RESILIENCE AND DEPRESSIVE DISORDERS

Introduction: There is considerable variability in the response of individuals to adverse environmental conditions, while some develop psychiatric illnesses like depression, others seem very capable of dealing with it. It is in this observation that the concepts of vulnerability and resilience are rooted. Methods: We conducted a review of the literature by inserting in PubMed the keywords resilience, vulnerability and depressive disorders. Discussion and conclusions: Freud formerly used the so-called crystal-principle to describe the concept of vulnerability: according to this, the different psychopathologies would arise depending on the different psychological weaknesses, just like a crystal thrown to the ground shatters along its lines of cleavage intrinsic to it, albeit invisible. The term resilience has been borrowed from physics where it is used to describe the ability of a material to withstand impact without cracking. In psychology, the term resilience refers to a complex and dynamic multidimensional construct, which derives from the interaction of neurobiological, social and personal factors and indicates the ability to adaptively cope with stress and adversity, preserving a normal physical and psychological functioning. Resilience has proven to be a protective factor against the development of psychiatric disorders such as depression. Making a conceptual leap, the concepts of vulnerability and resilience can be related to the psychodynamic classification of depression postulated by Gaetano Benedetti, who distinguished four kinds of depression: the first due to the failure of the ego, the second to the perversion of the superego, the third to the inhibition of the Id and the fourth to the collapse of the ego ideal. It is possible to improve the resilience of depressed subjects through pharmacological and psychotherapeutic interventions

DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH

Background: We currently define dysphoria as a complex and disorganized emotional state with proteiform phenomenology, characterized by a multitude of symptoms. Among them prevail irritability, discontent, interpersonal resentment and surrender. Dysphoria, in line with the most recent Interpersonal Dysphoria Model, could represent a “psychopathological organizer” of the Borderline Personality Disorder. We would like to extend this theoretical concept to other psychiatric disorders in order to consider dysphoria as a possible psychopathological nucleus, a syndrome on its own. This syndromic vision may open up the possibility of new paths both in the differential diagnosis and in the therapeutic approach to the various disorders. Aims: The goal of this paper is to understand if the dimensional spectrum that composes dysphoria differs from the different psychiatric disorders. Specifically, we would like to assess if the phenomenological expression of dysphoria differs in patients with Borderline Personality Disorder (BPD), Mixed State Bipolar Disorder (BDM) and Major Depressive Disorder (MDD) through an observational comparative study. Subjects and methods: In this study, 30 adult patients, males and females between the ages of 18 and 65, were enrolled from the Psychiatric Service of the Santa Maria della Misericordia Hospital in Perugia (PG), Italy, from January 1st to June 30th, 2018. The aim was to form 3 groups each one composed of 10 individuals affected respectively with Borderline Personality Disorder (BPD), with Bipolar Disorder, Mixed State (BPM) and Major Depression Disorder (MDD). After a preliminary assessment to exclude organic and psychiatric comorbidity, we administered them the Neapen Dysphoria Scale – Italian Version (NDS-I), a specific dimensional test for dysphoria. Starting from the dataset, with the aid of the statistical program SPSS 20, we have obtained graphs showing the comparison between disorders groups selected and NDS-I total score and subscales (irritability, discontent, interpersonal resentment, surrender). Finally, a comparison was made, taking two groups at a time, between the means of single groups for total scores and for single subscales considered into the NDS-I test. We made it using the Mann-Whitney U test, a nonparametric test with 2 independent samples, by setting a significance level =0.05. Conclusions: This study, through a transnosographic-dimensional approach, allowed us to explore dysphoria and its expressions in different psychopathological groups, despite analyzing a small sample. Differences between means of values obtained through NDS-I subscales were statistically significant in patients with BPD, BDM and MDD (p<0.05). Among the latter, the group of BPD patients has greater pervasiveness and severity of dysphoria symptoms

DOES POST-TRAUMATIC SPECTRUM COMORBIDITY INFLUENCE SYMPTOM SEVERITY IN BIPOLAR DISORDERS? A CROSS-SECTIONAL STUDY IN A REAL-WORLD SETTING

Background: The present cross-sectional study investigates the relationship between post-traumatic spectrum comorbidity and the severity of symptoms in subjects diagnosed with Bipolar Disorders (BD). Subjects and methods: In- and outpatients diagnosed with BD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) were consecutively recruited. Sociodemographic and clinical data were collected. Psychopathology was evaluated by means of the Hamilton Rating Scale for Depression (HAM-D), the Young Mania Rating Scale (YMRS), and the Positive and Negative Syndrome Scale (PANSS). Sociodemographic, clinical and psychopathological characteristics of BD subjects with and without sub-threshold PTSD were compared by means of bivariate analyses (p<0.05). Results: BD subjects with post-traumatic spectrum comorbidity (n=24.49%) presented a significantly higher number of hospitalizations when compared to those who did not present the co-occurrence of the two conditions (2.67±2.3 versus 1.65±2.32, p=0.039). As for treatment features, subjects with subthreshold PTSD were more frequently prescribed benzodiazepines at the moment of evaluation or in the past (n=18, 100% versus n=22.55%, p=0.032). When assessing differences in terms of psychopathological characteristics, subjects with subthreshold PTSD showed higher HAM-D total score (16.22±9.06 versus 10.22±7.23, p=0.032) and higher PANSS negative symptom scale score (16.06±6.92 versus 11.41±4.68, p=0.017). Conclusions: Findings from the present study suggest that subthreshold PTSD may underpin higher symptom severity and worse outcomes when occurring as a comorbid condition in BD

Effectiveness of lithium in subjects with treatment-resistant depression and suicide risk: results and lessons of an underpowered randomised clinical trial

BACKGROUND: As lithium treatment might be effective in reducing the risk of deliberate self-harm (DSH) in adult patients with unipolar affective disorders, we designed a pragmatic randomised trial to assess its efficacy in more than 200 patients with treatment-resistant depression. However, we randomised 56 patients only. The aim of this report is therefore twofold: first, to disseminate the results of this underpowered study which may be incorporated into future meta-analytical reviews; second, to analyse some critical aspects of the study which might explain failure to reach the target sample size.METHODS: We carried out a randomised, parallel group, assessor-blinded superiority clinical trial. Adults with a diagnosis of major depression, an episode of DSH in the previous 12 months and inadequate response to at least two antidepressants given sequentially at an adequate dose for an adequate time for the current depressive episode were allocated to add lithium to usual care (intervention arm) versus usual care alone (control arm). Suicide completion and acts of DSH during the 12 months of follow-up constituted the composite primary outcome.RESULTS: Of 58 patients screened for inclusion, 29 were allocated to lithium plus usual care and 27 were assigned to usual care without lithium. Six patients in the lithium plus usual care group and seven in the usual care group committed acts of DSH during the follow-up phase. The survival probability did not differ between the two treatment arms (Chi2 = 0.17, p =0.676). With regard to changes in the severity of depressive symptomatology from baseline to endpoint, no significant differences were detected.CONCLUSIONS: The present study failed to achieve the minimum sample size needed to detect a clinically meaningful difference between the two treatment arms. Consequently, the finding that lithium, in addition to usual care, did not exert a positive effect in terms of reduction of DSH after 12 months of follow-up is likely due to the lack of sufficient statistical power to detect a difference, if a difference existed. The dissemination of the results of this underpowered study will inform future meta-analytical reviews on lithium and suicide-related outcomes.TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00927550

Rationale and design of an independent randomised controlled trial evaluating the effectiveness of aripiprazole or haloperidol in combination with clozapine for treatment-resistant schizophrenia

<p>Abstract</p> <p>Background</p> <p>One third to two thirds of people with schizophrenia have persistent psychotic symptoms despite clozapine treatment. Under real-world circumstances, the need to provide effective therapeutic interventions to patients who do not have an optimal response to clozapine has been cited as the most common reason for simultaneously prescribing a second antipsychotic drug in combination treatment strategies. In a clinical area where the pressing need of providing therapeutic answers has progressively increased the occurrence of antipsychotic polypharmacy, despite the lack of robust evidence of its efficacy, we sought to implement a pre-planned protocol where two alternative therapeutic answers are systematically provided and evaluated within the context of a pragmatic, multicentre, independent randomised study.</p> <p>Methods/Design</p> <p>The principal clinical question to be answered by the present project is the relative efficacy and tolerability of combination treatment with clozapine plus aripiprazole compared with combination treatment with clozapine plus haloperidol in patients with an incomplete response to treatment with clozapine over an appropriate period of time. This project is a prospective, multicentre, randomized, parallel-group, superiority trial that follow patients over a period of 12 months. Withdrawal from allocated treatment within 3 months is the primary outcome.</p> <p>Discussion</p> <p>The implementation of the protocol presented here shows that it is possible to create a network of community psychiatric services that accept the idea of using their everyday clinical practice to produce randomised knowledge. The employed pragmatic attitude allowed to randomly allocate more than 100 individuals, which means that this study is the largest antipsychotic combination trial conducted so far in Western countries. We expect that the current project, by generating evidence on whether it is clinically useful to combine clozapine with aripiprazole rather than with haloperidol, provides physicians with a solid evidence base to be directly applied in the routine care of patients with schizophrenia.</p> <p>Trial Registration</p> <p><b>Clincaltrials.gov Identifier</b>: NCT00395915</p

The Influence of the Urban Environment on Mental Health during the COVID-19 Pandemic: Focus on Air Pollution and Migration—A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic caused a crisis worldwide, due to both its public health impact and socio-economic consequences. Mental health was consistently affected by the pandemic, with the emergence of newly diagnosed psychiatric disorders and the exacerbation of pre-existing ones. Urban areas were particularly affected by the virus spread. In this review, we analyze how the urban environment may influence mental health during the COVID-19 pandemic, considering two factors that profoundly characterize urbanization: air pollution and migration. Air pollution serves as a possibly risk factor for higher viral spread and infection severity in the context of urban areas and it has also been demonstrated to play a role in the development of serious mental illnesses and their relapses. The urban environment also represents a complex social context where minorities such as migrants may live in poor hygienic conditions and lack access to adequate mental health care. A global rethinking of the urban environment is thus required to reduce the impact of these factors on mental health. This should include actions aimed at reducing air pollution and combating climate change, promoting at the same time a more inclusive society in a sustainable development perspective