Sex Differences in the Relationship between PTSD Spectrum Symptoms and Autistic Traits in a Sample of University Students.

BACKGROUND: While growing literature is stressing the link between Autistic Traits (AT) and trauma-/stress-related disorders, in both conditions significant differences have been separately reported. OBJECTIVE: This study aims to evaluate the relationship between AT and trauma-/stress-related symptoms with respect to sex. METHODS: 178 university students were assessed with the Structured Clinical Interview for DSM-5, the Trauma and Loss Spectrum (TALS) and the Adult Autism Subthreshold Spectrum (AdAS). In order to evaluate sex differences in trauma-/stress-related symptoms among subjects with higher or lower AT, the sample was split in two groups with an equal number of subjects on the basis of the median score reported on AdAS Spectrum ("AdAS high scorers" and "AdAS low scorers"). RESULTS: Females reported significantly higher TALS total score, Loss events and Grief reaction domain scores than males in the whole sample, while AdAS high scorers reported significantly higher TALS total and domain scores than AdAS low scorers. A significant interaction between high/low AdAS score and sex emerged for TALS domains, with females scoring significantly higher than males only among AdAS low scorers, specifically on Loss events, Grief reaction, Re-experiencing and Personal characteristics/Risk factors domains. Finally, among AdAS high scorers a significantly higher rate of subjects fulfilled symptomatological criteria for PTSD than among AdAS low scorers, without sex differences. CONCLUSION: Our results confirm a significant relationship between AT and trauma-/stress-related symptoms, which seems to prevail on sex differences among high-risk subjects.

Mood symptoms and suicidality across the autism spectrum.

BACKGROUND: Autism spectrum is a psychopathological dimension which encompasses a wide range of clinical presentations: from subthreshold forms and autistic traits (AT), that can be found in the general population, to full-blown autism spectrum disorder (ASD). Many studies reported high rates of comorbidity between both ASD and AT and mood disorders, as well as a high prevalence of suicidal ideation among patients with ASD/AT. The aim of this study was to investigate the presence of mood symptoms and suicidal ideation and behaviors in patients with full-blown ASD and in subjects with AT, as well in a healthy control (HC) group, with a specific focus on which of the autistic features may be predictive of suicidal ideation and behaviors. METHODS: We recruited 262 adult subjects: 34 with ASD without intellectual impairment or language disability (ASD group), 68 fulfilling only one symptom criterion for ASD according to DSM-5 but who do not meet criteria for a full-blown diagnosis of ASD (AT group), and 160 HC. All subjects were assessed with the Structured Clinical Interview for DSM-5 (SCID-5); in addition, they were asked to fill two questionnaires: The Mood Spectrum, Self-report (MOODS-SR) and the Adult Autism Subthreshold Spectrum (AdAS Spectrum). RESULTS: ASD subjects reported significantly higher AdAS Spectrum and MOODS-SR total scores, as well as higher MOODS-SR depressive component total scores, when compared with AT and HC subjects. AT subjects scored significantly higher than the HC group. No significant differences were reported between ASD and AT subjects for the suicidality score according to MOODS-SR, despite both groups scored significantly higher than the HC group. The strongest predictor of suicidality score were MOODS-SR depressive component score and AdAS Spectrum Restricted interests and rumination domain score. CONCLUSIONS: Our results highlight a correlation between autism and mood spectrum, as well as between suicidality and both ASD and AT. Subthreshold forms of ASD should be accurately investigated due to their relationship with suicidal thoughts and behaviors.

Real-world effectiveness of long acting aripiprazole: Treatment persistence and its correlates in the Italian clinical practice.

OBJECTIVES: To identify the variables that are associated with persistence to Aripiprazole-Long Acting (A-LAI), in adult patients with schizophrenia. METHODS: Observational, retrospective, non-interventional study involving 261 patients with schizophrenia. RESULTS: Eighty-six percent of study subjects were persistent for at least 6 months. All subjects with baseline CGI-S of 1 or 2, 95% of subjects with CGI-S of 3, 86% with CGI-S of 4, 82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7 were persistent. A-LAI treatment continuation rate was higher in patients with: 1) baseline CGI score ≤ 4; 2) schizophrenia dimension (LDPS) mania score ≤ 5; 3) psychotic spectrum schizoid score ≤ 11. CONCLUSIONS: A relatively high number of patients (n = 225, 86%) were persistent to A-LAI for at least 6 months. Not surprisingly, very severe patients were more unlikely to be persistent. However, it is noteworthy that a large number of subjects with high CGI score at the time when A-LAI was started (82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7) were persistent. Larger, controlled, prospective and longer studies are warranted.

Premorbid academic and social functioning in patients with schizophrenia and its associations with negative symptoms and cognition.

OBJECTIVE: The study aimed to explore premorbid academic and social functioning in patients with schizophrenia, and its associations with the severity of negative symptoms and neurocognitive impairment. METHOD: Premorbid adjustment (PA) in patients with schizophrenia was compared to early adjustment in unaffected first-degree relatives and healthy controls. Its associations with psychopathology, cognition, and real-life functioning were investigated. The associations of PA with primary negative symptoms and their two factors were explored. RESULTS: We found an impairment of academic and social PA in patients (P ≤ 0.000001) and an impairment of academic aspects of early adjustment in relatives (P ≤ 0.01). Patients with poor PA showed greater severity of negative symptoms (limited to avolition after excluding the effect of depression/parkinsonism), working memory, social cognition, and real-life functioning (P ≤ 0.01 to ≤0.000001). Worse academic and social PA were associated with greater severity of psychopathology, cognitive impairment, and real-life functioning impairment (P ≤ 0.000001). Regression analyses showed that worse PA in the academic domain was mainly associated to the impairment of working memory, whereas worse PA in the social domain to avolition (P ≤ 0.000001). CONCLUSION: Our findings suggest that poor early adjustment may represent a marker of vulnerability to schizophrenia and highlight the need for preventive/early interventions based on psychosocial and/or cognitive programs.

Disorganization and real-world functioning in schizophrenia: Results from the multicenter study of the Italian Network for Research on Psychoses.

BACKGROUND: A general consensus has not yet been reached regarding the role of disorganization symptoms in real-world functioning in schizophrenia. METHODS: We used structural equations modeling (SEM) to analyze the direct and indirect associations between disorganization and real-world functioning assessed through the Specific Levels of Functioning Scale (SLOF) in 880 subjects with schizophrenia. RESULTS: We found that: 1) conceptual disorganization was directly and strongly connected with SLOF daily activities; difficulty in abstract thinking was associated with moderate strength to all SLOF domains, and poor attention was connected with SLOF work skills; 2) grandiosity was only related with poor work skills, and delusions were associated with poor functioning in all SLOF domains; interpersonal relationships were weakly indirectly influenced by hallucinatory behavior, delusions and unusual thought contents through the mediation of social cognition (SC); 3) among the negative symptoms, avolition had only direct links with SLOF work skills and SLOF activities; anhedonia had direct links with SLOF work skills and SLOF interpersonal and indirect link with SLOF work skills through functional capacity (FC); asociality with SLOF interpersonal; blunted affect had direct links with SLOF activities and indirect links with SLOF interpersonal relationships mediated by SC. Lastly, alogia had only indirect links mediated by SC, FC, and neurocognition (NC). CONCLUSIONS: Overall conceptual disorganization is the symptom that contributed more (both directly and indirectly) to the activities of community living in real-world. Thus, it should be considered as a treatment target in intervention programs for patients with schizophrenia.

Familial aggregation of MATRICS Consensus Cognitive Battery scores in a large sample of outpatients with schizophrenia and their unaffected relatives.

BACKGROUND: The increased use of the MATRICS Consensus Cognitive Battery (MCCB) to investigate cognitive dysfunctions in schizophrenia fostered interest in its sensitivity in the context of family studies. As various measures of the same cognitive domains may have different power to distinguish between unaffected relatives of patients and controls, the relative sensitivity of MCCB tests for relative-control differences has to be established. We compared MCCB scores of 852 outpatients with schizophrenia (SCZ) with those of 342 unaffected relatives (REL) and a normative Italian sample of 774 healthy subjects (HCS). We examined familial aggregation of cognitive impairment by investigating within-family prediction of MCCB scores based on probands' scores. METHODS: Multivariate analysis of variance was used to analyze group differences in adjusted MCCB scores. Weighted least-squares analysis was used to investigate whether probands' MCCB scores predicted REL neurocognitive performance. RESULTS: SCZ were significantly impaired on all MCCB domains. REL had intermediate scores between SCZ and HCS, showing a similar pattern of impairment, except for social cognition. Proband's scores significantly predicted REL MCCB scores on all domains except for visual learning. CONCLUSIONS: In a large sample of stable patients with schizophrenia, living in the community, and in their unaffected relatives, MCCB demonstrated sensitivity to cognitive deficits in both groups. Our findings of significant within-family prediction of MCCB scores might reflect disease-related genetic or environmental factors.

Never too late to be anxious: validation of the Geriatric Anxiety Inventory, Italian version.

AIM: The aim of this work was to validate the Italian version of GAI (GAI-It) and its short form (GAI-It SF) in an over 65-population. METHODS: In 3 recruitment areas across Italy, two raters reciprocally blind to results assessed eligible subjects; a semi-structured diagnostic clinical interview was performed by a psychiatrist. RESULTS: Among the 76 enrolled subjects (mean age 72.7±6.8 years), anxiety symptoms were very common: 69.7% (moderate/ severe HADS-Anxiety), 76.3% (moderate/severe STAI-state), 71.0% (moderate/severe STAI-trait), 61.8% (GAI), 55.3% (GAI-SF). Sensitivity, specificity and positive predictive value of GAI confirmed a good reliability of the Italian version, with Cronbach's Alpha equal to 0.93 for GAI-It and to 0.77 for GAI-It SF, indicating a very good and good construct validity, respectively, of the scales. The Pearson correlation index demonstrated a moderately positive correlation among GAI, GAI-SF and STAI. CONCLUSIONS: Our data confirm the validity of GAI-It as a valuable instrument to assess anxiety in an elderly population, for clinical and research purposes.

Adult Autism Subthreshold Spectrum (AdAS Spectrum): Validation of a questionnaire investigating subthreshold autism spectrum.

AIM: Increasing literature has shown the usefulness of a dimensional approach to autism. The present study aimed to determine the psychometric properties of the Adult Autism Subthreshold Spectrum (AdAS Spectrum), a new questionnaire specifically tailored to assess subthreshold forms of autism spectrum disorder (ASD) in adulthood. METHODS: 102 adults endorsing at least one DSM-5 symptom criterion for ASD (ASDc), 143 adults diagnosed with a feeding and eating disorder (FED), and 160 subjects with no mental disorders (CTL), were recruited from 7 Italian University Departments of Psychiatry and administered the following: SCID-5, Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale 14-item version (RAADS-14), and AdAS Spectrum. RESULTS: The AdAS Spectrum demonstrated excellent internal consistency for the total score (Kuder-Richardson's coefficient=.964) as well as for five out of seven domains (all coefficients>.80) and sound test-retest reliability (ICC=.976). The total and domain AdAS Spectrum scores showed a moderate to strong (>.50) positive correlation with one another and with the AQ and RAADS-14 total scores. ASDc subjects reported significantly higher AdAS Spectrum total scores than both FED (p<.001) and CTL (p<.001), and significantly higher scores on the Childhood/adolescence, Verbal communication, Empathy, Inflexibility and adherence to routine, and Restricted interests and rumination domains (all p<.001) than FED, while on all domains compared to CTL. CTL displayed significantly lower total and domain scores than FED (all p<.001). A significant effect of gender emerged for the Hyper- and hyporeactivity to sensory input domain, with women showing higher scores than men (p=.003). A Diagnosis* Gender interaction was also found for the Verbal communication (p=.019) and Empathy (p=.023) domains. When splitting the ASDc in subjects with one symptom criterion (ASD1) and those with a ASD, and the FED in subjects with no ASD symptom criteria (FED0) and those with one ASD symptom criterion (FED1), a gradient of severity in AdAS Spectrum scores from CTL subjects to ASD patients, across FED0, ASD1, FED1 was shown. CONCLUSIONS: The AdAS Spectrum showed excellent internal consistency and test-retest reliability and strong convergent validity with alternative dimensional measures of ASD. The questionnaire performed differently among the three diagnostic groups and enlightened some significant effects of gender in the expression of autistic traits.

Social cognition in people with schizophrenia: a cluster-analytic approach.

BACKGROUND: The study aimed to subtype patients with schizophrenia on the basis of social cognition (SC), and to identify cut-offs that best discriminate among subtypes in 809 out-patients recruited in the context of the Italian Network for Research on Psychoses. METHOD: A two-step cluster analysis of The Awareness of Social Inference Test (TASIT), the Facial Emotion Identification Test and Mayer-Salovey-Caruso Emotional Intelligence Test scores was performed. Classification and regression tree analysis was used to identify the cut-offs of variables that best discriminated among clusters. RESULTS: We identified three clusters, characterized by unimpaired (42%), impaired (50.4%) and very impaired (7.5%) SC. Three theory-of-mind domains were more important for the cluster definition as compared with emotion perception and emotional intelligence. Patients more able to understand simple sarcasm (⩾14 for TASIT-SS) were very likely to belong to the unimpaired SC cluster. Compared with patients in the impaired SC cluster, those in the very impaired SC cluster performed significantly worse in lie scenes (TASIT-LI <10), but not in simple sarcasm. Moreover, functioning, neurocognition, disorganization and SC had a linear relationship across the three clusters, while positive symptoms were significantly lower in patients with unimpaired SC as compared with patients with impaired and very impaired SC. On the other hand, negative symptoms were highest in patients with impaired levels of SC. CONCLUSIONS: If replicated, the identification of such subtypes in clinical practice may help in tailoring rehabilitation efforts to the person's strengths to gain more benefit to the person.

Estimating the Impact of Workplace Bullying: Humanistic and Economic Burden among Workers with Chronic Medical Conditions.

BACKGROUND: Although the prevalence of work-limiting diseases is increasing, the interplay between occupational exposures and chronic medical conditions remains largely uncharacterized. Research has shown the detrimental effects of workplace bullying but very little is known about the humanistic and productivity cost in victims with chronic illnesses. We sought to assess work productivity losses and health disutility associated with bullying among subjects with chronic medical conditions. METHODS: Participants (N = 1717) with chronic diseases answered a self-administered survey including sociodemographic and clinical data, workplace bullying experience, the SF-12 questionnaire, and the Work Productivity Activity Impairment questionnaire. RESULTS: The prevalence of significant impairment was higher among victims of workplace bullying as compared to nonvictims (SF-12 PCS: 55.5% versus 67.9%, p < 0.01; SF-12 MCS: 59.4% versus 74.3%, p < 0.01). The adjusted marginal overall productivity cost of workplace bullying ranged from 13.9% to 17.4%, corresponding to Italian Purchase Power Parity (PPP) 2010 US$ 4182-5236 yearly. Association estimates were independent and not moderated by concurrent medical conditions. CONCLUSIONS: Our findings demonstrate that the burden on workers' quality of life and productivity associated with workplace bullying is substantial. This study provides key data to inform policy-making and prioritize occupational health interventions.

Italian Study on Depressive Disorders (STudio Italiano MAlattia Depressiva, or STIMA-D): a nationwide snapshot of the status of treatment for major depression.

INTRODUCTION: Major depression is a worldwide problem and often remains undetected and untreated. Given the low rates of detection plus the need to intervene in a short time, it is important to identify factors which are likely to improve treatment outcomes. METHODS: STIMA-D was designed to provide the profile of patients with major depression in Italy (focusing on pathway to care, patient characteristics, drug therapy and treatment outcomes). The patients enrolled (M/F, aged between 18 and 65) experienced single/multiple episodes of major depression (DSM-IV-TR). Patients with lifetime or current bipolar syndrome or other mental disorders were excluded. RESULTS: 44 of the 50 invited centers sent data concerning 1 140 patients. The majority of patients were women. Among working individuals, 52.5% of them were absent from work due to depression in the previous 6 months. Recurrent episodes of major depression were very common and were associated with persistence of residual post-episodic symptoms, a family history of mood disorders and presence of anxiety. 59.6% of the patients were treated with monotherapy (SSRI or SNRI), while 19.2% of them were treated with SSRI plus SNRI. Only the 25.5% on monotherapy had a complete response compared to 12.4% of patients on dual therapy. DISCUSSION: Poor outcomes in major depression have profound implications on patients' quality of life and cost burden. New pharmacological approaches with novel modes of action are therefore urgently needed.

Transcranial magnetic stimulation in the assessment of motor cortex excitability and treatment of drug-resistant major depression.

Major depression is one of the leading causes of disabling condition worldwide and its treatment is often challenging and unsatisfactory, since many patients become refractory to pharmacological therapies. Transcranial magnetic stimulation (TMS) is a noninvasive neurophysiological investigation mainly used to study the integrity of the primary motor cortex excitability and of the cortico-spinal tract. The development of paired-pulse and repetitive TMS (rTMS) paradigms has allowed investigators to explore the pathophysiology of depressive disorders and other neuropsychiatric diseases linked to brain excitability dysfunctions. Repetitive transcranial magnetic stimulation has also therapeutic and rehabilitative capabilities since it is able to induce changes in the excitability of inhibitory and excitatory neuronal networks that may persist in time. However, the therapeutic effects of rTMS on major depression have been demonstrated by analyzing only the improvement of neuropsychological performance. The aim of this study was to investigate cortical excitability changes on 12 chronically-medicated depressed patients (test group) after rTMS treatment and to correlate neurophysiological findings to neuropsychological outcomes. In detail, we assessed different parameters of cortical excitability before and after active rTMS in the test group, then compared to those of 10 age-matched depressed patients (control group) who underwent sham rTMS. In line with previous studies, at baseline both groups exhibited a significant interhemispheric difference of motor cortex excitability. This neurophysiological imbalance was then reduced in the patients treated with active rTMS, resulting also in a clinical benefit as demonstrated by the improvement in neuropsychological test scores. On the contrary, after sham rTMS, the interhemispheric difference was still evident in the control group. The reported clinical benefits in the test group might be related to the plastic remodeling of synaptic connection induced by rTMS treatment.

Subthreshold depression in older subjects: an unmet therapeutic need.

Major depression, defined according to DSM IV TR criteria, is less common in older subjects, while other types of depression are two to three times more prevalent. This heterogeneous group of disturbances has received different names: depression not otherwise specified, minor depression, subthreshold or subsyndromal depression. Moreover, each condition has been defined using heterogeneous criteria by different authors. The term of subthreshold depression will be adopted in this position statement. Subthreshold depression has been associated with the same negative consequences of major depression, including reduced well being and quality of life, worsening health status, greater disability, increased morbidity and mortality. Nevertheless, there is a dearth of clinical trials in this area, and therefore older patients with subthreshold depression are either not treated or they are treated with the same non pharmacological and pharmacological therapies used for major depression, despite the lack of supporting scientific evidence. There is an urgent need to reach a consensus concerning the diagnostic criteria for subthreshold depression as well as to perform clinical trials to identify effective and safe therapies in this too long neglected patient group.

Use and treatment modalities for SSRI and SNRI antidepressants in Italy during the period 2003-2009.

OBJECTIVES: This drug utilization study aims to evaluate the incidence and prevalence of prescribed antidepressants (SSRIs or SNRIs) and to describe treatment modalities in Italy during the period 2003-2009. METHODS: This retrospective analysis on the prescription and treatment modalities of SSRIs or SNRIs is based on an Italian general practice database, which includes data on about 1,000,000 patients. Eligible patients should have age≥18 years, and ≥1 year of clinical history. Prevalence, incidence of use and adherence were calculated for SSRIs and SNRIs and for the individual agents. RESULTS: The prevalence of SSRI use increased from 7.5% (2003) to 13.1% (2009) while the prevalence of SNRI use increased from 0.8% to 2.5%. The most evident increase was reported for escitalopram (+2.78%). The number of new antidepressant users (incidence rate) showed a modest decrease for SSRIs (-0.3%) and a slight increase for SNRIs (+0.9%). A higher percentage of continuers was reported for SSRIs versus SNRIs (15.1% vs 13.0%). Escitalopram was associated with the highest percentage of continuers and with the highest number of days of uninterrupted treatment. Overall, over 10% of antidepressant users switched their first choice during one year of follow-up. Escitalopram was associated with the highest frequency of 'high' adherers (28.5%). CONCLUSIONS: SSRIs may be regarded as the elective treatment for depression. Of the SSRIs, escitalopram seems to be associated with the highest number of days of uninterrupted treatment, the lowest proportion of switchers and the highest adherence. This consideration might have practical relevance when comparing escitalopram to other SSRIs and to venlafaxine and duloxetine.

Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD).

BACKGROUND: Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD. OBJECTIVES: To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual. SEARCH STRATEGY: We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field. SELECTION CRITERIA: Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD DATA COLLECTION AND ANALYSIS: Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality. MAIN RESULTS: Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I(2) test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity. AUTHORS' CONCLUSIONS: The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

Different perception of cognitive impairment, behavioral disturbances, and functional disabilities between persons with mild cognitive impairment and mild Alzheimer's disease and their caregivers.

Insight in dementia is a multifaceted concept and ability, which includes the persons' perception of their behavioral and cognitive symptoms and functional disability. This ability seems to deteriorate as dementia progresses. The aim of this study was to evaluate the level of insight in the cognitive, behavioral, and functional disorders in a group of persons with mild cognitive impairment (MCI) or mild AD (Alzheimer's disease) and to compare their perception of their illness with that of their caregivers. The study involved a group of 121 persons with MCI and mild AD and their caregivers. The persons with MCI and mild AD were administered the tests Mini-Mental State Examination, Instrumental Activities of Daily Living, Activities of Daily Living, Neuropsychiatric Inventory, Schedule for the Assessment of Insight, Clinical Insight Rating Scale, and a short interview. Major differences were identified between how the persons with MCI or mild AD and their caregivers perceived the persons' cognitive and behavioral disorders. The group with MCI or mild AD underestimated their deficits, which were considered serious and disabling by their caregivers.

An open-label, comparative study of rivastigmine, donepezil and galantamine in a real-world setting.

OBJECTIVE: We analysed the effects of donepezil, rivastigmine and galantamine, prescribed for the treatment of Alzheimer disease in a real-world setting in Italy. METHODS: Outcome measures included the MiniMental State Examination (MMSE), the Alzheimer Disease Assessment Scale cognitive subscale (ADAS-cog), Instrumental Activity of Daily Living (IADL) and ADL scales. RESULTS: Seventy patients were treated with donepezil, 121 with rivastigmine and 51 with galantamine. At 6 months, rivastigmine-treated patients improved by 1.29 points from baseline on the ADAS-cog, while donepezil- and galantamine-treated patients showed 'no change' (changes of < 0.2 points). On the IADL, patients treated with rivastigmine, donepezil and galantamine showed decreases of 0.42, 0.58 and 0.75 points, respectively. On the ADL, donepezil- and galantamine-treated patients showed decreases of 0.44 and 0.86 points, respectively, while there was 'no change' with rivastigmine. On the MMSE, donepezil- and rivastigmine-treated patients showed 'no change' and galantamine-treated patients showed a mean decrease of 1.19 points. A subgroup analysis of 'pseudo-randomised' patients (rivastigmine, n = 63; donepezil, n = 55; galantamine, n = 51) supported the main findings. Side effects were similar (in type and frequency) in the three treatment groups. CONCLUSIONS: This is the first study to compare the effects of the three most commonly-used cholinesterase inhibitors on the MMSE, ADAS-cog, IADL and ADL. Limitations included its small population size, its open-label design, and the fact that patients were randomised only after the introduction of galantamine. There were no statistically significant differences between the three drugs at 3 months. While numerical trends were observed suggesting the effect of rivastigmine > donepezil > galantamine, larger, longer-term prospective studies are needed to confirm whether there are important differences in the long-term efficacy of the three drugs.

Stress in the caregivers of Alzheimer's patients: an experimental investigation in Italy.

In Italy, the family constitutes the major caregiving response to the needs of the elderly who are no longer self-sufficient. These caregivers are often wives or daughters who have chosen to keep the patient at home with them. On average, three-quarters of the caregiver's day is devoted to the patient, a proportion that tends to increase linearly as the disease progresses. The primary aim of our study was to describe a group of Italian caregivers of patients with a diagnosis of dementia to assess their levels of stress. We then correlated these caregivers with a number of sociodemographic variables and the patients' degree of cognitive impairment and independence in daily life activities. The study was conducted on a sample group of 236 caregivers of patients with a diagnosis of Alzheimer's disease (AD) according to the DSM-IV criteria. Each caregiver took part in a sociodemographic interview and filled in two questionnaires: the Caregiver Burden Inventory (CBI), to quantify the caregiving workload and the Brief Symptom Inventory (BSI), to assess the level of anxiety and depression. Patients were administered the Mini-Mental State Examination (MMSE) to evaluate their level of cognitive impairment and the Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) tests to quantify their level of independence. The analysis of the results shows that the average Italian caregiver of an AD patient is a woman, approximately 60 years old. The majority of caregivers are spouses, followed by children. In general, these caregivers work at home, are housewives or retired, and are personally involved in caring for the patients. The greater the level of a patient's cognitive impairment and the less independent they are, the greater amount of care and supervision they require, leaving less free time for the caregiver; this leads to higher levels of anxiety related to caregiving. Toward the final stages of the disease, patient care tasks take up nearly all of the caregiver's free time, leaving them only about two hours per week for themselves or their friends. In conclusion, the management of dementia patients places a particular burden on the caregiver and involves several economic and social costs. The burden becomes heavier as the disease progresses, since the increase of cognitive disorders and the resulting reduction of independence in daily life, together with the onset of behavioral symptoms, heighten the caregiver's distress, anxiety, and depression. Establishing a network of community services able to alleviate the burden on families is therefore a priority. Parallels can be drawn between the stresses documented for American caregivers and their Italian counterparts.

Reboxetine in the maintenance therapy of depressive disorder in the elderly: a long-term open study.

Depression in the elderly is often not recognised and is frequently under-treated. Reboxetine is a selective noradrenaline reuptake inhibitor (selective NRI) which is effective and well tolerated in the treatment of depressed adult patients. This prospective, uncontrolled, multicentre study was designed to assess the efficacy and tolerability of reboxetine as maintenance therapy for major depressive disorder or dysthymia in 160 elderly patients (aged 65-94 years). One hundred and thirty-nine patients completed the 6-week run-in period and entered the long-term phase; 104 patients completed the 52-week treatment period. The proportion of patients with CGI-global improvement ratings assessed as 'much' and 'very much' improved increased from 15.1% at week 2 to 88.7% at week 6 and to 95.2% at week 52. The mean HAM-D total score showed a reduction from 24.0 at baseline to 10.4 at week 6 and 7.5 at week 52. Twenty-five patients discontinued treatment due to adverse events. The most frequently reported adverse events were nausea (11.9%), insomnia (11.9%), headache (10.0%) and dry mouth (9.1%), and these were of mild or moderate severity. In summary, results from this study show reboxetine to be effective, and well tolerated in both the short- and long-term treatment of elderly depressed or dysthymic patients.

Stress of routine follow-up in colorectal cancer operated patients.

Postoperative follow-up is the logical consequence of cancer treatment, but colorectal cancer follow-up does not achieve all its goals. These unfavourable findings induced us to assess whether follow-up also causes negative psychological stress in our colorectal cancer patients. In this trial 100 colorectal cancer follow-up patients were asked to compile three questionnaires: 1) the McGil Pain Questionnaires; 2) Profile of Mood Status; and 3) Locus of Control. The questionnaires were handed to the patients at follow-up and were compiled immediately. In addition, the patients were asked to answer the firsts two tests spontaneously 30 days after follow-up and mail the questionnaires. Our results showed that only 41% of the patients complied the tests 30 days after follow-up. The scores for pain and mood disorders were greater in women, especially during the "before follow-up" period. The third test revealed a prevalence of subjects with internal-type reinforcement. Our data revealed that: 1) patients tend to repress the problem; 2) women are affected by greater stress and anxiety; 3) subjects with internal-type reinforcement have a positive attitude during follow-up and this enables the ego to bear the anguish, process it and dilute it to anxiety, thus favouring future life experiences.