[Does ECT raise the risk of a recurrent stroke?] / Vormt ECT een risico op een recidief van cerebrovasculair accident?

BACKGROUND: As the guidelines and evidence for the use of electroconvulsive therapy (ECT) in patients with a recent or past history of stroke are unclear, ECT tends to be avoided in this population. AIM: To give a systematic review the literature on the risk and incidence of cerebrovascular accidents after ECT in these patients. METHOD: A systematic literature search was performed according to the PRISMA guidelines in PubMed and in the Cochrane Library. Publications in which ECT was applied in patients with a history of stroke were included by using specific MeSH terms. RESULTS: The following 19 articles met the criteria for review: 1 wide-scale prospective study, 1 small-scale prospective study with a control group, 3 small-scale retrospective studies, and 14 case reports. In the vast longitudinal Danish study, ECT was not associated with an elevated risk of recurrent stroke. Similarly, none of the other studies found the risk to be raised. CONCLUSION: Despite the limited number of prospective studies and the methodological discrepancies in the reports, ECT does not seem to be associated with an elevated risk of recurrent stroke. This review supports the safe use of ECT in patients with a recent or past history of stroke, if prior neurologic and cardiovascular assessments are being performed, as well as monitoring during the treatment.

[Barriers in mental health care for asylum seekers]. / Barrières in de ggz voor asielzoekers in hoge-inkomenslanden.

Background  Despite high prevalence of psychopathology, the use of mental health services by asylum seekers seems low. Barriers to care may play an important role in this. Aim  To explore the barriers in mental health care for adult and adolescent asylum seekers and their care providers in high-income countries. Method  A narrative literature review, based on a systematic evaluation of the current scientific literature. Results  In a narrative synthesis of the results, we identified the following six categories of barriers: lack of knowledge of the healthcare system, language barriers, discrepant beliefs and expectations of mental healthcare, lack of trust towards authority, and structural difficulties. Conclusion  Six thematic barriers were retained. Different interventions are possible to address these barriers. Further research into needs and interventions is recommended, with specific attention to the Belgian and Dutch context.

[Between response and resistance: pseudo-resistance during treatment of major depressive disorder]. / Tussen respons en resistentie: pseudo­resistentie bij de behandeling van een depressieve stoornis.

BACKGROUND: Although the efficacy of antidepressants has been clearly established, 30-60% of patients with major depressive disorder (MDD) appear to have a poor response. However, many patients labeled with treatment-resistant depression actually have pseudo-resistance due to suboptimal approach. AIM: To provide an overview of the causes of pseudo-resistance, as well as the interventions to counteract it in patients with MDD. METHOD: A literature search was conducted using the PubMed, Embase, and Web of Science databases. RESULTS: The causes of pseudo-resistance can be multiple and can be attributed to both the clinician (inappropriate prescribing behavior, misdiagnosis or incomplete diagnosis) and the patient (ultra-fast metabolism, poor medication adherence, comorbidity). Advice and interventions to prevent pseudo-resistance must therefore be targeted to the clinician (knowledge of clinical guidelines, simplified dosage schedules, correct diagnosis, interventions to improve poor medication adherence), as well as the patient (personalized psychoeducation, social support, care management). CONCLUSION: Pseudo-resistance is a multifactorial phenomenon that requires complex intervention strategies. In addition to adequate treatment provided by the clinician, personalized psychoeducation, good patient support and intensive follow-up of, as well as open communication with the patient are also required.

Hair cortisol in patients with a depressive episode treated with electroconvulsive therapy.

BACKGROUND: There is substantial evidence showing changes in hypothalamic pituitary adrenal (HPA)-axis activity in patients with major depressive disorder (MDD). Also, there seem to be differences in HPA-axis functioning between MDD subgroups. It is however unclear whether hair cortisol concentrations (HCC), which are a stable marker of long-term cortisol levels, are suitable as a biomarker for identifying subgroups in MDD. METHODS: We were able to attain valid HCC from a scalp hair sample of sixty-two patients with a major depressive episode right before electroconvulsive therapy (ECT). HCC were our main biological outcome measure. We created subgroups using depression severity as defined by the Hamilton Depression Rating Scale, the presence/absence of psychotic symptoms, the presence of melancholia as defined by the CORE and catatonia as defined by the Bush-Francis Catatonia Rating Scale. RESULTS: Our analyses of the total group showed a median HCC of 4.4 pg/mg. We found patients with catatonia (N = 10) to have substantially higher median HCC (8.3 pg/mg) than patients without catatonia (3.8 pg/mg). Although presence of melancholia and depression severity were not significantly associated with HCC, more severe psychomotor agitation was associated with higher HCC. Pre-treatment HCC was not associated with ECT outcome. STRENGTHS AND LIMITATIONS: A complicating factor in interpretation of our results was the large variability in HCC. This could be related to potential confounders such as cardiometabolic and other comorbidities, that were however addressed to the extent possible. CONCLUSIONS: HCC is a potential biomarker for MDD patients with severe agitation and/or catatonia. CLINICALTRIALS.GOV: Identifier: NCT02562846.

[Il faut imaginer Sisyphe heureux. The special position of the existential dimension in humanistic psychiatry]. / Il faut imaginer Sisyphe heureux. De bijzondere positie van de existentiële dimensie in de humanistische psychiatrie.

BACKGROUND: The models used in theoretical and practical psychiatry mostly encompass, with varying accents, the biological, psychological and social dimension. However, humanistic psychiatry concerns the existence as a whole. What about the care for the existential dimension?
AIM: To explore and to describe the existential dimension in psychiatry as containing the biopsychosocial aspects and continuously in interaction with them.
METHOD: Personal reflection of three senior authors, also in exchange with authors who have accompanied us during our professional life.
RESULTS: The existential dimension should be included as a special, encompassing dimension in the models used in psychiatry. In humanistic psychiatry every intervention, whether biomedical or psychosocial, should be situated in an existential perspective. Care for the existential dimension surpasses the dichotomy biomedical-psychosocial.
CONCLUSION: Not respecting the existential dimension induces shortcomings towards patients and harms a truly humanistic psychiatry.

[Effectiveness of anti-stigma interventions regarding severe mental illness: a systematic literature review]. / Effectiviteit van interventies tegen stigma van ernstige psychiatrische aandoeningen; systematisch literatuuroverzicht.

BACKGROUND: Stigma is one of the greatest challenges facing people with severe mental illness (smi) and can have profound psychological, social and professional consequences.
AIM: To systematically review the evidence of effectiveness of anti-stigma interventions (anti-stigma campaigns and specific interventions to reduce public stigma and self-stigma) for people with smi and to make recommendations for clinical practice.
METHOD: A systematic literature search for individual studies and reviews concerning the efficacy of interventions that reduce stigma for people with smi.
RESULTS: Anti-stigma interventions have small-to-medium effects. Although head-to-head comparisons do not show a clear advantage for educational or contact interventions, results suggest that the elements of contact, recovery and continuity (for public stigma) and psycho-education (for self-stigma) may yield the greatest effects. Due to the short follow-up period of most studies, there is limited evidence on the long-term effectiveness of these interventions. More specifically, it remains unknown whether these interventions lead to changes in actual behavior.
CONCLUSION: Anti-stigma interventions have limited effects on knowledge, attitudes and behavior. Several methodological shortcomings, as well as short follow-up periods in most studies, preclude making firm conclusions.

Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design.

INTRODUCTION: Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown. METHODS: The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience). RESULTS: Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general. CONCLUSION: Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.

[Psychosis due to idiopathic basal ganglia calcification]. / Psychose door idiopathische calcificatie van de basale ganglia.

Idiopathic basal ganglia calcification is a rare neuropathological syndrome characterised by symmetrical and bilateral calcifications found primarily in the basal ganglia. Psychosis is describedas an acute presentation of idiopathic ganglia calcification. We describe the development of psychosis in a 48-year-old man, initially hospitalised on the neurology ward due to syncope. A ct scan of the brain showed bilateral, symmetrical calcification of the basal ganglia and nucleus dentatus. Laboratory research excluded other pathological disorders. The patient was referred to a psychiatric ward, where the administration of risperidone led to alleviation of his mental state. This case report underlines the importance of an accurate, comprehensive differential diagnosis and the associated significance of neuroimaging.

The longitudinal course of cognitive insight and mood in bipolar disorder.

Cognitive insight or the ability to be self-reflective and to retain from being over-confident in own beliefs is an upcoming topic in research regarding psychiatric disorders. In bipolar disorder investigations are scarce and an important lacuna is the unexamined longitudinal relationship between cognitive insight and mood. Therefore, in this study the level of cognitive insight, mania and depression were assessed in a total of 56 patients with bipolar disorder at baseline, four months and eight months follow-up. In addition, the cognitive insight of 35 healthy controls was assessed at baseline and at four months follow-up. The current research shows that self-reflectiveness and self-certainty remained stable over time in bipolar disorder. The improvement of mood did not affect the course of cognitive insight. However, at baseline higher levels of depression were correlated with more self-reflectiveness. In addition, self-reflectiveness was higher for bipolar disorder patients in comparison with the healthy controls. Our results could imply that higher levels of self-reflectiveness are a specific characteristic in bipolar disorder that is independent from an improvement in mood.

Cognitive insight: A systematic review.

Cognitive insight is the ability to re-evaluate thoughts and beliefs in order to make thoughtful conclusions. It differs from clinical insight, as it focuses on more general metacognitive processes. Therefore, it could be relevant to diverse disorders and non-clinical subjects. There is a growing body of research on cognitive insight in individuals with and without psychosis. This review has summarised the current state of the art regarding this topic. We conclude that while cognitive insight in its current form seems valid for use in individuals with psychosis, it is less so for individuals without psychosis. Additionally, higher cognitive insight not always leads to better psychological functioning. For instance, higher levels of self-reflection are often associated with depressive mood. We therefore recommend the sub-components of cognitive insight to be studied separately. Also, it is unclear what position cognitive insight takes within the spectrum of metacognitive processes and how it relates to other self-related concepts that have been defined previously in literature. Combining future and past research on cognitive insight and its analogue concepts will help in the formation of a uniform definition that fits all subjects discussed here.

How self-reflection and self-certainty are related to neurocognitive functioning: an examination of cognitive insight in bipolar disorder.

INTRODUCTION: The pattern of associations between clinical insight, cognitive insight, and neurocognitive functioning was assessed in bipolar disorder patients. METHODS: Data from 42 bipolar disorder patients were examined. Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS). The BCIS is a 15-item self-report instrument consisting of two subscales, self-reflectiveness and self-certainty. Clinical insight was measured by the use of the item G12 of the Positive and Negative Syndrome Scale. Neurocognitive functioning was assessed using the International Society for Bipolar Disorders-Battery for Assessment of Neurocognition. RESULTS: Correlation analyses revealed significant positive associations between self-reflectiveness and speed of processing, attention, working memory, visual learning, and reasoning and problem solving. The subscale self-certainty was negatively correlated to working memory, however, this correlation disappeared when we controlled for confounding variables. No correlations between clinical insight and neurocognition were found. In addition, there was no association between cognitive insight and clinical insight. CONCLUSION: Better neurocognitive functioning was more related to higher levels of self-reflectiveness than to diminished self-certainty.

[Measuring alexithymia in fibromyalgia: the need for a multimodal measurement method to replace the TAS-20]. / Alexithymie bij fibromyalgie: meetinstrumenten; argumenten voor een multimodale benadering.

BACKGROUND: In an earlier publication that investigated alexithymia in fibromyalgia, we showed the Toronto Alexithymia Scale was the only instrument being used to measure alexithymia. AIM: To find out which instruments are currently available for measuring alexithymia, to compare the psychometric properties of these instruments and to decide whether some of the test methods involved should be used to give extra value to alexithymia research. METHOD: We conducted a systematic review of the literature in Medline/PubMed with a number of search terms. We selected articles relating to psychometric properties of the tests performed and decided whether they could be influenced by negative affect. RESULTS: We found that 14 different instruments were used to measure alexithymia. From our evaluation we excluded tests which had weak psychometric properties or had been inadequately assessed. There remained three observation scales and two self-report questionnaires, which had been adequately validated and whose relative strengths and weaknesses were compared. CONCLUSION: In view of these findings, we recommend that in studies of alexithymia in fibromyalgia a multimodal measurement method should be used rather than only the tas-20.

[Instrumental registration of psychomotor symptoms in schizophrenia: has the time come to use the technique in clinical practice?]. / Instrumenteel meten van psycho-motorische symptomen bij schizofrenie: klaar voor de praktijk?

BACKGROUND: In clinical practice, psychomotor deficits are currently assessed by means of observation scales. However, instrumental (including mechanical and electronic) measurement techniques might also be valuable in clinical practice. AIM: To discuss the added value of using instrumental registration of psychomotor functioning into clinical practice. METHOD: We investigated the main pros and cons of instrumental registration by searching the literature systematically and we discuss our findings using concrete examples. RESULTS: Compared to observation scales, instrumental registration yields more reliable and sensitive information about the psychomotor functioning of patients. Another advantage of instrumental registration is that it gives us an opportunity to study affected sub-processes and underlying mechanisms. However, the validity of these measurements depends on whether instrumental registration can adequately reflect aspects of a movement that can be observed clinically. CONCLUSION: Clinical practice could benefit substantially from using instrumental registration of psychomotor disturbances in schizophrenia. However, more time and money needs to be invested in research before the new technique is fully validated and ready for use in clinical practice.

[Psychometric properties of the Hospital Ethical Climate Survey: a cross-sectional study among Belgian psychiatric nurses]. / Psychometrische kwaliteiten van de Hospital Ethical Climate Survey: een cross-sectionele studie bij Belgische psychiatrische verpleegkundigen.

BACKGROUND: The task of caring for psychiatric patients is so complex that it often leads to ethical dilemmas. The ethical climate on a ward is a crucial factor. This is the first study about the ethical climate in mental healthcare. AIM: To investigate whether the only instrument currently available for measuring the ethical climate in general hospitals, namely the 'Hospital Ethical Climate Survey' (HECS), is a reliable and valid instrument for use on psychiatric wards. METHOD: A cross-sectional study was performed in a psychiatric hospital in Belgium. All 320 nurses were invited to participate (response rate = 265). The factor structure of the HECS was examined by means of explorative principal component analysis (PCA) and confirmatory factor analysis (CFA). The reliability of the constructed scale and subscales was investigated. RESULTS: Five factors were identified. The structure of these factors in the translated list was almost identical to the structure obtained with the original instrument and its underlying theoretical basis. Items relating to several other allied healthcare professions were added. This addition widened the subscale 'relationship with physician' so that it included 'relationship with other disciplines' (medical and allied healthcare workers). CONCLUSION: The reliability of the instrument appeared to be good and yielded scores comparable to those obtained as a result of earlier research performed in general hospitals. The setting for our investigation produced a significantly higher main score for the ethical climate than did previous studies.

[Alexithymia in fibromyalgia: prevalence]. / Alexithymie bij fibromyalgie: prevalentie.

BACKGROUND: In fibromyalgia, problems of affect regulation are considered important. Alexithymia, too, is related to disturbed affect regulation. Recognising alexithymia is important with regard to the doctor-patient relationship, the pitfalls in this relationship and the therapeutic strategy. AIM: To look into the prevalence of alexithymia in fibromyalgia and find out which measures were used. METHOD: We reviewed the literature systematically using Medline, PubMed and Cochrane and key words. RESULTS: We found 11 relevant studies which revealed a significantly high prevalence of alexithymia in fibromyalgia patients, namely between 15 and 52%, whereas the prevalence in the general population was only 6 to 8%. All of these studies used the Toronto Alexithymia Scale (20-item or 26-item version) as the only test for alexithymia. Male fibromyalgia patients were not examined adequately, nor were patients in a residential setting. Three studies used patients with a painful chronic condition as a control group, but we did not find any studies that involved psychiatric control groups. CONCLUSION: In view of the high prevalence of alexithymia and the implications of this for therapy, we recommend that patients with fibromyalgia should be screened systematically for alexithymia. Further research involving male patients and residential fibromyalgia patients is required and future studies will have to include psychiatric control groups.

The relationship between impulsivity and craving in alcohol dependent patients.

RATIONALE: Impulsivity and craving are both associated with higher relapse rates and a worse prognosis in patients with a substance use disorder, but the relationship between these two phenomena has been largely ignored in the field of alcohol use disorders. OBJECTIVES: The primary aim of this study was to investigate the relationship between different dimensions of impulsivity and different forms of self-reported craving. Additionally, the influence of the severity of alcohol dependence on impulsivity, craving, and on their relationship was exploed. METHODS: Impulsivity and craving levels were investigated in 87 abstinent alcohol-dependent (AD) patients using a broad range of self-report questionnaires and behavioral impulsivity measures. Alcohol use was measured by means of the timeline followback method. RESULTS: Higher scores of emotional craving (Alcohol Urge Questionnaire-AUQ) were significantly related to higher self-reported impulsivity (Barratt Impulsiveness Scale, version 11) and to higher cognitive impulsivity (information sampling task). Additionally, exploratory analyses suggest that these relationships are more pronounced in severe AD patients compared to less severe AD patients. No significant relationships were found between emotional craving (AUQ) and motor impulsivity (stop signal task) or delay discounting and between obsessive-compulsive craving (Obsessive Compulsive Drinking Scale) and measures of impulsivity. CONCLUSIONS: Emotional craving is related to self-reported impulsivity and to cognitive impulsivity. These relationships seem to be more pronounced in AD patients with severe alcohol dependence. Further research is needed to explore the effect of this relationship on treatment outcome and relapse.

[Neuro-endocrine correlates of burnout]. / Neuro-endocriene correlaten van burn-out.

BACKGROUND: The symptoms of burnout are similar to those of depression on the one hand and chronic fatigue syndrome on the other hand. However, the neuro-endocrine correlates of these two syndromes are the opposite, the former being a hyperfunction of the hypothalamic-hypophysial-cortical axis (HPA) and the latter being a hypofunction of the hpa-axis. AIM: To find out, via a systematic review of the literature, whether burnout is associated with either a hyperfunction or a hypofunction of the HPA-axis. METHOD: We searched PubMed using the following search terms: 'burnout syndrome and burnout', 'adrenocorticotropic hormone', 'corticotropin releasing factor', 'hypothalamic pituitary adrenal axis' and 'cortisol'. We retrieved 16 original articles en one meta-analysis were included in the study. RESULTS: Functional stress testing showed hypersuppression of the HPA-axis after dexamethasone. Basal cortisol values were found to be less conclusive, although a meta-analysis pointed to a negative association between burnout and cortisol. We did not find any studies that were carried out with the help of physiological, physical or psychological stress factors in burnout. CONCLUSION: Burnout is associated primarily with a hypofunction of the HPA-axis, which is a neuro-endocrine characteristic of exhaustion, rather than of depression. However, further studies involving functional stress testing are needed in order to map the neuro-endocrine profile fully and to clarify the link with the deregulation of the immune system.

[ADHD and addiction: a complicated liaison]. / ADHD en verslaving: een ingewikkelde liaison.

BACKGROUND: The presence of ADHD has been linked to a 100% increase in a person's chance of developing a substance use disorder. The prevalence of childhood and adult ADHD in substance-abusing populations has been estimated to be three times higher than in the general population. In addiction centres ADHD is often unrecognized and untreated. AIM: To describe the obstacles to the diagnosis and treatment of ADHD in addicts. METHOD: Using a historical approach, we analysed the evolution of the diagnostic descriptions of the two disorders, giving attention to the influence of social change and scientific research. RESULTS: The two disorders have developed in remarkably similar ways; people have been and still are much inclined to make moral judgments about these disorders than about other psychic disorders. Neurobiological research has added a extra dimension to the debate on topics such as impulsivity, personal responsibility and free will. CONCLUSION: It is only recently that ADHD has been recognised as having a place in addiction treatment and, as a result, there is a growing need for explanatory models.

[Antidepressants and the risk of bleeding]. / Antidepressiva en risico op bloedingen: een literatuuroverzicht.

BACKGROUND: By blocking the serotonin transporter system antidepressants can, in theory, result in bleedings. However, we do not yet know how great the risk of bleeding is and what the clinical implications are. AIM: To assess how great the risk of bleeding is and what the clinical implications are. METHOD: Using keywords 'antidepressants' and 'bleeding' we searched the relevant literature up to March 2011 to find out what the risk of bleeding were for users of antidepressants. RESULTS: 34 studies met our selection criteria. Most studies reported upper gastrointestinal bleeding and hemorrhagic cerebrovascular accidents (CVA). Antidepressants with high serotonin affinity can slightly increase the risk of upper gastrointestinal bleeding. Antidepressants do not increase the risk for hemorrhagic CVA. Very little information is available about other types of bleeding. CONCLUSION: Our systematic review of the literature shows that antidepressants are relatively safe as far as bleeding is concerned. Precautions can be taken in the case of high risk patients.

Impact of one HF-rTMS session on fine motor function in right-handed healthy female subjects: a comparison of stimulation over the left versus the right dorsolateral prefrontal cortex.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive tool to investigate neural conduction in motor processes. Most rTMS research has been conducted by targeting the primary motor cortex. Several studies have also found increased psychomotor speed after rTMS of the dorsolateral prefrontal cortex (DLPFC). However, these studies were mainly performed in psychiatric patients, only targeting the left DLPFC, and often without sham control. Moreover, psychomotor speed is mostly measured based on tasks that also require higher executive functions. METHODS: Here, we examined the lateralized effect of one sham-controlled high-frequency rTMS session applied to the left or right DLPFC on fine motor function in 36 healthy right-handed females, using the Fitts' paradigm. RESULTS: We found a significant improvement in psychomotor speed only after actively stimulating the right DLPFC. CONCLUSION: Our results support the assumption of a right prefrontal neural network implicated in visuomotor behavior and performance processes, and that the improvement in psychomotor speed is not a secondary effect of decreased mood.