The Vulnerability to Suicidal Behavior is Associated with Reduced Connectivity Strength.

Suicidal behavior constitutes a major public health problem. Based on the stress-diathesis model, biological correlates of a diathesis might help to predict risk after stressor-exposure. Structural changes in cortical and subcortical areas and their connections have increasingly been linked with the diathesis. The current study identified structural network changes associated with a diathesis using a whole-brain approach by examining the structural connectivity between regions in euthymic suicide attempters (SA). In addition, the association between connectivity measures, clinical and genetic characteristics was investigated. We hypothesized that SA showed lower connectivity strength, associated with an increased severity of general clinical characteristics and an elevated expression of short alleles in serotonin polymorphisms. Thirteen euthymic SA were compared with fifteen euthymic non-attempters and seventeen healthy controls (HC). Clinical characteristics and three serotonin-related genetic polymorphisms were assessed. Diffusion MRI together with anatomical scans were administered. Preprocessing was performed using Explore DTI. Whole brain tractography of the diffusion-weighted images was followed by a number of streamlines-weighted network analysis using NBS. The network analysis revealed decreased connectivity strength in SA in the connections between the left olfactory cortex and left anterior cingulate gyrus. Furthermore, SA had increased suicidal ideation, hopelessness and self-reported depression, but did not show any differences for the genetic polymorphisms. Finally, lower connectivity strength between the right calcarine fissure and the left middle occipital gyrus was associated with increased trait anxiety severity (rs = -0.78, p < 0.01) and hopelessness (rs = -0.76, p < 0.01). SA showed differences in white matter network connectivity strength associated with clinical characteristics. Together, these variables could play an important role in predicting suicidal behavior.

Cost-effectiveness of health promotion targeting physical activity and healthy eating in mental health care.

BACKGROUND: There is a higher prevalence of obesity in individuals with mental disorders compared to the general population. The results of several studies suggested that weight reduction in this population is possible following psycho-educational and/or behavioural weight management interventions. Evidence of the effectiveness alone is however inadequate for policy making. The aim of the current study was to evaluate the cost-effectiveness of a health promotion intervention targeting physical activity and healthy eating in individuals with mental disorders. METHODS: A Markov decision-analytic model using a public payer perspective was applied, projecting the one-year results of a 10-week intervention over a time horizon of 20 years, assuming a repeated yearly implementation of the programme. Scenario analysis was applied evaluating the effects on the results of alternative modelling assumptions. One-way sensitivity analysis was performed to assess the effects on the results of varying key input parameters. RESULTS: An incremental cost-effectiveness ratio of 27,096€/quality-adjusted life years (QALY) in men, and 40,139€/QALY in women was found in the base case. Scenario analysis assuming an increase in health-related quality of life as a result of the body mass index decrease resulted in much better cost-effectiveness in both men (3,357€/QALY) and women (3,766€/QALY). The uncertainty associated with the intervention effect had the greatest impact on the model. CONCLUSIONS: As far as is known to the authors, this is the first health economic evaluation of a health promotion intervention targeting physical activity and healthy eating in individuals with mental disorders. Such research is important as it provides payers and governments with better insights how to spend the available resources in the most efficient way. Further research examining the cost-effectiveness of health promotion targeting physical activity and healthy eating in individuals with mental disorders is required.

Health promotion in individuals with mental disorders: a cluster preference randomized controlled trial.

BACKGROUND: The existing literature on weight management interventions targeting physical activity and healthy eating in mental health care appears to provide only limited evidence. The aim of the study was to examine the effectiveness of a 10-week health promotion intervention, followed by a 6-month follow-up period in individuals with mental disorders living in sheltered housing in the Flanders region (Belgium). METHODS: The study had a cluster preference randomized controlled design. Twenty-five sheltered housing organisations agreed to participate (16 in the intervention group, nine in the control group). In the intervention group, 225 individuals agreed to participate, while in the control group 99 individuals entered into the study. The main outcomes were changes in body weight, Body Mass Index, waist circumference and fat mass. Secondary outcomes consisted of changes in physical activity levels, eating habits, health-related quality of life and psychiatric symptom severity. RESULTS: A significant difference was found between the intervention group and the control group regarding body weight (-0.35 vs. +0.22 kg; p=0.04), Body Mass Index (-0.12 vs. +0.08 kg/m2; p=0.04), waist circumference (-0.29 vs. + 0.55 cm; p<0.01), and fat mass (-0.99 vs. -0.12%; p<0.01). The decrease in these outcomes in the intervention group disappeared during the follow up period, except for fat mass. Within the intervention group, a larger decrease in the primary outcomes was found in the participants who completed the intervention. No significant differences between the two groups in changes in the secondary outcomes were found, except for the pedometer-determined steps/day. In the intervention group, the mean number of daily steps increased, while it decreased in the control group. CONCLUSIONS: The study demonstrated that small significant improvements in the primary outcomes are possible in individuals with mental disorders. Integration of health promotion activities targeting physical activity and healthy eating into daily care are, however, necessary to maintain the promising results. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov NCT 01336946.

Do restrictive and bingeing/purging subtypes of anorexia nervosa differ on central coherence and set shifting?

OBJECTIVE: Anorexia nervosa (AN) has been associated with weak central coherence (CC) and weak set shifting (SS). The main aim of this study was to examine possible differences between restrictive AN (AN-R) and bingeing/purging AN (AN-BP) on these features. METHODS: A total of 31 patients with AN-R, 20 patients with AN-BP and 26 healthy controls (HC) completed five neuropsychological tests (Block Design, Object Assembly, an adapted task-switching paradigm, Wisconsin Card Sorting Test and Trail Making Test). RESULTS: Using Block Design and Object Assembly, indicative for CC, AN-R patients performed significantly worse than AN-BP patients and HC, without any difference between AN-BP and HC. On SS measures, no group differences were observed. DISCUSSION: The results suggest that cognitive profiles of AN-R and AN-BP patients differ significantly on CC and not on SS. Our current findings support the idea that the two subtypes of AN have a distinctive underlying nature and might need a different approach in cognitive remediation.

Health promotion in mental health care: perceptions from patients and mental health nurses.

AIMS AND OBJECTIVES: To gain insight into the factors influencing the integration of physical activity and healthy eating into the daily care of individuals with mental disorders (MD) living in sheltered housing and to increase the understanding of the relationships between and complexities of these factors. BACKGROUND: Growing attention is given to the implementation of health promotion activities in mental health care. By improving the understanding of perceptions of patients and mental health nurses, health promotion programmes targeting physical activity and healthy eating can be developed that better meet the patients' needs. DESIGN: A descriptive qualitative study. METHODS: Based on a purposive sampling strategy, three focus groups including 17 mental health nurses and individual interviews with 15 patients were conducted. RESULTS: Although physical and mental health benefits of physical activity and healthy eating were identified, several barriers to integrate healthy lifestyles into the daily life of patients were reported. Important barriers identified by the patients consisted of lack of energy and motivation as a result of the MD, side effects of psychotropic drug use, and hospitalisation. Lack of time and personal views and attitudes towards health promotion were reported by the mental health nurses as important elements influencing the way in which they integrate health promotion in the care provided. Support from the mental health nurse was considered important by the patients in changing their unhealthy lifestyle behaviour. CONCLUSIONS: The results of the study provide insight into important factors influencing the integration of health promotion activities targeting physical activity and healthy eating in individuals with MD living in sheltered housing. RELEVANCE TO CLINICAL PRACTICE: The information derived from this study is useful and relevant in the design and implementation of health promotion interventions targeting physical activity and healthy eating in people with MD living in sheltered housing.

Health promotion intervention in mental health care: design and baseline findings of a cluster preference randomized controlled trial.

BACKGROUND: Growing attention is given to the effects of health promotion programs targeting physical activity and healthy eating in individuals with mental disorders. The design of evaluation studies of public health interventions poses several problems and the current literature appears to provide only limited evidence on the effectiveness of such programs. The aim of the study is to examine the effectiveness and cost-effectiveness of a health promotion intervention targeting physical activity and healthy eating in individuals with mental disorders living in sheltered housing. In this paper, the design of the study and baseline findings are described. METHODS/DESIGN: The design consists of a cluster preference randomized controlled trial. All sheltered housing organisations in the Flanders region (Belgium) were asked if they were interested to participate in the study and if they were having a preference to serve as intervention or control group. Those without a preference were randomly assigned to the intervention or control group. Individuals in the intervention group receive a 10-week health promotion intervention above their treatment as usual. Outcome assessments occur at baseline, at 10 and at 36 weeks. The primary outcomes include body weight, Body Mass Index, waist circumference, and fat mass. Secondary outcomes consist of physical activity levels, eating habits, health-related quality of life and psychiatric symptom severity. Cost-effectiveness of the intervention will be examined by calculating the Cost-Effectiveness ratio and through economic modeling.Twenty-five sheltered housing organisations agreed to participate. On the individual level 324 patients were willing to participate, including 225 individuals in the intervention group and 99 individuals in the control group. At baseline, no statistical significant differences between the two groups were found for the primary outcome variables. DISCUSSION: This is the first trial evaluating both the effectiveness and cost-effectiveness of a health promotion intervention targeting physical activity and healthy eating in mental health care using a cluster preference randomized controlled design. The baseline characteristics already demonstrate the unhealthy condition of the study population. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov - NCT 01336946.

Attempted suicide among immigrants in European countries: an international perspective.

PURPOSE: This study compares the frequencies of attempted suicide among immigrants and their hosts, between different immigrant groups, and between immigrants and their countries of origin. METHODS: The material, 27,048 persons, including 4,160 immigrants, was obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour, the largest available European database, and was collected in a standardised manner from 11 European centres in 1989-2003. Person-based suicide-attempt rates (SARs) were calculated for each group. The larger immigrant groups were studied at each centre and compared across centres. Completed-suicide rates of their countries of origin were compared to the SARs of the immigrant groups using rank correlations. RESULTS: 27 of 56 immigrant groups studied showed significantly higher, and only four groups significantly lower SARs than their hosts. Immigrant groups tended to have similar rates across different centres. Moreover, positive correlation between the immigrant SAR and the country-of-origin suicide rate was found. However, Chileans, Iranians, Moroccans, and Turks displayed high SARs as immigrants despite low suicide rates in the home countries. CONCLUSIONS: The similarity of most immigrant groups' SARs across centres, and the correlation with suicidality in the countries of origin suggest a strong continuity that can be interpreted in either cultural or genetic terms. However, the generally higher rates among immigrants compared to host populations and the similarity of the rates of foreign-born and those immigrants who retained the citizenship of their country of origin point to difficulties in the acculturation and integration process. The positive correlation found between attempted and completed suicide rates suggests that the two are related, a fact with strong implications for suicide prevention.

Effectiveness and cost-effectiveness of lifestyle interventions on physical activity and eating habits in persons with severe mental disorders: a systematic review.

BACKGROUND: There is a high prevalence of overweight and obesity in persons with severe mental disorders and this has serious implications on the short and long term health outcomes of these patients. The aim of this review was to evaluate the effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders. Special attention was given if any of the included studies in the review also examined the cost-effectiveness of these health promotion interventions. METHODS: A systematic search through the electronic databases Medline, Web of Science, CINAHL and Cohrane Library was conducted, and by hand-searching the reference lists of the retrieved articles from the electronic databases. Studies were included if they examined effectiveness and/or cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders, with primary outcome changes in Body Mass Index and body weight. RESULTS: Fourteen studies met the inclusion criteria. Weight loss and Body Mass Index decrease were observed in intervention groups in 11 studies. The difference in weight change between intervention and control groups was statistically significant in nine studies. Differences in mean Body Mass Index between intervention and control groups were statistically significant in eight studies. Five studies reported improvements in quality of life and general health. In none of the studies cost-effectiveness of lifestyle interventions was examined. CONCLUSION: Further research on both effectiveness and cost-effectiveness of lifestyle interventions targeting physical activity and eating habits in persons with severe mental disorders is required to assist in the development of new health promotion interventions in this population.

Concurrent use of lamotrigine and electroconvulsive therapy.

OBJECTIVE: : To evaluate the effect of lamotrigine (LMT) on electroconvulsive therapy (ECT)-induced seizures. METHODS: : Charts of all patients receiving LMT while undergoing an ECT course from July 2001 through May 2009 were reviewed. Apart from demographic variables, data collection consisted of diagnosis, indication for ECT, index or continuation ECT, electrode placement, stimulus dose, motor and electroencephalographic seizure duration, LMT dose, and number of restimulations. The stimulus dose and the seizure duration of ECT treatments with concurrent LMT (≥200 mg/d) were compared with the stimulus dose and seizure duration of ECT treatments without concurrent LMT. RESULTS: : Lamotrigine was used by 19 patients (16 women, 3 men) during 289 treatment sessions. Eleven patients had ECT treatments with and without LMT, of which 8 were at a dosage of 200 mg/d or higher. Analyses did not reveal a significant difference in seizure duration and stimulus dose. Missed seizures, however, occurred more frequently during ECT treatments with concurrent LMT. CONCLUSIONS: : In all patients, seizures of adequate duration could be elicited. The combination was well tolerated. Therapeutic doses of LMT do not seem to have a clinically significant influence on the length of ECT-induced seizures nor on the stimulus dose.

Quetiapine treatment and improved cognitive functioning in borderline personality disorder.

OBJECTIVE: We aimed to assess whether executive functioning improved over time in a sample of borderline personality disorder (BPD) subjects that took part in a quetiapine treatment trial. METHODS: Performance on the following neurocognitive tasks was assessed at enrolment and at the end of the 12 weeks quetiapine treatment: Trail Making Task, Word Fluency Task and Tower of London Task. Forty-one BPD patients were recruited, of whom 32 completed the trial. An intention-to-treat analysis with a mixed linear model was applied. RESULTS: The data show that participants significantly improved on most executive functioning measures. Patients' scores decreased significantly (mean [SD] difference; p-value) on the Trail Making Task Part A (11.7 [2.3]; p < 0.0001), Part B (51.8 [9.2]; p < 0.0001) and 'B minus A' (40.1 [8.2]; p < 0.0001), on a Phonological (15.9 [1.6]; p < 0.0001) and Semantic (9.8 [1.1]; p < 0.0001) Verbal Fluency tasks, and on the Tower of London total correct score (2.5 [0.4]; p < 0.0001), total move score (29.5 [4.5]; p < 0.0001) and total time (172.9 [35.8]; p < 0.0001). CONCLUSIONS: In this study we have demonstrated that executive functioning in BPD is improved after treatment with quetiapine. Neurocognitive measures of executive functioning should be considered as valuable outcomes in the study of treatment efficacy in BPD.

Efficacy of quetiapine for impulsivity and affective symptoms in borderline personality disorder.

Data on the efficacy of quetiapine in borderline personality disorder (BPD) are still scarce. We aimed to investigate the efficacy of quetiapine for impulsivity and a broad range of affective symptoms in BPD. In this 12-week open-label study, we included individuals with BPD who presented to psychiatric in- and outpatient services. After a gradual titration of quetiapine, a flexible dose (range, 100-800 mg) was administered. The main outcome measures consisted of the scores on patient-rated questionnaires (Barratt Impulsiveness Scale, Buss-Durkee Hostility Inventory, Affective Lability Scale, Spielberger State and Trait Anxiety Inventory, Spielberger State and Trait Anger Inventory, and Beck Depression Inventory) and on neurocognitive tasks related to impulsivity (Stroop Color Word Task and IOWA Gambling Task). A mixed linear model, correcting for age, sex, antidepressant use, and weeks in psychotherapy, was applied. Forty-one patients (34 females and 7 males; mean [SD] age, 27.0 [9.0] years) were enrolled in the study, 32 of which completed the trial. Patients' scores decreased significantly (mean [SD] difference; P value) on the Barratt Impulsiveness Scale (19.7 [2.0]; P < 0.0001), Buss-Durkee Hostility Inventory (11.5 [1.4]; P < 0.0001), Affective Lability Scale (0.75 [0.08]; P < 0.0001), Beck Depression Inventory (25.0 [1.7]; P < 0.0001), Spielberger State and Trait Anxiety Inventory state (19.9 [1.9]; P < 0.0001) and trait (20.8 [1.7]; P < 0.0001) subscale, and Spielberger State and Trait Anger Inventory state (7.3 [1.1]; P < 0.0001) and trait (10.1 [1.0]; P < 0.0001) subscale. In addition, patients showed significantly less inference on the Stroop Color Word Task and had more 'good choices' on the IOWA Gambling Task. These results suggest that quetiapine may be efficacious in the treatment of impulsivity and affective symptoms in BPD.

Euthanasia: the role of the psychiatrist.

Belgium has become one of the few countries in the world where euthanasia is legally allowed within a specific juridical framework. Even more unique is the inclusion of grounds for requesting euthanasia on the basis of mental suffering. Further refinement of the legal, medical and psychiatric approach to the issue is required in order to clear up essential practical and ethical matters. Psychiatrists and their professional organisations need to play a greater role in this ongoing debate and contribute from a clinical, scientific and ethical point of view.

Suicidal behavior and violence in male adolescents: a school-based study.

OBJECTIVE: To investigate characteristics of suicidal and violent behavior in a community school sample of adolescents. METHOD: Self-report questionnaires were administered to 794 male students (aged 12-18 years) from Antwerp, Belgium. Subjects were classified into four groups: a suicidal-only (n = 40; suicidal ideation and/or self-harming behavior), a violent-only (n = 142), a suicidal-violent (n = 21), and a control group (n = 591). RESULTS: Compared with controls, higher levels of internalizing problems, risk-taking behavior (substance use, diminished perception of risk, sensation seeking), and aggression were found in the comparison groups. The suicidal-violent group had the highest levels of depression, somatization, overt and covert aggression, and risk-taking behavior. Compared with the suicidal-only group, the violent-only group had less depression, anxiety, and covert aggression, but higher levels of overt aggression, sensation seeking, diminished perception of risk, and marijuana use. CONCLUSIONS: Although adolescent suicidal and violent behavior are both related to internalizing problems, aggression, and risk-taking behavior, marked differences in severity and nature exist in these relationships. Differentiation of suicidal youths based on the presence or absence of violent behavior may add to our understanding of suicidal phenomena and may thus have important clinical consequences.

Effects of aging on brain perfusion and serotonin-2A receptor binding in the normal canine brain measured with single photon emission tomography.

Normal aging is associated with a decrease in number and size of neurons, loss of synapses and neuronal branching and with a reduced functioning neurotransmitter systems, such as the serotonergic system. These structural and functional alterations have important impact on the behavioural, cognitive and affective status of the individual. With the introduction of functional brain imaging in veterinary medicine, the canine brain can be examined in vivo, evaluating changes in perfusion, metabolism and neurotransmitter systems. Since cognitive decline is recognised in the aging dog, it was our aim to investigate whether age related changes concerning cerebral perfusion and binding index of the selective 5-HT2A receptor ligand 123I-5-I-R91150 could be found in the canine brain. A group of twelve normal, aging dogs, older than 96 months, was compared to a normal reference group (n = 12), younger than 96 months. SPET images were obtained, using the radiopharmaceutical 99mTc-N,N''-1,2-ethylene-diylbis-L-cysteine diethylester dihydrochloride (99mTc-ECD) for evaluation of the regional perfusion and the selective radioligand 123I-5-I-R91150 for visualization of the 5-HT2A receptor. Regional decrease of cerebral blood-flow was noted in the fronto- and temporocortical area and in the subcortical region. Age was negatively correlated with perfusion in the left and right fronto-cortical region. The binding index of the neuroreceptor radioligand was decreased in the fronto-cortical region, with a significant negative correlation with age in the right fronto-cortical area. No correlation was found between alteration of perfusion and binding index of the receptor ligand, suggesting that age related perfusion differences do not influence the binding of this radioligand. These results suggest that age related effects should be considered in functional canine brain imaging.