Psichiatria per Professioni Sanitarie

Il presente manuale offre una preparazione psichiatrica per gli operatori delle professioni sanitarie. Considerata la grande prevalenza di disturbi psichiatrici nella popolazione, appare importante avere le basi dei disturbi psichiatrici, dei trattamenti, delle strutture che configurano l'attività psichiatrica e dei diversi approcci da tenere nei confronti di persone affette da patologie psichiatriche. Il manuale è diviso in capitoli specifici per consentire un rapido accesso alle informazioni necessarie

Lezioni Psichiatria

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Clinical correlates and prognostic implications of severe suicidal ideation in major depressive disorder

Suicidal ideation (SI) is a risk factor for suicidal behaviour. To ascertain the clinical correlates and prognostic impact of severe SI, we analysed 249 outpatients with major depressive disorder (MDD) and suicidal thoughts included in the COmbining Medications to Enhance Depression outcome (CO-MED) trial. Patients with severe SI (36%) were younger at disease onset (P = 0.0033), more severely depressed (P = 0.0029), had more lifetime suicidal behaviour (P < 0.0001) and psychiatric comorbidities (panic disorder: P = 0.0025; post-traumatic stress disorder: P = 0.0216), and a history of childhood maltreatment (neglect: P = 0.0054; emotional abuse: P = 0.0230; physical abuse: P = 0.0076; sexual abuse: P = 0.0016) than those experiencing low-moderate SI. After controlling for depression score, severe SI was positively correlated with lifetime suicidal behaviour (OR [95% CI]: 1.26 [1.12-1.41]), panic disorder (1.05 [1.00-1.12]), and childhood maltreatment (neglect: 1.93 [1.13-3.30]; physical abuse: 2.00 [1.11-3.69]; sexual abuse: 2.13 [1.17-3.88]), and inversely correlated with age of onset (0.97 [0.95-0.99]) and sleep-onset insomnia (0.76 [0.61-0.96]). Finally, the occurrence of serious lifetime suicidal behaviour was predicted by SI severity (2.18 [1.11-4.27]), bipolar score (1.36 [1.02-1.81]), and childhood sexual abuse (2.35 [1.09-5.05]). These results emphasise the importance of assessing childhood maltreatment and bipolar liability in MDD to estimate suicidal behaviour risk

Obsessive-Compulsive, Psychotic, and Autism Dimensions Overlap in Real World: A Case Report

BackgroundObsessions, compulsions, and stereotypes are common psychopathological manifestations of obsessive-compulsive, psychotic, and autism spectrum disorders (ASDs). These nosological entities may be present in comorbidity, with relevant clinical difficulties in the differential diagnosis process. Moreover, ASDs are a complex group of disorders, with a childhood onset, which also persist into adulthood and present heterogeneous symptom patterns that could be confused with psychotic disorders.Methods and ResultsWe report a case of a 21-year-old man characterized by sexual and doubt obsessions; disorganized, bizarre, and stereotyped behaviors and compulsions; and social withdrawal, inadequate social skills, visual dispersions, and hypersensitivity to light stimuli. Obsessive and compulsive features were initially included within the differential diagnosis of psychotic and obsessive-compulsive spectrum disorders. However, aforementioned psychopathological elements did not improve when multiple antipsychotic drugs (olanzapine, haloperidol, and lurasidone) were administered in the hypothesis of schizophrenia and even worsened with clozapine therapy at a dose of 100 mg/d. Obsessions and compulsions progressively reduced during the fluvoxamine 14-week treatment paradigm at a dose of 200 mg/d. Considering the persistent deficits in social communication and interactions as well as the restricted interests pattern, a differential diagnostic hypothesis of ASD was formulated, and it was then confirmed at the final evaluation at a third-level health care center.ConclusionsWe discuss similarities and differences in the psychopathology of obsessions, compulsions, and stereotypes in the previously mentioned disorders, to underline factors that can help in the differential diagnosis of similar cases, and consequently in the appropriateness of treatment choice

Polimorfizam gena za serotoninski transporter (5-HTTLPR) i učinkovitost selektivnih inhibitora ponovne pohrane serotonina – imamo li dovoljno dokaza za kliničku praksu

Depression pharmacotherapy can be described with weak predictability of individual response. Antidepressants are prescribed based on trial and error, as it is not possible to determine which patients will respond to antidepressants. It would appear that pharmacogenetics is the most promising path towards achieving the goal of individualized therapy. Today, the most commonly prescribed antidepressants are those from the group of selective serotonin reuptake inhibitors (SSRI). The most investigated genetic variations in the prediction and individualization of antidepressant therapy is the serotonin transporter gene (5-HTT LPR). The objective of this paper is to provide an overview of the research to date on 5-HTT LPR polymorphism in response to SSRI. This paper gives an overview of 35 studies investigating the efficacy of SSRI antidepressants in dependence of 5-HTT LPR polymorphism. The results of three meta-analyses examining this issue are discussed. Briefly, the great majority of studies conducted have shown that L-allele carriers have a faster and better response to SSRI antidepressants, if they are Caucasians. Studies with negative results included ethnically mixed populations, and it is known that there are different allele frequencies among ethnic groups and the consequence of this are the varying results of pharmacogenetic studies. Pharmacogenetic analysis of 5-HTT LPR polymorphism has proven to be economically cost-effective considering the recurrent course of the disease. It would appear that the response to SSRI antidepressants and the development of adverse reactions are associated with 5-HTT LPR polymorphism in Caucasians and this pharmacogenetic analysis could be one of the first in future clinical practice.Farmakoterapija depresije mogla bi se opisati slabom predvidljivosti individualnog odgovora. Antidepresivi se ordiniraju po načelu slučaj ili pogreška, jer kliničkim značajkama ne uspijevamo odrediti koji će bolesnik odgovoriti na antidepresive ili razviti nuspojave. Čini se da je farmakogenetika put koji najviše obećava kako bi se postigao zadani cilj, individualizirana terapija. Danas se najčešće primjenjuju antidepresivi iz skupine selektivnih inhibitora ponovne pohrane serotonina (SSRI). S druge strane, najistraživanija genetska varijanta u predviđanju i individualizaciji antidepresivne terapije je polimorfizam gena za serotoninski transporter (5-HTT LPR). Cilj ovoga rada je prikazati dosadašnja istraživanja polimorfizma 5-HTT LPR i odgovora na SSRI. U radu je prikazano 35 studija u kojima se istraživala učinkovitost antidepresiva SSRI u ovisnosti o polimorfizmu 5-HTT LPR. Prikazani su i rezultati 3 meta analize koje su istraživale navedenu problematiku. Ukratko, velika većina dosadašnjih studija je pokazala da nosioci L alela imaju brži i bolji odgovor na antidepresive SSRI ako su bijelci. Navedeno potvrđuju i 2 meta analize. Studije koje su bile negativne imale su etnički miješanu populaciju, a zna se da su frekvencije alela drugačije kod različitih etničkih skupina i posljedično tome i različiti rezultati farmakogenetskih istraživanja. Za Azijate rezultati su još proturječni. Farmakogenetska analiza polimorfizma 5-HTT LPR se pokazala i ekonomski isplativa ako se uračuna rekurentni tijek bolesti. Čini se da su odgovor na antidepresive SSRI i razvoj nuspojava povezani s polimorfizmom 5-HTT LPR u bijelaca i navedena farmakogenetska analiza bi mogla biti jedna od prvih u budućoj psihijatrijskoj kliničkoj praksi

Antipsychotic Response in the First Week Predicts Later Efficacy

Background and Aims: Time of onset of antipsychotic action is still a debated matter. We aimed to replicate and extend previous findings that early response can predict subsequent non-response. Methods: 86 acutely psychotic patients treated with haloperidol were studied. Results: A PANSS reduction = 23% at 1 week of treatment predicts response at 3 weeks, with a specificity of 84% and a sensitivity of 86%. Conclusion: Our results confirm that an early response to antipsychotic treatment accurately predicts the treatment effectiveness and extends it to a prediction performed as early as 1 week. Copyright (c) 2012 S. Karger AG, Base

Imputed expression of schizophrenia-associated genes and cognitive measures in patients with schizophrenia

Background: Cognitive dysfunction is a core manifestation of schizophrenia and one of the best predictors of long-term disability. Genes increasing risk for schizophrenia may partly act through the modulation of cognition.Methods: We imputed the expression of 130 genes recently prioritized for association with schizophrenia, using PsychENCODE variant weights and genotypes of patients with schizophrenia in CATIE. Processing speed, reasoning, verbal memory, working memory, vigilance, and a composite cognitive score were used as phenotypes. We performed linear regression models for each cognitive measure and gene expression score, adjusting for age, years of education, antipsychotic treatment, years since the first antipsychotic treatment and population principal components.Results: We included 425 patients and expression scores of 91 genes (others had no heritable expression; Bonferroni corrected alpha = 5.49e-4). No gene expression score was associated with cognitive measures, though ENOX1 expression was very close to the threshold for verbal memory (p = 6e-4) and processing speed (p = 7 e-4). Other genes were nominally associated with multiple phenotypes (MAN2A1 and PCGF3).Conclusion: A better understanding of the mechanisms mediating cognitive dysfunction in schizophrenia may help in the definition of disease prognosis and in the identification of new treatments, as the treatment of cognitive impairment remains an unmet therapeutic need

Challenging sequential approach to treatment resistant depression: Cost-utility analysis based on the Sequenced Treatment Alternatives to Relieve Depression (STAR⁎D) trial

In major depression, when a first antidepressant does not cause remission of symptoms (60%–75%), there are several options for continuing treatment in the next step. This study is a cost-utility analysis (CUA) of different second-line approaches. In a simulated trial outpatients with MDD were treated with citalopram for 13 weeks (level 1), then based on two alternative algorithms implemented from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Algorithm A: citalopram was continued until study endpoint (week 26). Algorithm B: patients who remitted during level 1 continued citalopram. Those who did not remit could opt for switching to another antidepressant (venlafaxine; sertraline) (b1) or adding bupropion to citalopram treatment (augmentation; b2). Algorithm B increased remission rate by 10.6% over Algorithm A (number needed to treat: 9.9; sensitivity range: 9.1–12.5). As a comparison, differences between active antidepressants and placebo are associated with NNT values of 6 to 8. In CUA Algorithm B was dominant with an ICER of $11,813 (sensitivity range=$1783 – $21,784), which is <1GDP per capita cost-effectiveness threshold (USA=$47,193). Among Algorithm B options, switching (b1) dominated Algorithm A with a smaller number of responders than augmentation approach (b2) (NNT 11 vs. 7.7), whereas ICER values were similar (b1: $14,738; b2:$15,458). However we cannot exclude a bias in selecting second treatment. This cost-utility analysis shows (in line with current guidelines) a benefit in modifying antidepressant treatment if response to first-line agent does not occur within 3 months, but not a clear-cut evidence in terms of NNT