To explore the possible association between dystonia severity, psychiatric symptom severity, and cognitive performance, in a sample of patients with primary focal dystonia. Methods: cross-sectional, case-control, descriptive study. Cases: forty-five consecutive, primary pure focal dystonia patients recruited from the Portuguese Dystonia Association case register (fifteen patients with blepharospasm, 15 with cervical dystonia and 15 with writer’s cramp). Inclusion criteria were: age = 18; primary pure focal, late-onset dystonia (excluding possible or probable psychogenic dystonia according to the Fahn & Williams criteria); normal copper metabolism and Magnetic Resonance Imaging. Diseased controls: forty-six consecutive subjects from our hospital case register (15 patients with hemi-facial spasm; 14 with cervical spondilarthropathy and cervical spinal root compression; 17 with carpal tunnel syndrome). Healthy controls were 30 volunteers.Exclusion criteria for all groups: Mini-Mental State Examination score below the validated cut-off for the Portuguese population (<23 for education between 1 and 11 years; <28 for education >11 years); use of anti-cholinergics, neuroleptics, selective serotonin reuptake inhibitors, triciclic or tetraciclic antidepressants. Assessment: neurological assessment: complete medical and neurological history and physical examination; dystonia severity scoring with the Unified Dystonia Rating Scale. Psychiatric assessment:Symptom Check-List-90-Revised; 60 minute-long psychiatric interview, including Mini-International Neuropsychiatric Interview (MINI), version 4.4 (validated Portuguese version), extended with the sections for life-time major depressive disorder and life-time alcohol and substance abuse disorder from MINI-Plus version 5.0.0; Yale-Brown Obsessive-Compulsive Symptom Checklist and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Cognitive assessment: Wisconsin Card Sorting Test (WCST; cognitive set-shifting ability); Stroop Test (response inhibition); Block Assembly Test(visual-constructive ability); Benton’s Visual Retention Test (visual-spatial working memory). Statistic analysis: Data were analyzed with SPSS for Windows version 13. Proportions were compared using Chi-Square test, or Fisher’s exact test when appropriate. Student’s t-test or Mann-Whitney’s U test (or Wilcoxon’s teste in the case of matched samples) were used for two-group comparisons. P-values were corrected for multiple comparisons. One-way ANOVA with Bonferroni post-hoc analysis (interval data), or the Kruskal-Wallis Test (ordinal data), were used for three-group comparisons. Associations were analysed with Pearson’s or Spearman’s correlation coefficients, canonical correlations, path analysis and logistic regression analysis. Alpha was set at 0.05. Results: Dystonia patients had higher Yale-Brown Obsessive-Compulsive Symptom scores than both control groups. 24.4% of primary dystonia patients had a Y-BOCS score > 16. These patients were predominantly women; they had longer disease duration, and showed a predominance of hygiene-related OCS. The two groups with chronic disease had higher anxiety, somatization and global psychopathology scores than healthy subjects. Primary dystonia patients undergoing treatment with botulinum toxin had lower anxiety, phobia, somatization and depression scores than their untreated counterparts, but similar Y-BOCS scores. Sixty percent of primary dystonia patients had at least one lifetime psychiatric diagnosis. The odds of having a currently active psychiatric diagnosis were lower in botulinum toxin treated patients, and increased with dystonia severity. The prevalence of OCD was 6.7%, and the lifetime prevalence of major depression was 37.7%. Primary dystonia patients had a lower performance than the two control groups in both the WCST and Benton’s Visual Retention Test, mainly due to an excess of perseveration errors. Primary dystonia patients with Y-BOCS score > 16 had much higher perseveration error and perseveration response scores than dystonia patients with Y-BOCS = 16. Correlation and path analysis showed that, in the primary dystonia group, dystonia severity, along with age and education, was the main factor influencing cognitive performance. Discussion: our study is the first description ever of concomitant significant OCS and cognitive impairment in primary dystonia patients. Our results confirm that primary dystonia is specifically associated with obsessive-compulsive psychopathology. They also confirm that primary focal dystonia patients are at a higher risk of developing anxious and depressive psychiatric morbidity. Treatment with botulinum toxin decreases this risk, but does not influence OCS. Primary focal dystonia patients with significant OCS may constitute a particular subgroup. They are predominantly women, with higher disease duration (but not severity) and a predominance of hygiene related OCS.In terms of cognitive performance, primary focal dystonia patients have significant deficits involving set-shifting ability and visual-spatial working memory. The latter result from an essentially executive deficit, rather than from a primary visual-constructive apraxia or perceptual deficit. Furthermore, cognitive flexibility difficulties were more prominent in the subset of primary dystonia patients with significant OCS. The cognitive dysfunction found in dystonia patients is not attributable to depressive psychopathology or motor disability, as their performance was significantly lower than that of similarly impaired diseased controls. Our results suggest that OCS in primary focal dystonia are a direct, primary manifestation of the motor disorder’s neurobiology. The predominance of hygiene-related symptoms and the disexecutive pattern of cognitive impairment – set-shifting and visual-spatial working memory deficits – suggest that the dorsal-lateral cortical-basal pathway may play a decisive role in the triple association of motor dysfunction, OCS and cognitive impairment. Conclusions: primary focal dystonia is a complex neuropsychiatric syndrome with significant non- -motor manifestations, namely cognitive executive deficits and obsessive-compulsive symptoms.Clinically, our results show that PFD patients may have needs for care that extend far beyond a merely motor disability and must be actively searched for and treated.

Rating corporate groups a modelling experience

This paper aims to provide a model that allows BPI to measure the credit risk, through its rating scale, of the subsidiaries included in the corporate groups who are their clients. This model should be simple enough to be applied in practice, accurate, and must give consistent results in comparison to what have been the ratings given by the bank. The model proposed includes operational, strategic, and financial factors and ends up giving one of three results: no support, partial support, or full support from the holding to the subsidiary, and each of them translates in adjustments in each subsidiary’s credit rating. As it would be expectable, most of the subsidiaries should have the same credit rating of its parent company.

Change in cognitive errors and coping over the course of brief psychodynamic intervention.

OBJECTIVE: Cognitive change over the course of psychodynamic psychotherapy has been postulated by several models, but has rarely been studied. Based on the adaptive skills model (Badgio, Halperin, & Barber, 1999), it is reasonable to expect that very brief dynamic psychotherapy may be associated with change in coping patterns and cognitive errors (also known as cognitive distortions) y. METHOD: N = 50 outpatients presenting with various psychiatric disorders and undergoing 4 sessions of Brief Psychodynamic Intervention (BPI; Despland, Drapeau, & de Roten, 2005; Despland, Michel, & de Roten, 2010) were included in this naturalistic study (mean age: 31 years; 56% female; all Caucasian). Cognitive errors and coping strategies were assessed using the Cognitive Errors Rating Scale (Drapeau et al., 2008) and Coping Patterns Rating Scale (Perry et al., 2005). These observer rated methods were applied to the verbatim transcriptions of all 4 therapy sessions completed by each patient. RESULTS: Results indicate change in both cognitive errors and coping patterns over the course of BPI, including an increase in the Overall Coping Functioning and a decrease in unhelpful coping processes, such as isolation, which reflects a shift in participant appraisal towards stress appraised as a challenge at the end of treatment. These changes predicted symptom change at the end of treatment. While cognitive errors also changed over the course of BPI, no predictive effect was found with regard to symptom change. CONCLUSIONS: These results are interpreted within the framework of common change principles in psychotherapy. Implications and future research are discussed.

Validation of the Addiction Severity Index in French-speaking alcoholic patients.

OBJECTIVE: Evaluation of a French translation of the Addiction Severity Index (ASI) in 100 (78 male) alcoholic patients. METHOD: Validity of the instrument was assessed by measuring test-retest and interrater reliability, internal consistency and convergence and discrimination between items and scales. Concurrent validity was assessed by comparing the scores from the ASI with those obtained from three other clinimetric instruments. RESULTS: Test-retest reliability of ASI scores (after a 10-day interval) was good (r = 0.63 to r = 0.95). Interrater reliability was evaluated using six video recordings of patient interviews. Severity ratings assigned by six rates were significantly different (p < .05), but 72% of the ratings assigned by those who viewed the videos were within two points of the interviewer's severity ratings. Cronbach alpha coefficient of internal consistency varied from 0.58 to 0.81 across scales. The average item-to-scale convergent validity (r value) was 0.49 (range 0.0 to 0.84) for composite scores and 0.35 (range 0.00 to 0.68) for severity ratings, whereas discriminant validity was 0.11 on average (range-0.19 to 0.46) for composite scores and 0.12 (range-0.20 to 0.52) for severity ratings. Finally, concurrent validity with the following instruments was assessed: Severity of Alcoholism Dependence Questionnaire (40% shared variance with ASI alcohol scale), Michigan Alcoholism Screening Test (2% shared variance with ASI alcohol scale) and Hamilton Depression Rating Scale (31% shared variance with ASI psychiatric scale). CONCLUSIONS: The Addiction Severity Index covers a large scope of problems encountered among alcoholics and quantifies need for treatment. This French version presents acceptable criteria of reliability and validity.

Assessing psychosocial vulnerability and care needs of pretransplant patients by means of the INTERMED.

OBJECTIVE: We investigated whether the INTERMED, a generic instrument for assessing biopsychosocial case complexity and direct care, identifies organ transplant patients at risk of unfavourable post-transplant development by comparing it to the Transplant Evaluation Rating Scale (TERS), the established measure for pretransplant psychosocial evaluation. METHOD: One hundred nineteen kidney, liver, and heart transplant candidates were evaluated using the INTERMED, TERS, SF-36, EuroQol, Montgomery-Åsberg Depression Rating Scale (MADRS), and Hospital Anxiety & Depression Scale (HADS). RESULTS: We found significant relationships between the INTERMED and the TERS scores. The INTERMED highly correlated with the HADS,MADRS, and mental and physical health scores of the SF-36 Health Survey. CONCLUSIONS: The results demonstrate the validity and usefulness of the INTERMED instrument for pretransplant evaluation. Furthermore, our findings demonstrate the different qualities of INTERMED and TERS in clinical practice. The advantages of the psychiatric focus of the TERS and the biopsychosocial perspective of the INTERMED are discussed in the context of current literature on integrated care.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial.

BACKGROUND: A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression. METHODS/DESIGN: The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher. DISCUSSION: Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12612000909820).

Patterns and factors associated with low adherence to psychotropic medications during pregnancy-a cross-sectional, multinational web-based study.

BACKGROUND: No previous studies have explored how closely women follow their psychotropic drug regimens during pregnancy. This study aimed to explore patterns of and factors associated with low adherence to psychotropic medication during pregnancy. METHODS: Multinational web-based study was performed in 18 countries in Europe, North America, and Australia. Uniform data collection was ensured via an electronic questionnaire. Pregnant women were eligible to participate. Adherence was measured via the 8-item Morisky Medication Adherence Scale (MMAS-8). The Beliefs about Prescribed Medicines Questionnaire (BMQ-specific), the Edinburgh Postnatal Depression Scale (EPDS), and a numeric rating scale were utilized to measure women's beliefs, depressive symptoms, and antidepressant risk perception, respectively. Participants reporting use of psychotropic medication during pregnancy (n = 160) were included in the analysis. RESULTS: On the basis of the MMAS-8, 78 of 160 women (48.8%, 95% CI: 41.1-56.4%) demonstrated low adherence during pregnancy. The rates of low adherence were 51.3% for medication for anxiety, 47.2% for depression, and 42.9% for other psychiatric disorders. Smoking during pregnancy, elevated antidepressant risk perception (risk≥6), and depressive symptoms were associated with a significant 3.9-, 2.3-, and 2.5-fold increased likelihood of low medication adherence, respectively. Women on psychotropic polytherapy were less likely to demonstrate low adherence. The belief that the benefit of pharmacotherapy outweighed the risks positively correlated (r = .282) with higher medication adherence. CONCLUSIONS: Approximately one of two pregnant women using psychotropic medication demonstrated low adherence in pregnancy. Life-style factors, risk perception, depressive symptoms, and individual beliefs are important factors related to adherence to psychotropic medication in pregnancy.