Air pollutants and daily number of admissions to psychiatric emergency services: evidence for detrimental mental health effects of ozone.

AIMS: Aim of the current study is to investigate the associations between daily levels of air pollutants (particulate matter, ozone, carbon monoxide, nitrogen dioxide) and daily admissions for mental disorders to the emergency department of two general hospitals in Umbria region (Italy). METHODS: We collected data about daily admissions to psychiatric emergency services of two general hospitals, air pollutants' levels and meteorological data for the time period 1 January 2015 until 31 December 2016. We assessed the impact of an increase in air pollutants on the number of daily admissions using a time-series econometric framework. RESULTS: A total of 1860 emergency department admissions for mental disorders were identified. We observed a statistically significant impact of ozone levels on daily admissions. The estimated coefficient of O3 is statistically significant at the 1% level. All other pollutants were not significantly associated with the number of daily admissions. CONCLUSIONS: Short-term exposure to ozone may be associated with increased psychiatric emergency services admissions. Findings add to previous literature on existing evidence for air pollution to have an impact on mental health. Ozone may be considered a potential environmental risk factor for impaired mental health.

Treatment decision-making capacity in non-consensual psychiatric treatment: a multicentre study.

AIMS: To evaluate treatment decision-making capacity (DMC) to consent to psychiatric treatment in involuntarily committed patients and to further investigate possible associations with clinical and socio-demographic characteristics of patients. METHODS: 131 involuntarily hospitalised patients were recruited in three university hospitals. Mental capacity to consent to treatment was measured with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T); psychiatric symptoms severity (Brief Psychiatric Rating Scale, BPRS-E) and cognitive functioning (Mini Mental State Examination, MMSE) were also assessed. RESULTS: Mental capacity ratings for the 131 involuntarily hospitalised patients showed that patients affected by bipolar disorders (BD) scored generally better than those affected by schizophrenia spectrum disorders (SSD) in MacCAT-T appreciation (p < 0.05) and reasoning (p < 0.01). Positive symptoms were associated with poorer capacity to appreciate (r = -0.24; p < 0.01) and reason (r = -0.27; p < 0.01) about one's own treatment. Negative symptoms were associated with poorer understanding of treatment (r = -0.23; p < 0.01). Poorer cognitive functioning, as measured by MMSE, negatively affected MacCAT-T understanding in patients affected by SSD, but not in those affected by BD (SSD r = 0.37; p < 0.01; BD r = -0.01; p = 0.9). Poorer MacCAT-T reasoning was associated with more manic symptoms in the BD group of patients but not in the SSD group (BD r = -0.32; p < 0.05; SSD r = 0.03; p = 0.8). Twenty-two per cent (n = 29) of the 131 recruited patients showed high treatment DMC as defined by having scored higher than 75% of understanding, appreciating and reasoning MacCAT-T subscales maximum sores and 2 at expressing a choice. The remaining involuntarily hospitalised patients where considered to have low treatment DMC. Chi-squared disclosed that 32% of BD patients had high treatment DMC compared with 9% of SSD patients (p < 0.001). CONCLUSIONS: Treatment DMC can be routinely assessed in non-consensual psychiatric settings by the MacCAT-T, as is the case of other clinical variables. Such approach can lead to the identification of patients with high treatment DMC, thus drawing attention to possible dichotomy between legal and clinical status.

The aggressor at the mirror: Psychiatric correlates of deliberate self-harm in male prison inmates.

BACKGROUND: Deliberate self-harm (DSH) causes important concern in prison inmates as it worsens morbidity and increases the risk for suicide. The aim of the present study is to investigate the prevalence and correlates of DSH in a large sample of male prisoners. METHODS: A cross-sectional study evaluated male prisoners aged 18+ years. Current and lifetime psychiatric diagnoses were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders - DSM-IV Axis I and Axis II Disorders and with the Addiction Severity Index-Expanded Version. DSH was assessed with The Deliberate Self-Harm Inventory. Multivariable logistic regression models were used to identify independent correlates of lifetime DSH. RESULTS: Ninety-three of 526 inmates (17.7%) reported at least 1 lifetime DSH behavior, and 58/93 (62.4%) of those reported a DSH act while in prison. After multivariable adjustment (sensitivity 41.9%, specificity 96.1%, area under the curve=0.854, 95% confidence interval CI=0.811-0.897, P<0.001), DSH was significantly associated with lifetime psychotic disorders (adjusted Odds Ratio aOR=6.227, 95% CI=2.183-17.762, P=0.001), borderline personality disorder (aOR=6.004, 95% CI=3.305-10.907, P<0.001), affective disorders (aOR=2.856, 95% CI=1.350-6.039, P=0.006) and misuse of multiple substances (aOR=2.024, 95% CI=1.111-3.687, P=0.021). CONCLUSIONS: Borderline personality disorder and misuse of multiple substances are established risk factors of DSH, but psychotic and affective disorders were also associated with DSH in male prison inmates. This points to possible DSH-related clinical sub-groups, that bear specific treatment needs.

Estimating the Impact of Workplace Bullying: Humanistic and Economic Burden among Workers with Chronic Medical Conditions.

BACKGROUND: Although the prevalence of work-limiting diseases is increasing, the interplay between occupational exposures and chronic medical conditions remains largely uncharacterized. Research has shown the detrimental effects of workplace bullying but very little is known about the humanistic and productivity cost in victims with chronic illnesses. We sought to assess work productivity losses and health disutility associated with bullying among subjects with chronic medical conditions. METHODS: Participants (N = 1717) with chronic diseases answered a self-administered survey including sociodemographic and clinical data, workplace bullying experience, the SF-12 questionnaire, and the Work Productivity Activity Impairment questionnaire. RESULTS: The prevalence of significant impairment was higher among victims of workplace bullying as compared to nonvictims (SF-12 PCS: 55.5% versus 67.9%, p < 0.01; SF-12 MCS: 59.4% versus 74.3%, p < 0.01). The adjusted marginal overall productivity cost of workplace bullying ranged from 13.9% to 17.4%, corresponding to Italian Purchase Power Parity (PPP) 2010 US$ 4182-5236 yearly. Association estimates were independent and not moderated by concurrent medical conditions. CONCLUSIONS: Our findings demonstrate that the burden on workers' quality of life and productivity associated with workplace bullying is substantial. This study provides key data to inform policy-making and prioritize occupational health interventions.

[Efficacy of aripiprazole on cognitive and behavioral changes in a young woman with systemic lupus erythematosus]. / Efficacia di aripiprazolo sui disturbi cognitivi e comportamentali in una giovane affetta da lupus eritematoso sistemico.

This paper describes the use of aripiprazole for the management of cognitive deficits and behavioral disorders in a young female patient suffering from systemic lupus erythematosus (SLE). Cognitive impairment, although often transient, is reported up to 75% of patients with SLE. The behavioral changes and, more generally, clear psychotic episodes have an incidence of 5% but they lead to considerable difficulties in clinical and therapeutic management. In cases with psychiatric manifestations of SLE, it is often necessary to introduce psychopharmacological therapy. The choice of aripiprazole has been made especially in light of low liability to cause weight gain and metabolic side effects. In fact aripiprazole is characterized by an original mechanism of action: it combines partial agonist activity on D(2), D(3) and 5-HT(1A) receptor with antagonistic activity on 5-HT(2A) and D(2). Aripiprazole has demonstrated efficacy in the management of behavioral disturbances and has improved some of impaired cognitive functions. Aripiprazole, therefore, could be a great tool in young patients with SLE.

Type A behaviour: a reappraisal of its characteristics in cardiovascular disease.

AIMS: The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description. METHODS: A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour. RESULTS: A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness. CONCLUSIONS: Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.

A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill.

BACKGROUND: The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill. METHOD: A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate. RESULTS: Three clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization. CONCLUSIONS: Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Psychopathology of first-episode psychosis in HIV-positive persons in comparison to first-episode schizophrenia: a neglected issue.

This study aims to detect different psychopathological dimensions in first-episode psychoses with different underlying causes. We evaluated 22 subjects with first-episode psychosis, who differed in biological variables (HIV-positive versus HIV-negative) and who were compared by using the Structured Clinical Interview for DSM-III-Reviewer, the 18-item Brief Psychiatric Rating Scale (BPRS), the 17-item Hamilton Depression Rating Scale, the 14-item Hamilton Anxiety Rating Scale and the Mini-Mental State Examination. HIV-positive subjects had higher mean scores on the global BPRS and on the paranoid Positive and Negative Syndrome Scale subscale compared with HIV-negative subjects. Conversely, higher prevalence of affective and anxious symptoms was found in the HIV-negative patients in comparison to HIV-positives. HIV-positives had significantly greater attention/concentration impairment than HIV-negative persons. In conclusion, taking into account psychopathological dimensions may help psychiatrists in clinical decision-making regarding the differential diagnosis of psychotic symptoms. The psychopathological pattern of first-episode psychosis in HIV-positive patients may represent an 'elementary model' of acute psychosis characterized by paranoid delusions in the absence of the usual affective symptoms.

Factors affecting dropout in outpatient eating disorder treatment.

OBJECTIVE: To evaluate the incidence and effects of factors potentially influencing eating disordered patients' dropping out of outpatient cognitive-behavioural therapy (CBT). METHOD: Sixty-seven (64 female, 3 male) patients with eating disorders participated in the study. All patients followed a multidisciplinary team approach for a median period of 9 months. Several factors potentially affecting dropout were retrospectively assessed prior to treatment. RESULTS: The dropout rate was significantly higher in patients with purging anorexia nervosa (AN) compared to those with restrictive AN, bulimia nervosa and eating disorder not otherwise specified (33% vs. 27%, 25% or 21%, respectively, p<0.05). Among several factors influencing dropout, there was a significant association of patient low cooperativeness, purging episodes, restrictive eating, use of several weight control practices and psychiatric co-morbidity in patients who dropped out compared to completers (all p<0.05). CONCLUSIONS: In outpatient eating disorder treatment, non-compliance and premature interruption of therapy are affected primarily by factors which are related to patients' attitude and behaviour. These factors should be carefully addressed in patients with eating disorders to improve outcome.

Cannabinoid receptors and their relationships with neuropsychiatric disorders.

Cannabinoids are the constituents of the marijuana plants. The central effects of exogenous cannabinoids are implicated in enhancing mood, altering emotional states, and interfering in the formation of short-term memory. Cannabinoid receptors are G protein-coupled receptors with seven transmembrane domains that are expressed on the cell surface with their binding domain exposed to the extracellular space. To date, two cannabinoid receptors have been cloned, CB1 and CB2. Recent evidence suggests that a third CB3 receptor is out there, waiting to be cloned. The endocannabinoids may represent the first members of a new classes of neuromodulators, that are not stored in cell vesicles, but rather synthesised by the cell on demand. The endogenous cannabinoid system could play a central role in several neuropsychiatric disorders and is also involved in other conditions such as pain, spasticity and neuroprotection. Implication of cannabinoid system in the pathogenesis and development of schizophrenia is also discussed.

Effect of mirtazapine on thyroid hormones in adult patients with major depression.

Hypothalamic pituitary thyroid (HPT) axis abnormalities and alterations in major depression are reported in the literature. The aim of our study was to evaluate the effect of mirtazapine on thyroid hormones after 6 months of therapy in a sample of adult outpatients with Major Depression (MD). 17 adult outpatients (7 men, 10 women) with MD according to DSM-IV criteria, were included in the study. All participants had to have met criteria for a major depressive episode with a score of at least 15 on the Hamilton Depression Rating Scale (HAM-D). Fasting venous blood samples were obtained for determination of serum Thyroid Stimulating Hormone (TSH), Free T3 (FT3) and Free T4 (FT4) concentrations both at baseline and after 6 months of therapy. HAM-D scores decreased significantly from the first day of treatment to the end of the treatment period (P<0.001) and twelve patients (70.6%) were classified as responders. A significant increase in FT3 concentrations was found between baseline and the end of the treatment period (P=0.015), whereas FT4 concentrations decreased (P=0.046). No significant changes were found in TSH levels. Higher FT4 concentrations at baseline predicted higher HAM-D scorers both at baseline and at the end of the treatment period. Furthermore, higher FT3 concentrations at endpoint were found to be predictors of lower HAM-D scores. Long-term treatment with mirtazapine increases FT3 levels and decreases FT4 maybe involving the deiodination process of T4 into T3.

The psychopharmacotherapy of anorexia nervosa: clinical, neuroendocrine and metabolic aspects.

Anorexia nervosa (AN) is a complex mental disorder presenting psychiatric and physical symptoms. Literature recognizes the role of several factors in the pathogenesis of this disorder, according to the biopsychosocial model. Many mechanisms are still partly unclear. Endocrine and metabolic alterations usually occur in AN, probably having a role in its pathogenesis and in the disorder perseverance. In consideration of the multifactorial pathogenesis, a multidisciplinary approach is needed in the treatment of anorexic patients. Up-to-date psychotherapy, psychopharmacological, endocrine and nutritional treatments are considered effective in improving AN. Literature does not however provide evidence of a single validated psychopharmacotherapy for anorexic patients. It is known that psychopharmacotherapy can influence hormonal and metabolic states in some conditions, but for the moment few data are present about these effects in AN. This article aims to review the data about the psychopharmacotherapy role in AN, focusing on the endocrine and metabolic effects of anti-depressants (AD) and novel antipsychotic drugs which seem to be the most effective in AN. Scant data are however available and further research should provide more evidence about these effects and also assess whether the severity of the neuroendocrine, hormonal and metabolic impairments can predict the lack of response to the psychopharmacological treatment with AD and neuroleptics.

Clinical and serological associations of ribosomal P autoantibodies in systemic lupus erythematosus: prospective evaluation in a large cohort of Italian patients.

OBJECTIVE: To verify the association of ribosomal anti-P antibodies (anti-P), as detected by a sensitive ELISA, with serological findings and clinical manifestations, including neuropsychiatric involvement evaluated according to the American College of Rheumatology (ACR) nomenclature, in a large cohort of patients with systemic lupus erythematosus (SLE). METHODS: Anti-P were evaluated in the serum of 149 consecutive Italian SLE patients by an ELISA using a multiple antigen peptide carrying four copies of a common P0, P1 and P2 epitope. A complete laboratory evaluation and clinical examination were performed in each patient. In addition, all patients underwent an accurate neuropsychiatric and neuropsychological assessment performed by trained specialists according to the 1999 ACR suggestions. RESULTS: Serum anti-P were detected in 18/149 patients (12.1%). The anti-P prevalence was similar (11.7%) when the analysis was performed in a larger series of sera including 82 additional SLE patients, who were not included in the clinical study. The age of anti-P-positive patients at disease onset was less than 33 yr and, in comparison with the anti-P-negative patients, these patients showed more active disease activity and a higher prevalence of photosensitivity and malar and discoid rash. A strong association between IgG anticardiolipin antibodies and anti-P was also found. However, anti-P were associated with neither neuropsychiatric syndromes nor cognitive impairment. CONCLUSION: This study does not seem to confirm the described association of anti-P with SLE neuropsychiatric manifestations. However, it supports the anti-P association with different skin manifestations as well as the presence of anticardiolipin in a subset of patients with SLE characterized by early disease onset.

Central nervous system involvement in systemic lupus erythematosus patients without overt neuropsychiatric manifestations.

OBJECTIVE: To verify whether features of CNS involvement can be detected in SLE patients without overt neuropsychiatric manifestations. METHODS: 114 SLE patients who had never received a diagnosis of neuropsychiatric lupus (never-NPSLE) were studied and compared to 65 SLE patients with known neuropsychiatric involvement (NPSLE). The study relied on evaluation of neurocognitive functions by means of a battery of neuropsychological tests, on psychiatric and neuropsychological assessments and on neuroimaging studies (computed tomography, magnetic resonance, single photon emission computed tomography (SPECT)). RESULTS: Clinical features, including disease duration/activity and pharmacological therapy, of never-NPSLE and NPSLE patients were similar. Short-term and long-term memory, visuo-spatial and verbal information processing were similarly compromised in never-NPSLE and in NPSLE patients; only attention was significantly more compromised in NPSLE patients. Psychiatric morbidity was higher than expected in never-NPSLE patients, although less than in the control neuropsychiatric group. Ischemic lesions, multiple small high intensity lesions and cortical atrophy, detected by CT and MR scans, as well as abnormal SPECT were also frequently detected in never-NPSLE patients. Interestingly, left parietal and occipital area hypoperfusion by SPECT was significantly more frequent in the patients with impaired visuo-spatial intelligence and short-term memory. CONCLUSIONS: Most abnormalities detected by available diagnostic tools and characteristics of neuropsychiatric SLE are also present in non-symptomatic patients. They may derive from an unexpected widespread involvement of the CNS and are not per se sufficient, in the absence of clinical manifestations, for a diagnosis of neuropsychiatric SLE.

Effects of acute benzodiazepine administration on growth hormone, prolactin and cortisol release after moderate insulin-induced hypoglycemia in normal women.

Benzodiazepines are known to affect pituitary hormone release, and it has recently been hypothesized that the adenohypophysial hormone response to stress may be modified by previous benzodiazepine treatment. We investigated, therefore, whether a single dose of triazolam, a short-acting benzodiazepine, and flurazepam, a long-acting one, could influence the response of prolactin (PRL), growth hormone (GH) and cortisol to a mild hypoglycemic stress in young healthy volunteers. Neither triazolam nor flurazepam pretreatment resulted in a significant effect on the pituitary response to hypoglycemic stimulus. The GH, PRL and cortisol peaks after both benzodiazepines were similar to those observed after placebo. Our results seem to exclude, therefore, any relevant effect of acute benzodiazepine administration on the neuroendocrine response to mild stress.