GENERAL PRACTICE MEETING THE NEEDS FOR PSYCHIATRIC CARE IN CROATIA

Background: In recent decades, general practitioners (GPs) have become critical components of mental health services. However, in Croatia the role of GPs in mental health services is still mostly perceived as “gate keeping”, whereas seeking help for serious mental illnesses is mostly restricted to psychiatrists. The aim of this study is to investigate the practices and attitudes of family doctors in providing care for psychiatric patients. Subjects and methods: The study included 111 GPs, working in 38 different locations in four major towns in Croatia. Data were collected using a questionnaire, specifically designed for the purpose of this study. Results: By their own estimation, GPs prescribed antidepressants without a psychiatrist’s recommendation in about 37% of patients who use them. Also, GPs prescribed sedatives without a psychiatrist’s recommendation in about 60% of patients who use them. Although certain categories of psychiatric patients (elderly, patients with PTSD) were almost always referred to a psychiatrist, it was GPs\u27 attitudes toward psychiatric casualties and their proneness to prescribe antidepressants and sedatives without a psychiatrist’s recommendation that predicted whether a patient will be treated by himself of referred to a psychiatrist. "Interest/Competency" and "Knowledge" of the GPs positively correlated with the number of courses attended as a part of continuous medical education (CME). Conclusion: Overall, the role of GPs in mental health services in Croatia is changing into a more active one, as a significant portion of patients with depression and anxiety are being treated by GPs. Personal interest and self confidence in proper knowledge and skills, in part acquired also from current CME programs, are determinants of higher autonomy of GPs in treating psychiatric patients. Psychiatrists, as active promoters of community mental health should more actively encourage their alliance with GPs, especially through offering higher quality CME courses

Preserving Cognitive Abilities in Schizophrenia Patients

Unatoč brojnim novim metodama i mogućnostima liječenja shizofrenija se i dalje smatra jednim od najtežih psihičkih poremećaja. Kognitivni simptomi shizofrenije smatraju se središnjim simptomima shizofrenije, a pojavljuju se već i u premorbidnoj fazi bolesti te postupno progrediraju u kasnijim fazama. Pokazuju najveću rezistentnost na trenutne mogućnosti liječenja, čime određuju ukupni ishod liječenja. Međutim, ovisno o fazi bolesti nužno je što dulje očuvati kognitivne sposobnosti i spriječiti progresiju simptoma. U prodromalnoj fazi shizofrenije kognitivne sposobnosti čuvaju se primjenom zdravoga životnog stila, prevencijom/liječenjem (zlo)upotrebe kanabisa, provođenjem vježbanja, pravodobnim liječenjem nefarmakološkim metodama, uključujući psihoterapiju i socioterapiju, te prema potrebi racionalnom primjenom psihofarmaka, što može uključivati i niske doze novijih antipsihotika. U prvoj psihotičnoj epizodi i ranoj fazi bolesti primjenjuje se princip racionalne psihofarmakologije, s uvođenjem atipičnih antipsihotika, dugodjelujućih antipsihotika, antidepresiva te izostavljanjem sedativa. Nužno je provođenje multimodalnoga socioterapijskog i psihoterapijskog pristupa, koji ima neizravan učinak na očuvanje kognitivnih sposobnosti kroz poboljšanje adherencije i smanjivanje negativnih i depresivnih simptoma. U liječenju kognitivnih simptoma shizofrenije u kasnijim fazama i dalje je nužna racionalna psihofarmakoterapija s posebnim osvrtom na nužnost izostavljanja sedativa, a od nefarmakoloških metoda preporučuje se primjena metakognitivnog treninga, kognitivne remedijacije te općenito upotreba psihosocijalnih metoda, uključujući i obiteljske intervencije. Vježbanje se preporučuje u svakoj fazi bolesti zato što ima izravan učinak na razvoj i očuvanje kognicije.Despite numerous new methods and treatments, schizophrenia is still considered one of the most severe of mental disorders. The cognitive symptoms are central and already appear in the premorbid phase of the disease, then gradually increase in later phases. The symptoms show the greatest resistance to current treatment options and determine the overall outcome. Depending on the stage of the disease it is necessary to preserve cognitive abilities as long as possible and prevent advancement of symptoms. In the prodromal phase, cognitive abilities are maintained through a healthy lifestyle, prevention/treatment of (mis)use of cannabis, physical exercise, timely treatment with non-pharmacological methods (psychotherapy and sociotherapy), and if required, the rational use of psychopharmaceuticals, which may also include low doses of new antipsychotics. In first-episode psychosis and early stage of the disease, the principle of rational psychopharmacology is applied, with the introduction of atypical, long-acting antipsychotics, antidepressants, and the exclusion of sedatives. It is necessary to implement a multimodal sociotherapeutic and psychotherapeutic approach, which has an indirect effect on protecting cognitive abilities through improving adherence and reducing negative and depressive symptoms. In treating cognitive symptoms of schizophrenia in later stages, rational psychopharmacotherapy is still required, but with the omission of sedatives. Regarding non-pharmacological methods, the use of metacognitive training, cognitive remediation, and psychosocial methods including familial intervention is recommended. Exercise is important in every stage of the disease, as it has a direct effect on the development and preservation of cognition

The influence of 5-HT(2C) and MDR1 genetic polymorphisms on antipsychotic-induced weight gain in female schizophrenic patients

We investigated the relationships between functional genetic variants of the 5-HT(2C) receptor and multidrug-resistant protein (MDR1), coding for P-glycoprotein, and second generation antipsychotic (SDA)-induced weight gain among 108 female schizophrenic patients treated with olanzapine or risperidone for up to 4 months. No significant differences in -759C/T allelic and genotype variants of 5-HT(2C) were found between patients who gained more than 7% of their initial weight compared with those who gained less. Haplotype-based analysis of two MDR1 loci, exon 21 G2677T and exon 26 C3435T, revealed a slightly lower representation of the G2677/C3435 haplotype in the >/=7% group. In the subgroup of patients treated with risperidone, we found borderline overrepresentation of 2677T, significant overrepresentation of 3435T variant and borderline overrepresentation of 2677T/3435T haplotype the >/=7% group, whereas G2677/C3435 haplotype was found to be less represented in the >/=7% group. Our data indicate a nonsignificant role of 759C/T 5-HT(2C) in SDA-induced weight gain, and a stronger influence of the MDR1 G2677T and C3435T polymorphisms on risperidone-induced weight gain in female schizophrenic patients. 3435T and 2677T MDR1 variants, both associated with lower P-gp function, might predispose to higher risperidone accessibility to the brain that would lead to stronger effects, including weight gain

Axon morphology of rapid Golgistained pyramidal neurons in the prefrontal cortex in schizophrenia

Aim To analyze axon morphology on rapid Golgi impregnated pyramidal neurons in the dorsolateral prefrontal cortex in schizophrenia. Methods Postmortem brain tissue from five subjects diagnosed with schizophrenia and five control subjects without neuropathological findings was processed with the rapid Golgi method. Layer III and layer V pyramidal neurons from Brodmann area 9 were chosen in each brain for reconstruction with Neurolucida software. The axons and cell bodies of 136 neurons from subjects with schizophrenia and of 165 neurons from control subjects were traced. The data obtained by quantitative analysis were compared between the schizophrenia and control group with the t test. Results Axon impregnation length was consistently greater in the schizophrenia group. The axon main trunk length was significantly greater in the schizophrenia than in the control group (93.7±36.6 μm vs 49.8±9.9 μm, P=0.032). Furthermore, in the schizophrenia group more axons had visibly stained collaterals (14.7% vs 5.5%). Conclusion Axon rapid Golgi impregnation stops at the beginning of the myelin sheath. The increased axonal staining in the schizophrenia group could, therefore, be explained by reduced axon myelination. Such a decrease in axon myelination is in line with both the disconnection hypothesis and the two-hit model of schizophrenia as a neurodevelopmental disease. Our results support that the cortical circuitry disorganization in schizophrenia might be caused by functional alterations of two major classes of principal neurons due to altered oligodendrocyte development

SMOKING IN SCHIZOPHRENIA: AN UPDATED REVIEW

Patients with schizophrenia continue to have the highest rate of both smoking and heavy nicotine dependence. The interaction between smoking and schizophrenia is complex. There is evidence of the shared genetic background. Recent preclinical and clinical research has further investigated self-medication hypothesis, given that nicotine might alleviate cortical dysfunction. While prior research indicated some favorable effects of smoking on cognitive performance, particulatly on attention/vigilance, recent studies did not confirm those findings. Lower severity of negative symptoms in smokers was not confirmed across studies. Cigarette smoking decreases clozapine and olanzapine concentrations. There is no consistent evidence of favorable effects of nicotine on symptoms in schizophrenia, but the evidence of detrimental effects of smoking on general health is highly consistent. Smoking cessation should be a priority in patients with schizophrenia