[From OPG to REMS: the role of a territorial health service in the implementation of security and non-custodial measures towards offenders with psychological problems]. / Dagli OPG alle REMS: il ruolo di un servizio sanitario territoriale nell'esecuzione delle misure di sicurezza detentive e non, nei confronti degli autori di reato con problemi psichici.

AIMS: Managing health care for people suffering from mental illness is undergoing deep changes in recent years in Italy. The purpose of this study is to describe the progressive process of overcoming the Forensic Hospitals in Italy (OPGs) and to identify the necessary care and rehabilitation pathways in this process, in the experience of the territorial health service in Salerno, Italy. METHODS: An analysis of the recent laws related to the ongoing process and an analysis of epidemiological and structural data referring to the time interval between 2010 and 2017 concerning the OPGs/Residential Services for the Execution of Security Measures (RSESM)/Mental Health System in Campania, Italy and in the territory of Salerno in particular. RESULTS: The acts governing the transition from OPG to RSESM include DPCM 1/4/2008 and subsequent "Conferenza Unificata" agreements, other laws and regional health organizational regulations. A thorough restructuring of the National Health Service is required. A substantial path in Campania has been completed, with the closure of OPGs, the realization of definitive RSESM, the Departments for Mental Health Care in prison, the Regional Technical Group for overcoming the OPGs, the territorial Services for overcoming the OPGs and for Mental Health in Prison. The result of these transformations is a deep change in the health care approach, as evidenced by the current changes in action in indicative parameters of care pathways and their outcomes. CONCLUSIONS: The new approach shows both improvement features and totally or partially unaddressed problematic features. As for the actual management issues, improvements in communication between Mental Health Care and the magistracy. The overall evaluation of the transformations in progress is positive. At this stage, it is crucial to identify and monitor indicators of the pathways of care and their outcomes and to implement synergies among the systems involved.

Nicotine and caffeine modulate haloperidol-induced changes in postsynaptic density transcripts expression: Translational insights in psychosis therapy and treatment resistance.

Caffeine and nicotine are widely used by schizophrenia patients and may worsen psychosis and affect antipsychotic therapies. However, they have also been accounted as augmentation strategies in treatment-resistant schizophrenia. Despite both substances are known to modulate dopamine and glutamate transmission, little is known about the molecular changes induced by these compounds in association to antipsychotics, mostly at the level of the postsynaptic density (PSD), a site of dopamine-glutamate interplay. Here we investigated whether caffeine and nicotine, alone or combined with haloperidol, elicited significant changes in the levels of both transcripts and proteins of the PSD members Homer1 and Arc, which have been implicated in synaptic plasticity, schizophrenia pathophysiology, and antipsychotics molecular action. Homer1a mRNA expression was significantly reduced by caffeine and nicotine, alone or combined with haloperidol, compared to haloperidol. Haloperidol induced significantly higher Arc mRNA levels than both caffeine and caffeine plus haloperidol in the striatum. Arc mRNA expression was significantly higher by nicotine plus haloperidol vs. haloperidol in the cortex, while in striatum gene expression by nicotine was significantly lower than that by both haloperidol and nicotine plus haloperidol. Both Homer1a and Arc protein levels were significantly increased by caffeine, nicotine, and nicotine plus haloperidol. Homer1b mRNA expression was significantly increased by nicotine and nicotine plus haloperidol, while protein levels were unaffected. Locomotor activity was not significantly affected by caffeine, while it was reduced by nicotine. These data indicate that both caffeine and nicotine trigger relevant molecular changes in PSD sites when given in association with haloperidol.

Postsynaptic density protein transcripts are differentially modulated by minocycline alone or in add-on to haloperidol: Implications for treatment resistant schizophrenia.

In this study, we investigated whether minocycline, a second-generation tetracycline proposed as an add-on to antipsychotics in treatment-resistant schizophrenia (TRS), may affect the expression of Homer and Arc postsynaptic density (PSD) transcripts, implicated in synaptic regulation. Minocycline was administered alone or with haloperidol in rats exposed or not to ketamine, mimicking acute glutamatergic psychosis or naturalistic conditions, respectively. Arc expression was significantly reduced by minocycline compared with controls. Minocycline in combination with haloperidol also significantly reduced Arc expression compared with both controls and haloperidol alone. Moreover, haloperidol/minocycline combination significantly affected Arc expression in cortical regions, while haloperidol alone was ineffective on cortical gene expression. These results suggest that minocycline may strongly affect the expression of Arc as mediated by haloperidol, both in terms of quantitative levels and of topography of haloperidol-related expression. It is noteworthy that no significant pre-treatment effect was found, suggesting that pre-exposure to ketamine did not grossly affect gene expression. Minocycline was not found to significantly affect haloperidol-related Homer1a expression. No significant changes in Homer1b/c expression were observed. These results are consistent with previous observations that minocycline may modulate postsynaptic glutamatergic transmission, affecting distinct downstream pathways initiated by N-methyl-D-aspartate (NMDA) receptor modulation, i.e. Arc-mediated but not Homer1a-mediated pathways.

Factor structure and reliability of the Italian adaptation of the Hypomania Check List-32, second revision (HCL-32-R2).

OBJECTIVE: To assess the psychometric properties of the Italian adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) treatment-seeking outpatients. METHODS: A back-to-back Italian adaption of the "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" English module of the HCL-32-R2 was administered between March 2013 and October 2014 across twelve collaborating sites in Italy. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls. RESULTS: In our sample (n=441, of whom, BD-I=68; BD-II=117; MDD=256), using a cut-off of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=89% and specificity=79%. Area under the curve was .888; positive and negative predictive values were 75.34% and 90.99% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factor analyses, whereas items n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the scale slightly loaded onto F2 and F1 respectively. Cronbach׳s α=.88 for F1 and .71 for F2. LIMITATIONS: No cross-validation with any additional validated screening tool; treatment-seeking outpatient sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, neither record of severity of current MDE. CONCLUSIONS: Our results seem to indicate fair accuracy of HCL-32 as a screening instrument for BD, though replication studies are warranted.

Progressive recruitment of cortical and striatal regions by inducible postsynaptic density transcripts after increasing doses of antipsychotics with different receptor profiles: insights for psychosis treatment.

Antipsychotics may modulate the transcription of multiple gene programs, including those belonging to postsynaptic density (PSD) network, within cortical and subcortical brain regions. Understanding which brain region is activated progressively by increasing doses of antipsychotics and how their different receptor profiles may impact such an activation could be relevant to better correlate the mechanism of action of antipsychotics both with their efficacy and side effects. We analyzed the differential topography of PSD transcripts by incremental doses of two antipsychotics: haloperidol, the prototypical first generation antipsychotic with prevalent dopamine D2 receptors antagonism, and asenapine, a second generation antipsychotic characterized by multiple receptors occupancy. We investigated the expression of PSD genes involved in synaptic plasticity and previously demonstrated to be modulated by antipsychotics: Homer1a, and its related interacting constitutive genes Homer1b/c and PSD95, as well as Arc, C-fos and Zif-268, also known to be induced by antipsychotics administration. We found that increasing acute doses of haloperidol induced immediate-early genes (IEGs) expression in different striatal areas, which were progressively recruited by incremental doses with a dorsal-to-ventral gradient of expression. Conversely, increasing acute asenapine doses progressively de-recruited IEGs expression in cortical areas and increased striatal genes signal intensity. These effects were mirrored by a progressive reduction in locomotor animal activity by haloperidol, and an opposite increase by asenapine. Thus, we demonstrated for the first time that antipsychotics may progressively recruit PSD-related IEGs expression in cortical and subcortical areas when administered at incremental doses and these effects may reflect a fine-tuned dose-dependent modulation of the PSD.

Intracellular pathways of antipsychotic combined therapies: implication for psychiatric disorders treatment.

Dysfunctions in the interplay among multiple neurotransmitter systems have been implicated in the wide range of behavioral, emotional and cognitive symptoms displayed by major psychiatric disorders, such as schizophrenia, bipolar disorder or major depression. The complex clinical presentation of these pathologies often needs the use of multiple pharmacological treatments, in particular (1) when monotherapy provides insufficient improvement of the core symptoms; (2) when there are concurrent additional symptoms requiring more than one class of medication and (3) in order to improve tolerability, by using two compounds below their individual dose thresholds to limit side effects. To date, the choice of drug combinations is based on empirical paradigm guided by clinical response. Nonetheless, several preclinical studies have demonstrated that drugs commonly used to treat psychiatric disorders may impact common intracellular target molecules (e.g. Akt/GSK-3 pathway, MAP kinases pathway, postsynaptic density proteins). These findings support the hypothesis that convergence at crucial steps of transductional pathways could be responsible for synergistic effects obtained in clinical practice by the co-administration of those apparently heterogeneous pharmacological compounds. Here we review the most recent evidence on the molecular crossroads in antipsychotic combined therapies with antidepressants, mood stabilizers, and benzodiazepines, as well as with antipsychotics. We first discuss clinical clues and efficacy of such combinations. Then we focus on the pharmacodynamics and on the intracellular pathways underpinning the synergistic, or concurrent, effects of each therapeutic add-on strategy, as well as we also critically appraise how pharmacological research may provide new insights on the putative molecular mechanisms underlying major psychiatric disorders.

The glucocorticoid analog dexamethasone alters the expression and the distribution of dopamine receptors and enkephalin within cortico-subcortical regions.

In humans, glucocorticoid excess may cause neuropsychiatric symptoms, including psychosis and cognitive impairment, and glucocorticoid signaling hyperactivation may sensitize to substance of abuse. The aim of this work was to evaluate whether exposure to glucocorticoid excess triggers molecular changes in dopaminergic and opioidergic systems within relevant forebrain areas. We acutely exposed Sprague-Dawley rats to dexamethasone, a glucocorticoid analog, or vehicle and evaluated the mRNA expression of dopamine D1 and D2 receptors and enkephalin within the cortex, the striatum, and the midbrain. Dexamethasone reduced mRNA expression of D1 receptor and enkephalin in the cortex. In the striatum, dexamethasone reduced the expression of D1 receptor mRNA, but not that of D2 receptor and enkephalin. No significant changes in D2 receptor mRNA expression were observed in the midbrain. Basal distribution of D1 and D2 receptor mRNA showed a clear-cut striatal/cortical gradient, while this distribution was less obvious for enkephalin mRNA. Dexamethasone increased the cortico-striatal separation in terms of D1 and D2 receptor mRNA expression. These molecular changes may represent adaptive mechanisms to dexamethasone-induced potentiation of dopaminergic and opioidergic transmission, mostly in cortical areas.

The expression of genes involved in glucose metabolism is affected by N-methyl-D-aspartate receptor antagonism: a putative link between metabolism and an animal model of psychosis.

Psychosis has been associated with glucose metabolism impairment. Here, we explored the gene expression of hexokinase 1 (Hk1) and glucose transporter 3 (GLUT3) after the administration of a subanesthetic or a subconvulsant dose of ketamine in rats, considered to provide an animal model of psychosis. Indeed, Hk1 and GLUT3 are crucially involved in the glucose utilization in brain tissues and have also been implicated in the pathophysiology of psychosis. Quantitative brain imaging of transcripts was used to evaluate Hk1 and GLUT3 mRNA in rat brain regions related to ketamine-induced behavioral abnormalities. Hk1 transcript was significantly increased by 50 mg/kg ketamine in cortical and subcortical areas, whereas 12 mg/kg ketamine affected Hk1 expression in the auditory cortex only. GLUT3 expression was increased by 12 mg/kg ketamine in the frontal cortex and decreased by 50 mg/kg ketamine in subcortical areas. The results show that Hk1 and GLUT3 are extensively and differentially affected by ketamine dose, supporting the view that glucose metabolism and psychosis may be causally related and suggesting that these molecules may play a role in the pathophysiology of ketamine-induced behavioral abnormalities.