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BACKGROUND: Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive. AIMS: To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis. METHOD: Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening. RESULTS: Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37-20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33-10.10). CONCLUSIONS: The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.
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Planes de Incentivos para los Médicos/economía , Planes de Incentivos para los Médicos/organización & administración , Trastornos Psicóticos/terapia , Calidad de la Atención de Salud/economía , Reembolso de Incentivo/economía , Atención Secundaria de Salud/normas , Pruebas Diagnósticas de Rutina , Inglaterra , Humanos , Mejoramiento de la Calidad/economía , Atención Secundaria de Salud/economía , GalesRESUMEN
BACKGROUND: In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population. AIMS: To examine the quality of assessment and treatment of physical health problems in people with schizophrenia. Method Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey. RESULTS: Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received. CONCLUSIONS: Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.
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Trastornos Psicóticos , Calidad de la Atención de Salud , Esquizofrenia , Adulto , Anciano , Consumo de Bebidas Alcohólicas/epidemiología , Consumo de Bebidas Alcohólicas/psicología , Glucemia/análisis , Índice de Masa Corporal , Colesterol/sangre , Estudios Transversales , Femenino , Necesidades y Demandas de Servicios de Salud , Disparidades en el Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Prioridad del Paciente , Trastornos Psicóticos/sangre , Trastornos Psicóticos/epidemiología , Trastornos Psicóticos/fisiopatología , Mejoramiento de la Calidad , Calidad de la Atención de Salud/normas , Calidad de la Atención de Salud/estadística & datos numéricos , Esquizofrenia/sangre , Esquizofrenia/epidemiología , Esquizofrenia/fisiopatología , Fumar/epidemiología , Fumar/psicología , Reino Unido/epidemiologíaRESUMEN
Genetic factors contribute to the individual variability in weight gain caused by several antipsychotic drugs. The FTO gene is associated with obesity in the general population; we have investigated whether a common risk polymorphism (rs9939609) in this gene is associated with antipsychotic drug-induced weight gain and obesity. Two samples were studied: (1) 93 first-episode patients receiving antipsychotic drugs for the first time and having body weight monitored for up to 12 months; (2) 187 chronic patients with schizophrenia assessed for measures of obesity and metabolic dysfunction. No association of FTO genotype with weight gain was found in initially drug-naive patients. The chronically treated patients had a significant association of genotype with body mass index (BMI), reflected in associations with waist circumference, waist:hip ratio and the frequency of central obesity. These findings indicate that FTO genotype has a major effect on body weight determined by BMI in chronically treated patients with schizophrenia.
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Peso Corporal/genética , Obesidad/complicaciones , Polimorfismo Genético/genética , Proteínas/genética , Esquizofrenia/complicaciones , Esquizofrenia/genética , Adolescente , Adulto , Dioxigenasa FTO Dependiente de Alfa-Cetoglutarato , Antipsicóticos/uso terapéutico , Índice de Masa Corporal , Peso Corporal/efectos de los fármacos , Enfermedad Crónica , Femenino , Estudios de Asociación Genética , Humanos , Masculino , Obesidad/genética , Esquizofrenia/tratamiento farmacológico , Adulto JovenRESUMEN
In this quality improvement project, we sought to increase the understanding and utilization of the antibiogram among physicians in family medicine, internal medicine, and surgery residency programs at a Midwest Academic Healthcare institution. Through simple, inexpensive measures the comfort with, access to, and utilization of the antibiogram can be improved.
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These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Antipsicóticos/uso terapéutico , Medicina Basada en la Evidencia , Esquizofrenia/tratamiento farmacológico , Humanos , Reino UnidoRESUMEN
BACKGROUND: Researching psychotic disorders in unison rather than as separate diagnostic groups is widely advocated, but the viability of such an approach requires careful consideration from a neurocognitive perspective. AIMS: To describe cognition in people with bipolar disorder and schizophrenia and to examine how known causes of variability in individual's performance contribute to any observed diagnostic differences. METHOD: Neurocognitive functioning in people with bipolar disorder (n = 32), schizophrenia (n = 46) and healthy controls (n = 67) was compared using analysis of covariance on data from the Northern Ireland First Episode Psychosis Study. RESULTS: The bipolar disorder and schizophrenia groups were most impaired on tests of memory, executive functioning and language. The bipolar group performed significantly better on tests of response inhibition, verbal fluency and callosal functioning. Between-group differences could be explained by the greater proclivity of individuals with schizophrenia to experience global cognitive impairment and negative symptoms. CONCLUSIONS: Particular impairments are common to people with psychosis and may prove useful as endophenotypic markers. Considering the degree of individuals' global cognitive impairment is critical when attempting to understand patterns of selective impairment both within and between these diagnostic groups.
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Trastorno Bipolar/psicología , Trastornos del Conocimiento/psicología , Psicología del Esquizofrénico , Adolescente , Adulto , Atención , Trastorno Bipolar/diagnóstico , Estudios de Casos y Controles , Trastornos del Conocimiento/diagnóstico , Femenino , Humanos , Inteligencia , Masculino , Recuerdo Mental , Persona de Mediana Edad , Pruebas Neuropsicológicas , Conducta Verbal , Adulto JovenRESUMEN
BACKGROUND: Substance misuse is a common comorbid problem in people presenting with first-episode psychosis and is associated with a poor short-term outcome. AIMS: The aim of this study is to examine differences in baseline characteristics and 1-year outcome between individuals with first-episode psychosis who have never misused substances, those who stop misusing substances after initial presentation and those who persistently misuse substances over the 1-year assessment period. METHOD: Patients were recruited to the Northern Ireland First Episode Psychosis Study (n = 272). Clinical assessments were performed at baseline and at 1 year (n = 194) and data were collected from the case notes. RESULTS: Individuals with persistent substance misuse had more severe depression, more positive symptoms, poorer functional outcome and greater rates of relapse at 1 year than those who stopped and those who had never misused substances. There were no differences in outcome between people who had never misused substances and those who stopped misusing after presentation. CONCLUSIONS: These results support assertive intervention targeted at comorbid substance misuse in individuals with first-episode psychosis.
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Trastornos Mentales/epidemiología , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Trastornos Relacionados con Sustancias/epidemiología , Adolescente , Adulto , Trastorno Bipolar/epidemiología , Comorbilidad , Trastorno Depresivo/epidemiología , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cooperación del Paciente/psicología , Cooperación del Paciente/estadística & datos numéricos , Escalas de Valoración Psiquiátrica , Recurrencia , Esquizofrenia/epidemiología , Psicología del Esquizofrénico , Trastornos Relacionados con Sustancias/psicología , Adulto JovenRESUMEN
Aims and methodWe conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.Declaration of interestNone.
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Dietary induced acute tryptophan depletion (ATD) is used to reduce central serotonergic function and to investigate the role of serotonin (5-HT) in psychiatric illness. In healthy volunteers ATD produces working memory deficits and decreases mood in some studies. Brain-derived neurotrophic factor (BDNF) plays a role in both cognition and in the regulation of mood; however, the possible contribution of central BDNF changes to the effects of ATD has not been examined. Therefore, using a rat model we have examined the effect of amino acid mixture-induced ATD on plasma and central BDNF protein levels. ATD significantly reduced free-plasma TRP by 79% and central hippocampal 5-HT by 35% when compared to controls. However, plasma or central BDNF protein levels in the hippocampus and midbrain were not significantly altered by ATD. These results suggest that changes in central BDNF do not contribute to the cognitive or mood effects of ATD.
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Factor Neurotrófico Derivado del Encéfalo/metabolismo , Encéfalo/metabolismo , Triptófano/deficiencia , Animales , Ensayo de Inmunoadsorción Enzimática/métodos , Ácido Hidroxiindolacético/sangre , Masculino , Ratas , Ratas Sprague-Dawley , Serotonina/metabolismo , Triptófano/sangreRESUMEN
RATIONALE: Tryptophan depletion is used to reduce central serotonergic function and to investigate its role in psychiatric illness. Despite widespread clinical use, its effects on serotonin (5-HT) receptors have not been well characterized. OBJECTIVE: The aim of this study was to examine the effect of acute (ATD) and chronic tryptophan depletion (CTD) on free-plasma tryptophan (TRP), central TRP and 5-HT and brain 5-HT(1A) and 5-HT(2A) receptor binding in the rat. METHODS: TRP and 5-HT were measured by high-performance liquid chromatography and receptor levels determined by homogenate radioligand binding and in-vitro receptor autoradiography. RESULTS: Free-plasma TRP, central TRP and central 5-HT levels were significantly and similarly reduced by ATD and 1- and 3-week CTD compared to controls. ATD significantly reduced 5-HT(1A) binding in the dorsal raphe (14%) but did not significantly alter postsynaptic 5-HT(1A) binding (frontal cortex, remaining cortex and hippocampus) or 5-HT(2A) binding (cortex and striatum). One-week CTD did not significantly alter cortical 5-HT(2A) binding or postsynaptic 5-HT(1A) binding. Furthermore, 3-week CTD did not significantly alter 5-HT(1A) binding but significantly increased cortical 5-HT(2A) binding without affecting striatal or hippocampal levels. In the CTD 1 and 3-week groups, rat body weight was significantly decreased as compared to controls. However, weight loss was not a confounding factor for decreased cortical 5-HT(2A)-receptor binding. CONCLUSION: ATD-induced reduction in somatodendritic 5-HT(1A) autoreceptor binding may represent an intrinsic 'homeostatic response' reducing serotonergic feedback in dorsal raphe projection areas. In contrast, the increase in 5-HT(2A) receptor after CTD may be a compensatory response to a long-term reduction in 5-HT.
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Encéfalo/metabolismo , Receptor de Serotonina 5-HT1A/metabolismo , Receptor de Serotonina 5-HT2A/metabolismo , Serotonina/metabolismo , Triptófano/deficiencia , Animales , Autorradiografía , Autorreceptores/metabolismo , Peso Corporal , Cromatografía Líquida de Alta Presión , Retroalimentación Fisiológica , Masculino , Unión Proteica , Ensayo de Unión Radioligante , Ratas , Ratas Sprague-Dawley , Factores de Tiempo , Triptófano/sangreRESUMEN
In healthy humans, there is an apparent dissociation between cognitive and affective consequences of reduced brain serotonin (5-HT), as rapid tryptophan depletion (RTD) causes alterations in a consistent constellation of cognitive processes in the general absence of mood deterioration. This study aimed to investigate possible neural mechanisms underlying this relative dissociation by measuring the effects of reduced 5-HT on regional cerebral blood flow (rCBF). A total of 16 healthy, euthymic male subjects (mean age 39+/-9 years) without a personal or family history of affective disorder had mood ratings and single photon emission computed tomography scans with the rCBF tracer 99mTc-HMPAO under reduced 5-HT (RTD) and control conditions. Across individuals, modest positive and negative changes in subjective happiness associated with RTD were significantly correlated with change of rCBF in a cluster comprising subgenual (affective) anterior cingulate cortex (ACC) and associated regions (Brodmann's area (BA) 25, posterior BA11 and 47, caudate nucleus and ventral striatum; SPM99 p<0.05, corrected). The covariation was such that increasing sadness was associated with increased rCBF and vice versa. Independent of mood change, RTD was associated with reduced rCBF in the dorsal (cognitive) ACC (BA32; SPM99 p<0.05, corrected). The subgenual prefrontal cortex and dorsal ACC are important components of the ventral and dorsal neural systems that regulate and integrate affective and cognitive functions. The results therefore suggest that the dissociation between affective and cognitive consequences of RTD may possibly be attributable to differential effects of reduced 5-HT on these neural systems.
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Giro del Cíngulo/irrigación sanguínea , Giro del Cíngulo/metabolismo , Corteza Prefrontal/irrigación sanguínea , Corteza Prefrontal/metabolismo , Triptófano/deficiencia , Adulto , Circulación Cerebrovascular/fisiología , Humanos , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional/fisiología , Serotonina/deficiencia , Serotonina/metabolismo , Tomografía Computarizada de Emisión de Fotón Único/métodos , Triptófano/metabolismoRESUMEN
Rapid tryptophan (Trp) depletion (RTD) has been reported to cause deterioration in the quality of decision making and impaired reversal learning, while leaving attentional set shifting relatively unimpaired. These findings have been attributed to a more powerful neuromodulatory effect of reduced 5-HT on ventral prefrontal cortex (PFC) than on dorsolateral PFC. In view of the limited number of reports, the aim of this study was to independently replicate these findings using the same test paradigms. Healthy human subjects without a personal or family history of affective disorder were assessed using a computerized decision making/gambling task and the CANTAB ID/ED attentional set-shifting task under Trp-depleted (n=17; nine males and eight females) or control (n=15; seven males and eight females) conditions, in a double-blind, randomized, parallel-group design. There was no significant effect of RTD on set shifting, reversal learning, risk taking, impulsivity, or subjective mood. However, RTD significantly altered decision making such that depleted subjects chose the more likely of two possible outcomes significantly more often than controls. This is in direct contrast to the previous report that subjects chose the more likely outcome significantly less often following RTD. In the terminology of that report, our result may be interpreted as improvement in the quality of decision making following RTD. This contrast between studies highlights the variability in the cognitive effects of RTD between apparently similar groups of healthy subjects, and suggests the need for future RTD studies to control for a range of personality, family history, and genetic factors that may be associated with 5-HT function.
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Atención/fisiología , Cognición/fisiología , Toma de Decisiones/fisiología , Dieta , Aprendizaje Inverso/fisiología , Triptófano/deficiencia , Adolescente , Adulto , Análisis de Varianza , Estudios Cruzados , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Tiempo de Reacción/fisiologíaRESUMEN
The impact of political violence on individuals presenting with an episode of first episode psychosis has not been examined. Individuals were assessed for exposure to political violence in Northern Ireland (the "Troubles") by asking for a response to 2 questions: one asked about the impact of violence "on your area"; the second about the impact of violence "on you or your family's life." The participants were separated into 2 groups (highandlowimpact) for each question. Symptom profiles and rates of substance misuse were compared across the groups at baseline and at 3-year follow up. Of the 178 individuals included in the study 66 (37.1%) reported ahighimpact of the "Troubles" on their life and 81 (45.5%) ahighimpact of the "Troubles" on their area. There were no significant differences in symptom profile or rates of substance misuse betweenhighandlowgroups at presentation. At 3-year follow-uphighimpact of the "Troubles" on life was associated with higher Positive and Negative Symptom Scale (PANSS) Total (P= .01), PANSS-Positive (P< .05), and PANSS-General (P< .01) scores and lower global assessment of functioning disability (P< .05) scores, after adjusting for confounding factors. Impact of the "Troubles" on area was not associated with differences in symptom outcomes. This finding adds to the evidence that outcomes in psychosis are significantly impacted by environmental factors and suggests that greater attention should be paid to therapeutic strategies designed to address the impact of trauma.
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Evaluación de Resultado en la Atención de Salud , Política , Trauma Psicológico/psicología , Trastornos Psicóticos/psicología , Violencia/psicología , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Irlanda del Norte , Trauma Psicológico/complicaciones , Trauma Psicológico/terapia , Trastornos Psicóticos/etiología , Trastornos Psicóticos/terapiaRESUMEN
BACKGROUND: Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact. AIMS: To examine associations between changes in staff, and patient satisfaction and quality of care. METHOD: A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder. RESULTS: Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments. CONCLUSIONS: Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients. DECLARATION OF INTEREST: M.J.C. was co-chair of the expert advisory group on the NICE quality standard on Service User Experience in Adult Mental Health. S.J.C. has previously been a member of the Health and Social Care Board Northern Ireland Formulary Committee. D.S. received a speaker's fee from Janssen Cilag in 2011. He is a topic expert on NICE guideline for psychosis and schizophrenia in children and young people and a board member of National Collaborating Centre for Mental Health. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users' negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance ('pre-diabetes'), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines.These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.
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Antipsicóticos/administración & dosificación , Enfermedades Cardiovasculares/prevención & control , Esquizofrenia/tratamiento farmacológico , Antipsicóticos/efectos adversos , Enfermedades Cardiovasculares/etiología , Humanos , Enfermedades Metabólicas/etiología , Enfermedades Metabólicas/terapia , Obesidad/etiología , Obesidad/terapia , Sobrepeso/etiología , Sobrepeso/terapia , Trastornos Psicóticos/complicaciones , Trastornos Psicóticos/tratamiento farmacológico , Factores de Riesgo , Esquizofrenia/complicaciones , Aumento de PesoRESUMEN
There have been no studies specifically examining the efficacy of selective serotonin reuptake inhibitor antidepressants for the symptoms of depression in schizophrenia. This study aimed to determine the efficacy and safety of sertraline as a treatment for depressive symptoms in patients with stable, chronic schizophrenia. The Beck Depression Inventory (BDI) was used as the principal outcome measure and other measures of depressive symptoms as secondary outcome measures. Twenty-six patients were entered into a double-blind, placebo-controlled, 8-week trial of sertraline and were included in the intent-to-treat (ITT) analysis (13 in each group). Eight patients in the sertraline group and 12 in the placebo group completed at least four weeks in the study and were considered to have had adequate treatment. On the ITT analysis, the mean score on the BDI fell 14.5% for the sertraline group and 5.6% for the placebo group (p > 0.05); the mean score on the Hamilton Depression Rating Scale (HDRS) fell 16.99% for the sertraline group and 8.3% for the placebo group (p > 0.05). When the analysis was repeated for those who had received adequate treatment, the mean BDI score fell by 28% for the sertraline group and 6% for the placebo group (p = 0.1); the mean HDRS score fell 31% for the sertraline group and 8.6% for the placebo group (p = 0.02). On the Clinical Global Impression-Improvement Scale, 10 of the 13 patients on sertraline improved against four of the 13 in the placebo group (p = 0.05). Sertraline-treated patients showed a significant improvement on the anxiety/ depression subscale of the BPRS on ITT analysis (F = 10.1, p = 0.004). There was no significant effect on negative or positive symptoms. Sertraline was well tolerated. The results suggest that sertraline is useful as a treatment for depressive symptoms in schizophrenia.
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Depresión/tratamiento farmacológico , Esquizofrenia/complicaciones , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Sertralina/uso terapéutico , Adolescente , Adulto , Anciano , Enfermedad Crónica , Depresión/etiología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Escalas de Valoración Psiquiátrica , Psicología del Esquizofrénico , Inhibidores Selectivos de la Recaptación de Serotonina/administración & dosificación , Inhibidores Selectivos de la Recaptación de Serotonina/efectos adversos , Sertralina/administración & dosificación , Sertralina/efectos adversos , Resultado del TratamientoRESUMEN
Low plasma folate and its derivatives have been linked with depressive disorders in studies dating back over 30 years. A thermolabile variant (677C>T) of the enzyme 5,10-methylenetetrahydrofolate reductase (MTHFR) is associated with low serum folate. The present study aimed to explore whether the thermolabile variant of MTHFR is associated with a vulnerability to depressive episodes. MTHFR C677T genotype frequencies in a cohort of patients (mean age 48 years) with depressive disorder (n = 100) were compared with those in age- and sex-matched controls. Serum levels of folate, homocysteine and vitamin B(12) were also compared between groups. The thermolabile variant of MTHFR was significantly more common in the group with a history of depressive disorder (P= 0.03). Serum levels of folate, homocysteine and vitamin B(12) did not differ significantly between groups. A MTHFR C677T genotype is associated with increased risk of depressive episodes in this homogenous patient population.
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Trastorno Depresivo/genética , Trastorno Depresivo/psicología , Metilenotetrahidrofolato Reductasa (NADPH2)/genética , Polimorfismo Genético/genética , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Trastorno Depresivo/epidemiología , Femenino , Ácido Fólico/sangre , Frecuencia de los Genes , Genotipo , Homocistina/sangre , Humanos , Irlanda/epidemiología , Masculino , Persona de Mediana Edad , Vitamina B 12/sangreRESUMEN
Noradrenergic function has been shown to be disrupted in depressive illness. The plasma noradrenaline response to a cognitive stressor (the Stroop test) was used to investigate noradenergic activity in subtypes of depressive illness. A Stroop test was carried out, under standardised conditions, on patients with melancholic or psychotic depression, non-melancholic depression, general anxiety disorder and normal controls. Blood samples were taken during testing for measurement of plasma noradrenaline. Although there was a trend for the plasma noradrenergic response to be reduced in the melancholic/psychotic depressed patients compared to all other groups, this did not reach statistical significance. No other inter-group comparisons were statistically significant. The plasma noradrenaline response to a cognitive stressor does not discriminate subtypes of depressive illness from normal controls. Copyright 2000 John Wiley & Sons, Ltd.
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The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9-16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3-10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5-24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.
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Antipsicóticos/uso terapéutico , Adhesión a Directriz , Auditoría Médica , Pautas de la Práctica en Medicina , Trastornos Psicóticos/tratamiento farmacológico , Esquizofrenia/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antipsicóticos/administración & dosificación , Clozapina/administración & dosificación , Clozapina/uso terapéutico , Estudios Transversales , Resistencia a Medicamentos , Quimioterapia Combinada/efectos adversos , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Gales , Adulto JovenRESUMEN
Hippocampus and amygdala changes have been implicated in the pathophysiology and symptomatology of both schizophrenia (SCZ) and bipolar disorder (BD). However relationships between illness course, neuropathological changes and variations in symptomatology remain unclear. This investigation examined the associations between hippocampus and amygdala volumes and symptom dimensions in schizophrenia and bipolar disorder patients after their first episode of psychosis. Symptom severity was associated with decreases in hippocampus/amygdala complex volume across groups. In keeping with previous work bilateral hippocampus and amygdala volume reductions were also identified in the SCZ patients while in BD patients only evidence of amygdala inflation reached significance. The study concludes that there appear to be important relationships between volume changes in the hippocampus and amygdala and dimensions and severity of symptomatology in psychosis. Structural alterations are apparent in both SCZ and BD after first episode of psychosis but present differently in each illness and are more severe in SCZ.