Acta Psychiatrica Scandinavica

Article of the Month

MAY 2013

Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data).
Grande, J. M. Goikolea, C. de Dios, A. Gonz_lez-Pinto, J. M. Montes, J. Saiz-Ruiz, E. Prieto, E. Vieta, for the PREBIS group.

The current evidence suggests that patients with bipolar disorder (BD) present a relevant functional impairment across all phases of the disorder including during interepisode intervals. Several variables have been reported to negatively influence functioning such as male gender, older age, living without a partner, number of previous episodes, number of previous hospitalizations, length of admission, rapid cycling, psychotic symptoms and substance use disorder. Moreover, occupational adjustment is one functional domain with a major impact on personal and societal costs. In the May issue of Acta Psychiatrica Scandinavica, Grande and colleagues present a relevant study that help to better understand the underlying causes of occupational disability in BD patients. The results emphasize the importance of early diagnosis and treatment of BD, the clinical relevance of comorbidity with personality disorders, the impact of social support, and the need to closely monitor patients who are occupationally disabled, given their high tendency to recurrence. Read more...

Vasco Videira Dias - Bipolar Disorder Field Editor
Lisbon, Portugal

APRIL 2013

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression
C Dack, J Ross, c Papadopoulos, D Stewart, L Bowers

Clinicians daily face the task of estimating the risk for aggressive behavior by psychiatric patients. Although ensuring the safety of patients and staff is a top priority of in-patient psychiatric wards, aggressive behavior is quite common in this setting. In fact, about one third of in-patients and 40-80% of staff of in-patient psychiatric wards report having suffered aggressive behavior. Unfortunately, the evidence about risk factors associated with inpatient aggression is very limited.

In the Acta Psychiatrica Scandinavica April issue Dack and colleagues present data from the first meta-analysis of aggression by psychiatric in-patients. They found that several clinical and socio-demographic factors are associated with in-patient aggression. However, given the small magnitude of these associations, the authors conclude that more attention should be paid to other dynamic factors such as the patient’s current state and context to prevent in-patient aggression.

FEBRUARY 2013

Antidepressant use in pregnancy: a critical review focused on risks and controversies.
N. Byatt, KM. Deligiannidis, MP.Freeman

There has been a long-standing debate about the use of antidepressants in pregnancy due to the lack of and conflicting data and the ethical restrictions of randomized controlled trials in pregnant women. In the Acta Psychiatrica Scandinavica February issue, Byatt and colleagues try to make order in such a complicated topic. The authors put the light on not only the review of the literature on risks of exposure to antidepressants during pregnancy but also on the risks of untreated depression and anxiety. Unfortunately, the findings are inconsistent and controversial. Moreover, the authors strongly suggest that the treatment is tailored to each patient. Read more...

In an accompanying Invited Comment, Einarson discusses the conclusions by Byatt and colleagues.

The importance of critical evaluation of the literature regarding safety of antidepressant use in pregnancy
A. Einarson

Maria Paola Rapagnani - Trainee Advisory Board
Verona, Italy

JANUARY 2013

Are immediate- and extended-release drugs interchangeable?
D. Cohen, AJM. Loonen

The January issue of Acta Psychiatrica Scandinavica brings a discussion paper by Dan Cohen and Anton J.M. Loonen in which they discuss whether immediate- and extended-release drugs are interchangeable and whether branded drugs can be substituted by generic drugs. The paper is commented by Stephen M. Stahl, David Taylor and Wolfgang Fleischhacker in three different editorial comments.

The tyranny of the majority and the interchangeability of drugs
S.M. Stahl

Just ask the patient
D.M. Taylor

Are original, branded psychotropics and generic medications interchangeable?
W. Fleischhacker

DECEMBER 2012

The mistaken claim of bipolar ‘overdiagnosis’: solving the false positives problem for DSM-5/ICD-11
J. Phelps, S.N. Ghaemi

“Overdiagnosis” of mental disorders, i.e. assigning a specific diagnosis to an individual, who does not suffer from the specific illness, is considered to be a significant problem by both physicians and laymen. In their article in the December issue of the Acta Psychiatrica Scandinavica, Phelps and Ghaemi address this issue, using bipolar disorder as example. Their main conclusion is that diagnostic accuracy in relation to low-prevalence illnesses can be improved considerably by taking non-symptom clinical information into account - in order to increase the prior probability of illness. In the case of bipolar disorder, important non-symptom features include early age at onset, family history of bipolar spectrum disorders, high recurrence rate of depression, and presence of psychotic symptoms. While this may seem trivial for an experienced clinician, giving emphasis to prior probability of illness is not part of current diagnostic manuals. Phelps and Ghaemi therefore suggest that this should be considered in the upcoming DSM-5/ICD-11. The article is well worth reading.

The above article is discussed by Ketter and Citrome in an accompanying editorial comment.

Addressing challenges in bipolar diagnosis: what do good clinicians already do?
T.A. Ketter, L. Citrome

Søren Dinesen Østergaard -Trainee Advisory Board
Aalborg, Denmark

NOVEMBER 2012

Pharmacological approaches in bipolar disorders and the impact on cognition: a critical overview
Dias VV, Balanzá-Martinez V, Soeiro-de-Souza MG, Moreno RA, Figueira ML, Machado-Vieira R. and Vieta E.

The presence of functionally relevant cognitive impairments in bipolar disorder (BD) has been established by many studies. Yet, for clinicians it is difficult to know whether cognitive complaints are intrinsic aspects of the illness or adverse effects of medication.

In the November issue of Acta Psychiatrica Scandinavica, Dias and colleagues provide a comprehensive overview of studies investigating the cognitive effects associated with pharmacological agents used in the treatment of BD. While the literature is still sketchy, with few controlled trials focusing on neurocognitive outcomes, some consistent trends emerged with distinct clinical implications. Given that neurocognitive functioning is already compromised in BD, the clear and convincing message of the paper is that pharmacotherapies for BD should be chosen to minimize neurocognitive side-effects. Read more.

Lydia Krabbendam - Cognition Field Editor
Amsterdam, the Netherlands

OCTOBER 2012

Cognitive functioning and age at onset in non-affective psychotic disorder
van der Werf M, Köhler S, Verkaaik M, Verhey F, van Os J, GROUP Investigators

The manuscript of the month in the October issue of Acta Psychiatrica Scandinavica is ”Cognitive functioning and age of onset in non affective psychotic disorder” by van der Werf et al. Age of onset of any psychiatric disorder seems to be a powerful predictor of several outcome variables, in this paper illustrated by a found association between early onset and higher antipsychotic prescribing and more negative symptoms. Although, the variable age of onset is limited by the inaccuracy of when the symptoms/disease really started, it still remain an important variable probably explaining more about etiology of psychotic disorder than any single psychotic symptom. Read more.

Jimmi Nielsen - Advisory Board
Aalborg, Denmark

SEPTEMBER 2012

A decision analysis of long-term lithium treatment and the risk of renal failure
Werneke U, Ott M, Renberg ES, Taylor D, Stegmayr B.

Lithium remains a first line maintenance treatment for bipolar disorder. However, its use seems in decline, and second-generation antipsychotics have increasingly been used as alternative treatment. The evidence base for choosing alternative treatment for these patients is limited. In this article the authors have conducted a systematic review of the literature in order to establish whether lithium or anticonvulsants should be the preferred treatment in patients at risk for end-state renal failure. Based on the findings, they conclude that at the current state of knowledge, lithium initiation and continuation should be recommended in most cases even in the presence of long-term adverse renal effects. Read more.

Participants ”scientific writing and publishing”
Aarhus Psychiatric Postgraduate Summer School 2012

Annette Holth Skogan,Bolette Daniels Beck,Bothild Bendiksen, Stine Lindhahl Jacobsen, Anne Sofie Lundberg, Adrian Pasareanu, Oriana Pinto, Tarig Salah, Helle Østermark Sørensen, Kristin Øvergaard

AUGUST 2012

Brain dysfunction in fibromyalgia and somatisation disorder using proton magnetic resonance spectroscopy: a controlled study.
Fayed N, Andres E, Rojas G, Moreno S, Serrano-Blanco A, Roca M, Garcia-Campayo J.

In the August issue of Acta Psychiatrica Scandinavica, Fayed et al present findings from a preliminary study using proton magnetic resonance spectroscopy (MRS) to investigate brain metabolite levels in two complicated and debilitating illnesses, fibromyalgia and somatization disorder. The authors investigated correlations between these levels and several different ratings of pain catastrophizing, anxiety, depression and quality of life. Interestingly, among other findings this group found an increase in glutamate and related metabolites in the posterior cingulate cortex (PCC), which was highly correlated with pain catastrophizing. The PCC is a region often associated with the Default Mode Network (a brain network involved in introspection and self-monitoring, also implicated in a wide range of psychiatric illnesses) Their results suggest that brain abnormalities in these two disorders may involve the glutamate system, and perhaps indicate deficiencies in learning processes associated with pain. This study suggests that glutmate-based medications may play a role in future treatment of fibromyalgia and somatization disorder, and that MRS may be a potentially useful tool to better investigate the pathophysiology of these complicated disorders. Read more.

Noah S. Philip - Trainee Advisory Board
Providence, CI, USA

JULY 2012

Glutamatergic changes in the cerebral white matter associated with schizophrenic exacerbation
M. Ota, M. Ishikawa, N. Sato et al.

The July issue of the Acta Psychiatrica Scandinavica is thematic, focusing on schizophrenia and its treatment.

Preclinical animal models and genetic studies have implicated aberrant glutamate signaling as a pathological process underlying schizophrenia. However, due to the complex challenges associated with in vivo neurochemistry in humans, few studies have tested this hypothesis directly in living subjects afflicted with the illness. In this month’s Acta Psychiatrica Scandinavica, Ota and colleagues present the results of an innovative nuclear magnetic resonance spectroscopy study that measured glutamate and glutamine (Glx) in the white matter of subjects with schizophrenia. They report that subjects in the midst of a psychotic exacerbation had elevated levels of Glx relative to patients with less active symptoms or healthy controls. In this way, they have advanced the glutamate hypothesis, broadened the base of support for the model, and perhaps developed an assay whereby treatment interventions targeting glutamate can be evaluated. Read more.

Michael McCarthy - Neurobiology Field Editor
La Jolla, CA, USA

JUNE 2012

Trajectory classes of depressive symptoms in a community sample of older adults
Kuchibhatla MN, Filenbaum GG, Hybels CF, Blazer DG.

In the Acta Psychiatrica Scandinavica June issue, Kuchibhatla and colleagues report on the trajectory of depressive symptoms over 10 years in a cohort of older adults. Consistent with some previous studies, the authors find evidence for four distinct trajectories and report that improving symptom trajectories are associated with higher education, better cognitive health and fewer stressful events. This study adds to a growing body of trajectory studies that promise to identify subsets of the population that could most benefit from depression prevention and treatment interventions. Read more.

Srijan Sen - Genetics Field Editor
Ann Arbor, MI, USA

MAY 2012

Menstrual exacerbation of schizophrenia symptoms
MV Seeman

Over decades, the phenomenon of cyclical mood disorders, particularly those associated with female reproductive cycles, have been studied extensively. However, despite strong evidence from epidemiological, genetic and neurobiological models suggesting shared susceptibility between mood disorders and schizophrenia, relatively scant attention has been devoted to the cyclical features of psychosis. In the May issue of Acta Psychiatrica Scandinavica, Mary Seeman presents a clinical overview of schizophrenia, highlighting changes in clinical status associated with the menstrual cycle, and interventions affecting female reproductive hormones. The review highlights a number of key issues that may be immediately relevant to improving clinical care of women with schizophrenia. More broadly, this summary will serve to stimulate further experimental research in this important area, ultimately improving the understanding of schizophrenia and other psychiatric disorders thought to be linked with rhythmic aspects of physiology. Read more...

Michael McCarthy - Neurobiology Field Editor
La Jolla, CA, USA

APRIL 2012

Predominant recurrence polarity among 928 adult international bipolar I disorder patients
R. J. Baldessarini, J. Undurraga, G. H. Vázquez et al.

The heterogeneity of bipolar disorder has inspired many attempts to define clinically and etiologically meaningful subtypes. A particularly promising approach is the recent focus on the predominant polarity of the recurrent major episodes, based on at least a two-fold excess of either depression or mania-like episodes. In the April issue of Acta Psychiatrica Scandinavica, Baldessarini and colleagues provide a comprehensive test of the use of predominant-polarity in a large sample (n=928) of bipolar I disorder patients from five international sites. Of note, long-term morbidity was predicted by the polarity of the first episode and predominant-depression was associated with higher suicide risk. Subtyping by predominant-polarity may contribute to future etiological research and to the planning of clinical care. Read more...

Lydia Krabbendam - Cognition Field Editor
Amsterdam, the Netherlands

MARCH 2012

Evidence that interactive effects of COMT and MTHFR moderate psychotic response to environmental stress
O Peerbooms O, BPF Rutten, D Collip et al.

The functional interaction between Catechol-O-methyltransferase (COMT) Val158Met and methylenetetrahydrofolate reductase (MTHFR) C677T has been shown to differentially affect cognition in patients with schizophrenia and healthy controls. The present study by Peerbooms et examined the effect of COMT Val158Met versus MTHFR interaction on resilience to stress in patients and controls. The authors argue that stress reactivity associated with COMT Val158Met in patients with psychosis may crucially depend on MTHFR C677T genotype. This is particularly important because it enhances the concept of reactivity to stress in patients with psychoses, suggestion a specific genotypes mediator for affective and psychotic components of the disease. Read more..

Vasco Videira Dias - Bipolar Disorder Field Editor
Lisbon, Portugal

FEBRUARY 2012

Meta-analysis of structural MRI studies in children and adults with attention deficit hyperactivity disorder indicates treatment effects.
T Frodl, N Skokauskas

Attention deficit hyperactivity disorder (ADHD) currently receives significant attention by the general public and the news media. Two of the most frequently raised questions are: “Is ADHD a real disorder or just bad behaviour?” and “Is it ethically sound to treat children with central stimulant drugs?” In their recent meta-analysis, Frodl and Skokauskas review the studies published on MRI brain scans of patients with ADHD. Their main conclusion is that ADHD is associated with significantly reduced volume of several brain regions, and that proper treatment seems to prevent progression of these changes. These conclusions are important in the light of the current public debate outlined above. ADHD is a neurodevelopmental disorder associated with structural changes of the brain and significant impairment. Proper treatment relieves symptoms and, according to the meta-analysis by Frodl and Skokauskas, also appears to prevent additional structural changes of the brain. Read more...

Srijan Sen - Genetics Field Editor
Ann Arbor, MI, USA

JANUARY 2012

Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis
S Drag, DH Nieman, F Schultze-Lutter et al.

Although numerous studies have found a robust association between cannabis use and the onset of psychosis, the relationship between cannabis use and the onset of symptoms of psychosis in not clear. This study focused on the relationship between cannabis use and early and high-risk symptoms in subjects at clinical high risk for psychosis. The authors argue that younger age at onset of cannabis use or a cannabis use disorder were significantly related to younger age at onset of six symptoms. They concluded that cannabis use plays an important role in the development of psychosis in vulnerable individuals and cannabis use in early adolescence should be discouraged. This study is particularly important because it highlights the effect on cannabis use in individuals with vulnerability and the facilitating role for the onset of psychosis. Read more..

Michael McCarthy - Neurobiology Field Editor
La Jolla, CA, USA

DECEMBER 2011

The heterogeneity of the depressive syndrome: when numbers get serious
SD Østergaard, SOW Jensen, P Bech

There has been a long-standing and fierce debate about whether major depression should be considered a single diagnostic entity or be split into multiple subtypes. In the Acta Psychiatrica Scandinavica December issue, Østergaard and colleagues take a fresh look at this debate. The authors first explicitly calculate the number of symptom combinations that can result in a DSM-IV diagnosis of major depression (about 1500) and then examine how recent clinical effectiveness and gene-environment interaction studies highlight the problems with the single diagnostic approach utilized in the DSM-IV.

In an accompanying “Invited Comment,” Ghaemi and Vöhringer respond to the points raised by Østergaard and colleagues and place the debate in a historical perspective. These pieces are thought provoking and well worth reading.

The heterogeneity of depression: an old debate renewed
SN Ghaemi, PA Vöhringer

Srijan Sen - Genetics Field Editor
Ann Arbor, MI, USA