MRI of osteosarcoma metastases in the brain of an old English Sheepdog.

A 9-year-old, male neutered old English Sheepdog was presented for further investigation of altered mentation, impaired vision, and hemineglect syndrome of 10 days duration. An MRI study of the brain revealed multifocal, contrast-enhancing intra-axial lesions that had a stippled hypointense appearance in all sequences but lacked evidence of a strong signal void on T2* images. Histological examination of the brain postmortem confirmed the lesions were metastases arising from an osteosarcoma, which was later identified in the right humerus. To the authors' knowledge, these MRI characteristics of osteosarcoma metastases in the canine brain have not been previously reported.

Catatonia in 26 patients with bipolar disorder: clinical features and response to electroconvulsive therapy.

OBJECTIVES: We describe the clinical characteristics and short-term outcomes of a sample of inpatients with bipolar disorder with severe catatonic features resistant to pharmacological treatment. METHODS: The study involved 26 catatonic patients, resistant to a trial of benzodiazepines, and then treated with electroconvulsive therapy (ECT). All patients were evaluated prior to and one week following the ECT course using the Bush-Francis Catatonia Rating Scale (BFCRS) and the Clinical Global Impression (CGI). RESULTS: In our sample, women were over-represented (n = 23, 88.5%), the mean (± standard deviation) age was 49.5 ± 12.5 years, the mean age at onset was 28.1 ± 12.8 years, and the mean number of previous mood episodes was 5.3 ± 2.9. The mean duration of catatonic symptoms was 16.7 ± 11.8 (range: 3-50) weeks, and personal history of previous catatonic episodes was present in 10 patients (38.5%). Seventeen (65.4%) patients showed abnormalities at cerebral computerized tomography and/or magnetic resonance imaging and neurological comorbidities were observed in 15.4% of the sample. Stupor, rigidity, staring, negativism, withdrawal, and mutism were observed in more than 90% of patients. At the end of the ECT course, 21 patients (80.8%) were classified as responders. The BFCRS showed the largest percentage of improvement, with an 82% reduction of the initial score. The number of previous mood episodes was significantly lower and the use of anticholinergic and dopamine-agonist medications was significantly more frequent in non-responders than in responders. CONCLUSIONS: Our patients with bipolar disorder had predominantly retarded catatonia, frequent previous catatonic episodes, indicating a recurrent course, and high rates of concomitant brain structure alterations. However, ECT was a very effective treatment for catatonia in this patient group that was resistant to benzodiazepines.

Clinical features, developmental course, and psychiatric comorbidity of adult autism spectrum disorders.

Autism spectrum disorders (ASDs) include a heterogeneous group of neurodevelopmental disorders with early onset in childhood. ASDs should be considered lifelong clinical entities, although there is a certain variability in developmental trajectories, and therefore should be considered of great interest also for adulthood psychiatrists. A few studies have been carried out to explore the clinical picture and course development of these disorders during adulthood, or their relationship with other mental disorders. Indeed, ASDs often share overlapping features with other disorders, such as schizophrenia and obsessive-compulsive, mood, and personality disorders, and as a result misdiagnoses often occur. The aim of this review is to summarize the available literature on ASDs in adulthood with a specific focus on the clinical picture, course, and psychiatric comorbidity. It is proposed that a careful diagnostic screening for ASDs in adults would contribute to clarifying the relationship with comorbid psychiatric disorders, while improving the possibility of treatment and outcome of such conditions.

The mood-stabilizing effects of electroconvulsive therapy.

The "ideal" mood stabilizer has been defined as an agent displaying demonstrated efficacy for the acute treatment and long-term prevention of both mania and depression. On the basis of a selective and an extensive review of the existing literature primarily focused on prospective and controlled studies, we discuss the potential mood-stabilizing effects of electroconvulsive therapy (ECT) and its efficacy for the acute treatment of bipolar depressive and mixed-manic states and the prevention of all types of recurrences of bipolar disorder (BD). We conclude that ECT should be considered an effective acute treatment for the depressive and manic-mixed states of BD, as ECT displays response and remission rates superior to those of other treatment approaches, even in severe and treatment-resistant cases. From this point of view, its clinical mood-stabilizing effects are clearly superior compared with other pharmacological approaches because most treatments that alleviate bipolar depression can cause mania, hypomania, mood instability, or rapid cycling and treatments that can control mania can induce or precipitate depressive symptoms or episodes. The ECT-induced mania is rare, and there are no data suggesting possible long-term mood destabilization, including cycle induction or acceleration. Conversely, several case reports and open trials reported a significant reduction in morbidity among patients experiencing rapid-cycling BD. Regarding relapse prevention, c-ECT and m-ECT are considered as appropriate therapies for treatment-resistant patients exhibiting high rates of depressive or mixed relapse. Further investigation is necessary to identify the frequency and duration of continued treatment after a successful index course of ECT.

Predictors of remission in 208 drug-resistant depressive patients treated with electroconvulsive therapy.

OBJECTIVES: This study aimed to explore predictors of remission to electroconvulsive therapy (ECT) in a sample of depressive patients resistant to pharmacological treatments. METHODS: Two hundred eight patients, 31 of whom had major depressive disorder, 101 had bipolar disorder II (BP II), and 76 had bipolar disorder I (BP I), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were treated with bilateral ECT on a twice-a-week schedule. All patients included were undergoing a depressive episode, excluding patients with mixed and manic episodes. Patients were assessed before (baseline) and a week after the ECT course (final score) using the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Young Mania Rating Scale (YMRS), the Brief Psychiatric Rating Scale, and the Clinical Global Impression-Improvement (CGI-I). RESULTS: At the end of the ECT course, 56 patients (26.9%) were considered nonresponders, and 80 patients (38.4%) were considered responders (HAM-D score of at least 50% and CGI-I subscale rating of 2, "much improved") and 72 remitters (34.6%) (HAM-D scores ≤8 and a CGI-I subscale rating of 1). On backward stepwise logistic regression length of current episode, Bipolar Disorder and baseline YMRS total mean scores were statistically significant predictors of nonresponders versus remitters. Among the YMRS items at basal evaluation 8 (thought content), 10 (appearance), and 11 (insight), the mean scores were significantly lower in the remitters than in the responders and nonresponders. CONCLUSION: Major depressive disorder, short duration of the current episode, absence of psychotic symptoms, preserved insight, and adequate personal care are associated with complete remission in our sample of drug-resistant depressive patients treated with ECT.

Clinical presentation, magnetic resonance imaging findings, and outcome of 80 Dachshunds with cervical intervertebral disc extrusion.

Introduction: Large clinical studies regarding cervical intervertebral disc extrusion (IVDE) in Dachshunds are lacking. This retrospective multicentric study therefore aims to describe the clinical features, magnetic resonance imaging (MRI) findings and outcomes of Dachshunds diagnosed with cervical IVDE. Methods: Medical records of Dachshunds with cervical IVDE were reviewed for signalment, onset of clinical signs, neurological examination, MRI features, treatment and outcome. Results: Eighty Dachshunds were included in the study, mostly ambulatory (55% grade 1 and 33% grade 2) and without nerve root signature (85% of cases) on presentation. Information on coat type was available for 56% of dogs; specifically, 41% were smooth-haired, 9% were long-haired and 6% were wire-haired Dachshunds. There were 29 (36%) neutered female, 27 (34%) male entire, 15 (19%) male neutered and 9 (11%) entire female dogs. The onset of clinical signs was most often >48 h (84%). The most common intervertebral disc space affected was C2-C3 (38%) and foraminal IVDEs were reported in 14% of dogs. A foraminal IVDE was diagnosed in only 25% of dogs presented with nerve root signatures. Most dogs (77.5%) were treated surgically. In this group, a higher body condition score on presentation and a higher mean spinal cord compression ratio calculated on MRI were directly and moderately associated with a longer hospitalization time (r = 0.490 p = 0.005 and r = 0.310 p = 0.012, respectively). The recovery time was longer in dogs with an onset of clinical signs <24 h or 24-48 h compared to those with an onset of clinical signs >48 h (3.1 ± 6.5 days versus 1.6 ± 6.2, p < 0.001) in both medically and surgically treated groups. Data about the outcome was available for 83% of dogs. Eighty percent of the entire population of dogs was considered to have completely returned to normal. There was no association between the therapeutic choice (surgical versus medical management) and the outcome of the dogs included in this study.

Impulsivity in patients with panic disorder-agoraphobia: the role of cyclothymia.

The relationship between Panic Disorder (PD) and impulsivity is not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in PD patients vs. healthy controls and to explore the influence of co-morbid Cyclothymic Disorder (CD) on the relationship between PD and impulsivity. Sixty-four subjects with PD and 44 matched controls underwent a diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0; the Bech-Rafaelsen Depression and Mania Scale (BRDMS), the State-Trait Anxiety Inventory (STAI), the Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI). Finally, psychometric and neurocognitive evaluations of impulsivity was carried out using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT/DMT). Subjects with PD were more impulsive than the controls in all the explored measures, reporting higher scores in symptomatological and temperamental scales. The comparison between PD patients with (Cyclo+) and without (Cyclo-) comorbid CD and controls showed that Cyclo+ are the most impulsive subjects in all the investigated measures and are characterized by the greatest symptomatological impairment, the highest scores in temperamental scales, and the highest levels of interpersonal sensitivity and separation anxiety. In our patients with PD, without lifetime comorbidity with major mood episodes, trait and state impulsivity may be related to the presence of comorbid cyclothymic mood instability.

Long-term naturalistic follow-up of patients with bipolar depression and mixed state treated with electroconvulsive therapy.

OBJECTIVE: The aim of the present study was to evaluate the long-term outcome in a sample of patients with bipolar disorder with severe depression or mixed-state resistant to pharmacological treatment who have responded to electroconvulsive therapy (ECT). METHOD: The study involved 36 patients with major depression (5 patients with bipolar I depression, and 14 patients with bipolar II depression) or mixed state (17 patients) treated with bilateral ECT delivered using a brief pulse stimulator Mecta 5000 Q on a twice-a-week schedule. The patients were evaluated before ECT (baseline) and 1 week after the ECT course (final score) using the Hamilton Depression Rating Scale, Mania Rating Scale, Brief Psychiatric Rating Scale, and Clinical Global Improvement. The Longitudinal Interval Follow-up Evaluation was administered every 16 weeks to assess time to relapse (defined as LIFE scores ≥5 for at least 2 consecutive weeks or as the need for hospitalization) and periods of response and remission. RESULTS: The mean duration of follow-up was 55.3 ± 30.4 weeks (range, 24-160 weeks). Thirteen patients (36.1%) showed a depressive relapse during the follow-up; the mean time (length) of depressive relapse was 20.4 ± 21.8 weeks (range, 2-60 weeks). Twenty-nine patients (80.5%) fulfilled the criteria for a full remission from depressive symptoms after 6.7 ± 7.9 weeks from the last ECT. Seventeen patients (47.2%) were in remission for more than 70% of the time. No manic episodes occurred during the follow-up, only 1 patient had a mixed episode, and 11 patients had a hypomanic episode. CONCLUSION: Electroconvulsive therapy showed a positive impact on the clinical course of severe and treatment-resistant patients with bipolar disorders, as suggested by the high number of weeks spent in remission during the follow-up period. In our study, the duration of depressive episode was related to early relapse during follow-up period.

Spirituality and religiosity in the aftermath of a natural catastrophe in Italy.

The aim of this study is to assess the influence of spirituality and religiousness on the psychological traumatic effects of a catastrophic event in a population that had been exposed to an earthquake compared with a control population that had not been exposed. A total of 901 people have been evaluated using: (1) Brief Multidimensional Measure of Religiousness/Spirituality; (2) Impact of Event Scale and (3) Trauma and Loss Spectrum-Self Report (TALS-SR). Self-perceptions of spirituality and religiousness were used to rank the samples, distinguishing between spiritual and religious, spiritual-only, religious-only and neither spiritual nor religious groups. The sample that had experienced the earthquake showed lower scores in spiritual dimension. The religious-only group of those who were exposed to the earthquake demonstrated TALS-SR re-experiencing and arousal domain scores similar to the population that was not exposed. A weakening of spiritual religiosity in people having difficulty coping with trauma is a consistent finding. We further observed that the religious dimension helped to buffer the community against psychological distress caused by the earthquake. The religiosity dimension can positively affect the ability to cope with traumatic experiences.

Different measures of impulsivity in patients with anxiety disorders: a case control study.

The relationship between anxiety and impulsivity is controversial and not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in patients with anxiety disorders vs. healthy controls. Forty-seven subjects with different anxiety disorders and 45 matched controls underwent diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0, Bech-Raphaelsen Depression and Mania Scale (BRDMS), State-Trait Anxiety Inventory (STAI), Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); temperamental evaluations by the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI); and psychometric and a neurocognitive evaluations of impulsivity using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT-DMT). Subjects with anxiety disorders were more impulsive than the controls in all the explored measures, with higher scores in symptomatological and, temperamental scales. Patients with anxiety disorders but without a lifetime history of comorbid major mood episodes had greater trait and state impulsivity than controls. Further investigations are needed to assess the extent to which impulsivity might or might not be directly related to the anxiety disorder.

Risk of conversion to bipolar disorder in patients with late-onset major depression.

To evaluate the impact of age at onset on late-life depression course and on risk of conversion to bipolar disorder (BD). A retrospective chart review of 100 elderly patients (age ≥ 65 years) diagnosed with a moderate-to-severe depressive episode and followed up for at least 18 months was conducted. Among patients affected by major depressive disorder ( N = 57), follow-up morbidity differences between those with typical onset depression (TOD) (<60 years) and those with late-onset depression (LOD) (≥60 years) were investigated using Wilcoxon rank-sum test and Cox proportional hazard model. Patients belonging to the LOD group had a significantly lower percentage of follow-up time spent with depressive symptoms compared with patients with TOD ( r = 0.36; P = 0.006), but significantly more time spent with (hypo)manic episodes ( r = -0.31; P = 0.021). Moreover, LOD was significantly associated with a faster conversion to BD (hazard ratio = 3.05; P = 0.037). Depression first emerging in late life may represent an unstable condition with a high risk to convert to BD. Given the potential clinical implications, further studies on the course of LOD are required.

Clinical features, treatment and outcome of discospondylitis in cats.

OBJECTIVES: There is a paucity of information on feline discospondylitis. This study aimed to describe the signalment, clinical and laboratory findings, aetiological agents, treatment and outcome in cats affected by discospondylitis. METHODS: This was a retrospective review of the medical records of cats diagnosed with discospondylitis at four referral institutions. RESULTS: A total of 17 cats were identified. Most were domestic shorthair cats (76.5%) and male (58.8%), with a median age of 9 years (range 0.9-14) and a median duration of clinical signs of 3 weeks (range 0.3-16). All cats presented with spinal hyperaesthesia; 3/17 had pyrexia. Neurological dysfunction was found in 64.7% of cats, which was indicative of a T3-L3 or L4-S2 spinal segment, associated nerve root or associated nerve neurolocalisation. Haematology, serum biochemistry and urinalysis revealed occasional inconsistent non-specific changes. All cats underwent urine culture; 9/17 cats also had a distinct tissue cultured. Positive bacterial cultures were obtained in two cats (11.8%) for Staphylococcus species (urine, blood and intradiscal fine-needle aspirate) and Escherichia coli (urine); both presented with multifocal discospondylitis. Treatment was non-surgical in all cats, with sustained antibiotic therapy for a median of 3 months (range 1-9). Analgesia provided included non-steroidal anti-inflammatory drugs, alone or in combination with gabapentin. Restricted exercise was advised for a minimum of 4 weeks. Outcome information available in 12 cats was excellent in terms of pain control and neurological function in 10 cats (83.3%) at the time of stopping antibiotics. Recurrence occurred in one case, which had received a single antibiotic for 6 weeks, and relapsed 4 months after presentation. One other case failed to improve and was euthanased during the course of hospitalisation. CONCLUSIONS AND RELEVANCE: Feline discospondylitis is uncommon and no obvious signalment predisposition was found in this study. Spinal hyperaesthesia was universally present, with neurological dysfunction also highly prevalent. Bacterial culture was unrewarding in most cases. Amoxicillin-clavulanic acid or cephalosporins are reasonable choices for first-line antibiotics. Prognosis was favourable, with no long-term evidence of recurrence in cats on sustained antibiotic therapy, for a mean duration of 3 months.

Accuracy of Placement of Pedicle Screws in the Lumbosacral Region of Dogs Using 3D-Printed Patient-Specific Drill Guides.

OBJECTIVE: The aim of this study was to report the accuracy of pedicle screw placement using three-dimensional (3D)-printed, patient-specific drill guides in the lumbosacral region of dogs. STUDY DESIGN: This was a retrospective study. Thirty-two pedicle screws were placed in five dogs. Medical records were reviewed between November 2015 and November 2018 for dogs showing clinical signs associated with cauda equina syndrome. Inclusion criteria included preoperative magnetic resonance imaging, pre- and postoperative computed tomography (CT) and dorsal stabilization, with pedicle screws placed using 3D-printed, patient-specific drill guides and polymethylmethacrylate. Screw placement was evaluated for medial or lateral breaching on postoperative CT. RESULTS: Five dogs met the inclusion criteria. Four had degenerative lumbosacral stenosis and one had discospondylitis. All dogs had failed medical management prior to surgery. Of 32 bicortical pedicle screws placed, 30 were fully contained inside the pedicle and 2 were partially breaching the vertebral canal (less than one-third of the screw diameter). Postoperative CT revealed good alignment of L7-S1 in all planes. CONCLUSION: This technique enabled an accurate and safe placement of pedicle screws in the lumbosacral region of dogs with lumbosacral disease. Three-dimensional, printed patient-specific drill guides are a safe and effective method of placing pedicle screws in dogs with lumbosacral disease.

Adjunctive valproate in panic disorder patients with comorbid bipolar disorder or otherwise resistant to standard antidepressants: a 3-year "open" follow-up study.

The aim of the study was to report on the clinical utility of naturalistic adjunctive treatment with valproate (VPA) in a group of panic disorder (PD) patients with comorbid bipolar disorder (BD) or otherwise resistant to antidepressants. The hypothesis was that these patients might not respond because of coexisting low-grade mood instability and adjunctive VPA treatment might ameliorate PD symptoms. A group of 47 patients with lifetime comorbid BD (n = 35, 74.5%) or otherwise resistant to antidepressants (n = 12, 25.6%), from a population of 326 consecutive outpatients with PD-Agoraphobia evaluated and treated at the Psychiatric Institute of the University of Pisa from 1991 to 1995, and followed for a period of 3 years. All patients were evaluated at baseline and at least every 2 months by means of an intensive interview including semi-structured and structured instruments (SCID, Life-Up, and Panic Disorder/Agoraphobia Interview). Mean dosage was 687 (SD = 234) mg/day (min 400, max 1,500 mg/day). Adjunctive treatment with VPA was well tolerated by all subjects, and there was no treatment interruption because of side effects or adverse events. All antidepressants-resistant subjects and 31 of 35 (88.6%) patients with bipolar comorbidity achieved symptomatological remission. During the observation period, 7 (58.3%) among resistant subjects and 17 (48.6%) of bipolar patients had a relapse of panic disorder after remission. Survival analysis of remission durations and onset relapses for PD and Agoraphobia did not show significant differences between the two groups. Relapses of Agoraphobia were less frequent and more delayed than those for panic. According to the results, VPA seems to be an effective and a well-tolerated adjunctive treatment in PD patients who were resistant to antidepressant therapy or had BD in comorbidity. The results of the study support the hypothesis of resistance to antidepressant treatment being related to mood instability.

Retrospective comparison of first-line adjuvant anthracycline vs metronomic-based chemotherapy protocols in the treatment of stage I and II canine splenic haemangiosarcoma.

Splenectomy followed by adjuvant chemotherapy is commonly used to treat canine splenic haemangiosarcoma (HSA), although it is unclear if different treatment protocols may have a similar efficacy. The objective of this retrospective study was to assess outcome in dogs with stage I and II splenic HSA treated with either first-line adjuvant anthracycline (AC) or metronomic (MC)-based chemotherapy protocols, by comparing median time to progression (TTP) and median survival time (MST). Medical records of nine institutions were searched for dogs diagnosed with stage I and II splenic HSA that underwent adjuvant treatment with AC- or MC-based protocols following splenectomy. Patients treated with MC following AC were included in an additional group (AMC). Ninety-three dogs were included: 50 in the AC group, 23 in the AMC group and 20 in the MC group. The overall MST was 200 days (range 47-3352) and the overall median TTP was 185 days (range 37-1236). The median TTP of stage I dogs was significantly longer compared to stage II dogs (338 vs 151 days, respectively, P = .028). When adjusting for treatment type, the MST was 154 days for the AC group (range 47-3352 days), 338 days for the AMC group (range 79-1623 days) and 225 days for the MC group (range 57-911 days). The difference in MST and median TTP was not found to be statistically significant between treatment groups. This study suggests that adjuvant MC in canine splenic HSA may result in a similar outcome when compared to other treatment protocols. Further studies are warranted to confirm these findings.

The clinical-familial correlates and naturalistic outcome of panic-disorder-agoraphobia with and without lifetime bipolar II comorbidity.

BACKGROUND: Much of the literature on panic disorder (PD)-bipolar disorder (BP) comorbidity concerns BP-I. This literature emphasizes the difficulties encountered in pharmacologic treatment and outcome when such comorbidity is present. The present report explores these issues with respect to BP-II. METHODS: The sample comprised 326 outpatients (aged 34.5 +/- 11.5 years old; 222 females) with Diagnostic and Statistical Manual of Mental Disorders 3rd edn, revised (DSM-III-R) PD-agoraphobia; among them 52 subjects (16%) were affected by lifetime comorbidity with BP-II. Patients were evaluated by means of the Structured Clinical Interview for DSM-IV (SCID), the Panic-Agoraphobia Interview, and the Longitudinal Interview Follow-up Examination (Life-Up) and treated according to routine clinical practice at the University of Pisa, Italy, for a period of 3 years. Clinical and course features were compared between subjects with and without BP-II. All patients received the clinicians' choice of antidepressants and, in the case of the subsample with BP-II, mood stabilizers (for example, valproate, lithium) were among the mainstays of treatment. RESULTS: In comparison to patients without bipolar comorbidity, those with BP-II showed a significantly greater frequency of social phobia, obsessive-compulsive disorder, alcohol-related disorders, and separation anxiety during childhood and adolescence. Regarding family history, a significantly greater frequency of PD and mood disorders was present among the BP-II. No significant differences were observed in the long-term course of PD or agoraphobic symptoms under pharmacological treatment or the likelihood of spontaneous pharmacological treatment interruptions. CONCLUSION: Although the severity and outcome of panic-agoraphobic symptomatology appear to be similar in patients with and without lifetime bipolar comorbidity, the higher number of concomitant disorders in our PD patients with BP-II does indicate a greater complexity of the clinical picture in this naturalistic study. That such complexity does not seem to translate into poorer response and outcome in those with comorbid soft bipolarity probably reflects the fact that we had brought BP-II under control with mood stabilizers. We discuss the implications of our findings as further evidence for the existence of a distinct anxious-bipolar diathesis.

Obsessive-compulsive Disorder with Comorbid Bipolar Disorders: Clinical Features and Treatment Implications.

BACKGROUND: Obsessive-compulsive disorder (OCD) symptoms within the context of a bipolar disorder (BD) have been described since the 19th century. Interestingly, the existence of a relevant overlap between the aforementioned psychiatric syndromes has been confirmed by a number of recent epidemiological and family studies. AIMS: The aim of the present paper is to review the clinical features and the therapeutic implications of the OCD-BD comorbidity. DISCUSSION: In the last two decades, the frequent association between OCD and BD has been earning a growing interest given its relevant nosological and therapeutic implications. Usually patients suffering from OCD-BD comorbidity show a peculiar clinical course, characterized by a larger number of concomitant depressive episodes and episodic course. In these cases, the treatment with antidepressants is more likely to elicit hypomanic or manic switches, while mood stabilizers significantly improve the overall clinical picture. Moreover, OCD-BD patients are frequently comorbid with a number of other psychiatric disorders, in particular anxiety disorders, social phobia, and different substance abuses, such as alcohol, nicotine, caffeine and sedatives. CONCLUSIONS: BD-OCD comorbidity needs further investigations in order to provide more solid evidences to give patients a more precise clinical diagnosis and a more targeted therapeutic approach.

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode.

OBJECTIVE: This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18-45 years), middle age (46-64 years) and old (≥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode. METHOD: 402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score ≤ 7 on the HAM-D-17 at the final evaluation. RESULTS: Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects. CONCLUSION: Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected.

Diagnosis and treatment of agoraphobia with panic disorder.

Agoraphobia with panic disorder is a phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs. During the last half-century, agoraphobia has been thought of as being closely linked to the recurring panic attack syndrome, so much so that in most cases it appears to be the typical development or complication of panic disorder. Despite the high prevalence of agoraphobia with panic disorder in patients in primary-care settings, the condition is frequently under-recognised and under-treated by medical providers. Antidepressants have been demonstrated to be effective in preventing panic attacks, and in improving anticipatory anxiety and avoidance behaviour. These drugs are also effective in the treatment of the frequently coexisting depressive symptomatology. Among antidepressant agents, SSRIs are generally well tolerated and effective for both anxious and depressive symptomatology, and these compounds should be considered the first choice for short-, medium- and long-term pharmacological treatment of agoraphobia with panic disorder. The few comparative studies conducted to date with various SSRIs reported no significant differences in terms of efficacy; however, the SSRIs that are less liable to produce withdrawal symptoms after abrupt discontinuation should be considered the treatments of first choice for long-term prophylaxis. Venlafaxine is not sufficiently studied in the long-term treatment of panic disorder, while TCAs may be considered as a second choice of treatment when patients do not seem to respond to or tolerate SSRIs. High-potency benzodiazepines have been shown to display a rapid onset of anti-anxiety effect, having beneficial effects during the first few days of treatment, and are therefore useful options for short-term treatment; however, these drugs are not first-choice medications in the medium and long term because of the frequent development of tolerance and dependence phenomena. Cognitive-behavioural therapy is the best studied non-pharmacological approach and can be applied to many patients, depending on its availability.