Metabolic syndrome following a first episode of psychosis: results of a 1-year longitudinal study conducted in metropolitan Lisbon, Portugal.

OBJECTIVE: We aimed to assess the prevalence and course of metabolic syndrome (MetS) and the associated metabolic parameters during the year following a first episode pf psychosis (FEP). METHODS: We performed a 1-year longitudinal observation of 60 patients who experienced FEP. MetS was defined using the modified definition of the National Cholesterol Education Program Adult Treatment Panel III. We assessed the metabolic parameters and socio-demographic and psychopathological data for the participants. RESULTS: The mean age of the participants was 27.1 years, and 33.3% of them were women. There was an increase in the prevalence of MetS from 6.7% to 11.7% during the year following the baseline assessment during the year following the baseline assessment (p = 0.250). There were also significant increases in the prevalences of abnormal triglyceride concentration, waist circumference, and high-density lipoprotein (HDL)-cholesterol concentration during this period. In addition, there was a considerable worsening of the metabolic profile of the participants. No baseline parameters were identified to be predictors of MetS over the 1-year follow-up period. CONCLUSIONS: We can conclude that metabolic abnormalities are common in patients with FEP and that these rapidly worsen during the first year following the diagnosis of FEP. Studies on interventions are needed to reduce metabolic risk to cardiovascular diseases following the FEP.

Anti-NMDA Receptor Encephalitis Associated With an Ovarian Teratoma Presenting as First-episode Psychosis: A Case Report.

We report an unusual case of a 27-year-old previously healthy female who presented with a 15-day history of psychotic, cognitive, and unspecified somatic symptoms. She was admitted to the psychiatric ward of an early intervention in psychosis team and medicated with aripiprazole. The young age of onset, the rapid onset, the absent history of psychiatric disease, and the persistence of a marked memory deficit after the psychotic symptoms remitted strongly suggested a nonpsychiatric etiology and led us to hypothesize autoimmune encephalitis as the most probable diagnosis. An investigation was carried out for anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies in the patient's serum and cerebrospinal fluid, and both tests were positive. The patient was transferred to the neurology ward, where an endovaginal ultrasound showed an ovarian teratoma in her right ovary. She underwent laparoscopic surgery without complications. She was initially treated with intravenous immunoglobulin and methylprednisolone for 5 days, which resulted in marked improvement of her memory and attention performance. Anti-NMDA receptor encephalitis, first described in 2007 by Dalmau and colleagues, is a form of auto-immune encephalitis with prominent neuropsychiatric manifestations, particularly psychotic symptoms. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. This case report highlights the importance of early psychosis treatment teams considering the diagnosis of anti-NMDA receptor encephalitis when evaluating new referrals with a potential diagnosis of first-episode psychosis, particularly when young patients with no relevant personal or familial psychiatric history present with neuropsychiatric symptoms and a distinctive pattern of symptom fluctuation over time.

Poststroke Bipolar Disorder.

ABSTRACT: Various diseases that impact different systems and organs in the body may trigger manic episodes. Strokes are often associated with psychiatric symptoms, particularly depressive and, more rarely, manic. We herein report a case of bipolar disorder secondary to cerebrovascular disease in a 67-year-old man with no personal or family history of psychiatric illness who, at the age of 64, had a bilateral ischemic stroke in the middle cerebral artery territory. About 20 days after this stroke, he experienced a manic episode. Three years later, he experienced a second manic episode, with another hospitalization in a psychiatric ward. With this case, we intend to emphasize that, although rare, the diagnosis of mania after stroke should not be forgotten, and most important, one should be aware of the recurrence of affective episodes just as in non-medical-caused bipolar disorder.

Suicidal behaviour after first-episode psychosis: results from a 1-year longitudinal study in Portugal.

BACKGROUND: Suicide is one of the main causes of excess of premature death in psychotic patients. Published studies found that suicide risk begins in ultra-high risk of psychosis and continues in early years of the disease. Previous studies identifying predictive and risk factors associated with suicidality in first-episode psychosis (FEP) are highly inconsistent. Also, there are relatively few longitudinal studies on suicidal behaviour in FEP. The aim of this study was to examine prevalence, evolution and predictors of suicidal behaviour at baseline and the 12-month follow-up in patients presenting with FEP. METHODS: One hundred and eighteen patients presenting with FEP were recruited from two early psychosis units in Portugal. A comprehensive assessment examining socio-demographic and clinical characteristics was administered at baseline and the 12-month follow-up. Odds ratio were calculated using logistic regression analyses. McNemar test was used to evaluate the evolution of suicidal behaviour and depression prevalence from baseline to 12 months of follow-up. RESULTS: Follow-up data were available for 60 participants from the 118 recruited. Approximately 25.4% of the patients had suicidal behaviour at the baseline evaluation, with a significant reduction during the follow-up period to 13.3% (p = 0.035). A multivariate binary logistic regression showed that a history of suicidal behaviour and depression at baseline independently predicted suicidal behaviour at baseline, and a history of suicidal behaviour and low levels of total cholesterol predicted suicidal behaviour at the 12-month follow-up. A significant proportion of patients also had depression at the baseline evaluation (43.3%), with the last month of suicidal behaviour at baseline independently predicting depression at this time. CONCLUSIONS: The findings of our study indicate that suicidal behaviour was prevalent on the year after FEP. Patients with a history of suicidal behaviour, depression at baseline and low levels of cholesterol should undergo close evaluation, monitoring and possible intervention in order to reduce suicide risk in the early phases of psychosis.

Cariprazine Use in Early Psychosis: Three Case Reports.

Objective: Cariprazine is a new atypical antipsychotic approved for the acute and maintenance treatment of schizophrenia (1, 2) and for the treatment of manic or mixed episodes associated with bipolar I disorder (1). Recently, cariprazine also got extended FDA-approval for the treatment of depressive episodes in adults with bipolar I disorder (3). The use of low doses of atypical antipsychotics is an essential component of early intervention in psychosis. For its particular performance and tolerability, cariprazine is becoming an important option for the treatment of first-episode psychosis. Method: Three patients experiencing first-episode psychosis (FEP) were successfully treated with cariprazine. Two patients were in their first months of the disease, and the third patient was in his third year after the FEP. Results: The three patients had a diagnosis of non-affective FEP, which includes schizophrenia, delusional disorder, and schizoaffective disorder. One of them was in their third year after the FEP with a predominance of negative symptoms at this stage of the disorder. All the patients were treated with cariprazine with a target dose of 3-4.5 mg/day. The three patients showed improvements in their psychosis, including a decrease in negative symptoms. No significant side effects were reported. Conclusion: Our three case reports indicate that cariprazine is an atypical antipsychotic beneficial in the treatment of early psychosis. Treatment with low doses of cariprazine could be effective and tolerable in this phase of the disorder. Future studies with longer follow-up of FEP patients are recommended to confirm these positive results of cariprazine in the early phases of psychosis.

Changes in motor preparation affect the sensory consequences of voice production in voice hearers.

BACKGROUND: Auditory verbal hallucinations (AVH) are a cardinal symptom of psychosis but are also present in 6-13% of the general population. Alterations in sensory feedback processing are a likely cause of AVH, indicative of changes in the forward model. However, it is unknown whether such alterations are related to anomalies in forming an efference copy during action preparation, selective for voices, and similar along the psychosis continuum. By directly comparing psychotic and nonclinical voice hearers (NCVH), the current study specifies whether and how AVH proneness modulates both the efference copy (Readiness Potential) and sensory feedback processing for voices and tones (N1, P2) with event-related brain potentials (ERPs). METHODS: Controls with low AVH proneness (n = 15), NCVH (n = 16) and first-episode psychotic patients with AVH (n = 16) engaged in a button-press task with two types of stimuli: self-initiated and externally generated self-voices or tones during EEG recordings. RESULTS: Groups differed in sensory feedback processing of expected and actual feedback: NCVH displayed an atypically enhanced N1 to self-initiated voices, while N1 suppression was reduced in psychotic patients. P2 suppression for voices and tones was strongest in NCVH, but absent for voices in patients. Motor activity preceding the button press was reduced in NCVH and patients, specifically for sensory feedback to self-voice in NCVH. CONCLUSIONS: These findings suggest that selective changes in sensory feedback to voice are core to AVH. These changes already show in preparatory motor activity, potentially reflecting changes in forming an efference copy. The results provide partial support for continuum models of psychosis.

Anterior Limb of Internal Capsule and Bed Nucleus of Stria Terminalis Stimulation for Gilles de la Tourette Syndrome with Obsessive-Compulsive Disorder in Adolescence: A Case of Success.

Gilles de la Tourette syndrome (GTS) is a neurobehavioral disorder comprising motor and vocal tics. In most cases it is associated with other disorders such as obsessive-compulsive disorder (OCD). In refractory cases deep brain stimulation (DBS) is a valid treatment option. This paper describes the case of a 15-year-old adolescent with an extremely refractory GTS with associated OCD. The patient developed catatonia associated with OCD, which partially remitted after electroconvulsive therapy. At the peak of the disease the Yale Global Tic Severity Scale (YGTSS) was 100 and the patient required sedation and intubation. All medical treatment options were unsuccessful. Bilateral DBS of the anterior limb of internal capsule (ALIC)/bed nucleus of stria terminalis (BST) region was performed, using a target below the BST and a trajectory through the ALIC, with stimulation of contacts 0 and 3. Two weeks after surgery sedatives were suspended and the patient was successfully extubated. One year after surgery the patient reached a YGTSS of 19, representing an 81% improvement. OCD completely resolved. Adverse events were a superficial infection and weight gain. In conclusion, this ALIC/BST stimulation appears to have been an effective and safe treatment for GTS with OCD in this case. Young age should not be an exclusion criterion for DBS in severe GTS and OCD. Further studies should be pursued for this target.

Aripiprazole-induced Hepatitis: A Case Report.

Aripiprazole is an atypical antipsychotic that acts as a partial agonist of dopamine type 2 receptors as well as 5-HT1A receptors. It is used in the treatment of schizophrenia and in type 1 bipolar disorder for mania. Because aripiprazole is well tolerated with few side effects it is used off-label in other psychotic disorders. The prevalence of abnormal liver function tests with antipsychotic use is 32%, with clinically significant effects in 4% of cases. No cases of aripiprazole-induced liver injury have been published. We report a 28-year-old female who presented with non-affective first-episode psychosis and who was treated with aripiprazole. Initially she was medicated with 10 mg per day, with an increase to 20 mg per day on the 12th day of hospitalization. Nine days after she became icteric, with nausea and had a vomiting episode. Laboratory analysis revealed a very high level of alanine aminotransferase, and minor to moderately high levels of aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, and bilirubin. Aripiprazole was tapered and paliperidone was started with the improvement of clinical and laboratory findings.

Facilitating the Delivery of Cognitive Remediation in First-Episode Psychosis: Pilot Study of a Home-Delivered Web-Based Intervention.

We explored the adherence to a home-delivered, computer-based, cognitive remediation protocol in a first-episode psychosis outpatient cohort. Seventeen patients underwent a cognitive training protocol for 6 months using an online platform accessible from their home under the supervision of a qualified neuropsychologist. Neuropsychological, psychopathological, and functional data were collected at baseline and postintervention, whereas qualitative appraisal of the intervention was assessed monthly. Overall, participants' evaluation of the program was positive. This was reflected in a good adherence rate with 12 (70%) of 17 patients completing 80% of the prescribed sessions. Exploratory analysis revealed significant improvements in sustained attention (p = 0.020) and verbal memory (p = 0.018). A decrease in negative symptoms and an improvement on the Clinical Global Impression were also found (p = 0.009). We believe these are encouraging results to further explore the adopted delivery approach, which could facilitate access to cognitive training earlier and to a larger group of patients.

PROFIP: A Portuguese early intervention programme for first-episode psychosis in Lisbon.

AIM: There is currently no national plan for early intervention in first-episode psychosis in Portugal. Consequently, there is some heterogeneity in the evaluation and treatment of first-episode psychosis across the country. The aim of this article is to provide a complete description of the early intervention programme Programa de Intervenção nas Fases Iniciais da Psicose (PROFIP) in Lisbon, a pioneering team in Portugal for treating first-episode psychosis (FEP) patients. We also describe the baseline socio-demographic and clinical data obtained from new patients over a 1-year period. PROFIP programme accepts all cases of FEP, taking a transdiagnostic approach. METHODS: Description of PROFIP programme and baseline socio-demographic and clinical data obtained from new patients over a 1-year period. RESULTS: The team was constituted to provide early detection, treatment and support to people aged 16 to 35 years with affective and non-affective FEP. Over a 1-year period, 39 patients were included in the PROFIP programme. The majority of patients were young male patients with a diagnosis of non-affective psychosis, and with 56% of patients reporting cannabis use. Patients received pharmacological and psychosocial interventions based on evidence and individual needs. CONCLUSIONS: Our team allowed young people with early psychosis to receive effective care. We do need improvements, namely in referrals and the education of health professionals. More teams in our country should be constituted, allowing larger numbers of patients with early psychosis to be treated by specialized teams.

First-Episode Psychosis and Hypokalemia: A Case Report and Review of the Literature.

Hypokalemia is the most frequent electrolyte abnormality seen in clinical practice. Hypokalemia is defined as serum potassium below 3.5 mEq/L and is usually asymptomatic and only identified in routine laboratory analysis. However, in some cases, symptoms include hypertension, palpitations, muscle weakness, easy fatigability, cramping and myalgias, memory impairment, disorientation and confusion, depressed or anxious mood, and irritability. Although rare, hypokalemia has been associated with psychosis. In particular, hypokalemia has been associated with psychotic exacerbations in patients with chronic psychotic disorder. We present a case report of a young female who developed a first presentation of acute psychosis and in which complementary investigations revealed hypokalemia. The psychosis resolved in few hours after replacement therapy with potassium chloride. The patient returned her usual functioning after discharge and there were no signs of psychosis at six-month follow-up.

Practical guidance for prescribing ziprasidone in acute manic or mixed episodes of bipolar I disorder.

INTRODUCTION: Limited information is available on the clinical issues and strategies for optimal clinical usage of ziprasidone in the treatment of adult patients with acute manic or mixed episodes of bipolar disorder. AREAS COVERED: To address those issues, information from clinical trials addressing the efficacy and tolerability of ziprasidone in acute bipolar mania was reviewed and supplemented with the input from an expert faculty of European psychiatrists with extensive experience in treating patients with bipolar mania, both in clinical trials and in everyday clinical practice. EXPERT OPINION: Effective use of oral ziprasidone in the treatment of acute bipolar mania requires rapid titration to doses in the range 120 - 160 mg/day and administration with meals of ≥ 500 kcal. As in the clinical trials, temporary short-term use of benzodiazepines (in particular lorazepam for agitation or temazepam for insomnia) could be advisable. Available evidence from randomized clinical trials in combination with clinical experience supports the use of ziprasidone as one of the first-line effective and safe treatments for acute manic or mixed episodes associated with bipolar I disorder.

[Medication adherence rating scale]. / Adaptação e validação da versão portuguesa da escala de adesão à terapêutica.

UNLABELLED: Medication compliance is one of the foremost problems affecting neuroleptic efficacy in psychiatric patients. It is a crucial point to dispone of useful instruments that allow us a fiable assessment of patients' medication adherence in order to plan more appropriate therapeutical interventions. The aim of our study was to validade the Portuguese versión of the Medication Adherence Rating Scale (MARS), a concise instrument for assessment of medication compliance in psychosis. METHODS: A translation-backtranslation of the original scale was elaborated. The sample consisted of 77 psychotic patients according to the DSM-IV criteria. Feasibility and reliability were calculated. RESULTS: The results demonstrated that the MARS has a good internal consistence (Cronbach α = 0,73) and reliability (Pearson's r = 0,76; p < 0,05). DISCUSSION: These coefficients were similar to those found by the researchers who developed this scale. The MARS scale has proven to be easily applied and may be deemed a valid and reliable measure of compliancy for psychoactive medications.

[Early intervention in psychosis: first-episode psychosis and critical period]. / Intervenção precoce na psicose: primeiro episódio psicótico e período crítico.

Besides intervention in prepsychotic period, early intervention in psychosis includes interventions done after the onset of the first-episode psychosis, namely psychopharmacological and psychosocial phase-specific intervention. The main aim is to reduce the duration of untreated psychosis (DUP) and to ensure that besides remission of the symptoms there is also a psychosocial recovery. Many centers set up an assertive and integrated early intervention program, involving an active search of patients with a treatment that includes antipsychotic medication, cognitive behavioral therapy, psychoeducation, family and vocational interventions. The authors of this review explain the concepts and main studies that support this kind of treatment in early psychosis. The results of published data show that is possible to reduce the DUP and improve the clinical and functional outcomes with this intervention. Critical period hypothesis proposes that deterioration occurs aggressively in the first 2 to 5 years of early psychosis, so it is crucial to intervene in this period to ensure a functional recovery. Cost-benefit ratio seems to be favorable to early intervention model, with reduction of in-stay period, which is an important component of the direct costs of psychotic illness. Early intervention service model organization is also reviewed by the authors of this research. The results of many studies show favorable outcomes for the integrative early intervention and so many countries included it in their political mental health directives and attributed funds for early intervention in psychosis.

Switching among antipsychotics in everyday clinical practice: focus on ziprasidone.

OBJECTIVES: This article addresses points to consider when switching patients to the second-generation antipsychotic (SGA), ziprasidone, in everyday clinical practice: 1) the pharmacologic properties of the pre-switch antipsychotic and of ziprasidone; 2) switch and dosing strategies to ensure maintenance or attainment of efficacy; 3) recognition and management of possible rebound effects of the pre-switch medication discontinuation; 4) recognition and management of potential side effects of ziprasidone; and 5) education and support for patients/caregivers concerning correct ziprasidone administration. METHODS: A Medline search (up to July 7, 2010) identified studies in which adult patients with schizophrenia were switched to ziprasidone from another antipsychotic. In addition, based on their extensive clinical experience, an expert faculty of European psychiatrists provided advice on identifying patients who may be appropriate candidates for switching to ziprasidone, and on establishing optimal strategies for switching to ziprasidone in everyday clinical practice. RESULTS: Data from 10 studies, in which 1395 patients were switched to ziprasidone, showed that switching from first-generation antipsychotics (FGAs) or SGAs generally resulted in maintenance or improvement of efficacy across all studied symptom domains, improvements in tolerability, and acute and long-term benefits regarding cardiometabolic parameters, including body weight. Maintenance of efficacy is most likely to be achieved using a plateau cross-titration strategy, with a rapid uptitration of ziprasidone to a dose range of 60 to 80 mg administered twice daily with food. Temporary coadministration of benzodiazepines, anticholinergics, or beta-blockers should be considered for the management of potential rebound effects. CONCLUSION: Optimal switching of patients with schizophrenia from FGAs or SGAs to ziprasidone requires careful attention to differences in the pharmacological profiles of the pre-switch medication and of ziprasidone, which may impact efficacy and tolerability. Good communication between the clinician and patient/caregiver about the goals of switching, the importance of adherence to the chosen switch strategy, and the correct administration of ziprasidone are essential.

Strategies for successful clinical management of schizophrenia with ziprasidone.

IMPORTANCE OF THE FIELD: This review addresses practical clinical issues related to the use of ziprasidone in the treatment of schizophrenia using information from clinical trials, unpublished data, manufacturer's information, and input from an expert faculty of European psychiatrists with extensive experience of the use of ziprasidone, both in clinical trials and in everyday clinical practice. AREAS COVERED IN THIS REVIEW: A Medline search of published data (1998 - 2010) was carried out, together with a review of unpublished data and manufacturer's information. In addition, expert opinion was sought from psychiatrists with extensive experience of ziprasidone in the treatment of schizophrenia in clinical settings across Europe. WHAT THE READER WILL GAIN: This review has been undertaken to determine how the information from clinical trials can be optimally translated into 'real-life' practice and to establish how a decade of experience with ziprasidone in clinical practice can inform its optimal use to maximize effectiveness and minimize side effects. TAKE HOME MESSAGE: Effective use of ziprasidone in everyday clinical practice usually requires rapid titration to doses in the range of 120 - 160 mg/day and administration with proper meals, thereby achieving the high levels of schizophrenia symptom control reported in clinical trials. Additional guidance is provided about effective management of side effects, and appropriate coadministration of benzodiazepines and other agents, to achieve desired outcomes.