The Italian consensus conference on psychological therapies for anxiety and depressive disorders: findings and recommendations.

A Consensus Conference of clinicians, researchers, public health specialists and users was convened in Italy to review efficacy, effectiveness, treatment appropriateness and access to care for anxiety and depression, and to consider the role of psychological therapies. Expert opinion was sought concerning identification of people requiring psychological therapies according to levels of symptom severity matched to corresponding levels of treatment intensity, suitability of psychological therapies for subclinical anxiety or depression, definition of a minimum level of information on evidence-based psychotherapies to be provided by university medical and psychology courses, initiatives to raise awareness among potential users and decision makers on the role and effectiveness of psychological therapies in healthcare. The expert jury concluded that a number of psychological therapy models endorsed by most authoritative guidelines are supported by research showing their effectiveness at least equal to the drugs used in common mental disorders (CMDs). Such therapies are under-represented in the Italian public health system, leading many people to resort to the private sector, resulting in unacceptable wealth discrimination. The difficulty of accessing psychological treatments often entails the use of drug therapies in cases where they are not indicated. Starting from these assumptions, the experts recommended the promotion of better and timely recognition of anxiety and depressive disorders and their classification in terms of symptom intensity and functional impairment, differentiating subthreshold mood swings from clinical forms, to foster outcome studies of psychotherapies in CMDs in Italy, to introduce a stepped care model structured according to levels of intensity of treatment, based on wellbeing support strategies in nonmedical contexts for subthreshold situations, self-help, support and psychoeducation as frontline interventions in mild clinical forms, evidence-based psychotherapies in moderate and severe forms, with the option of combining psychological treatment and appropriate drug therapy in the most severe cases.

Comparing Long-Acting Antipsychotic Discontinuation Rates Under Ordinary Clinical Circumstances: A Survival Analysis from an Observational, Pragmatic Study.

BACKGROUND: Recent guidelines suggested a wider use of long-acting injectable antipsychotics (LAI) than previously, but naturalistic data on the consequences of LAI use in terms of discontinuation rates and associated factors are still sparse, making it hard for clinicians to be informed on plausible treatment courses. OBJECTIVE: Our objective was to assess, under real-world clinical circumstances, LAI discontinuation rates over a period of 12 months after a first prescription, reasons for discontinuation, and associated factors. METHODS: The STAR Network 'Depot Study' was a naturalistic, multicentre, observational prospective study that enrolled subjects initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centres were assessed at baseline and at 6 and 12 months of follow-up. Psychopathology, drug attitude and treatment adherence were measured using the Brief Psychiatric Rating Scale, the Drug Attitude Inventory and the Kemp scale, respectively. RESULTS: The study followed 394 participants for 12 months. The overall discontinuation rate at 12 months was 39.3% (95% confidence interval [CI] 34.4-44.3), with paliperidone LAI being the least discontinued LAI (33.9%; 95% CI 25.3-43.5) and olanzapine LAI the most discontinued (62.5%; 95% CI 35.4-84.8). The most frequent reason for discontinuation was onset of adverse events (32.9%; 95% CI 25.6-40.9) followed by participant refusal of the medication (20.6%; 95% CI 14.6-27.9). Medication adherence at baseline was negatively associated with discontinuation risk (hazard ratio [HR] 0.853; 95% CI 0.742-0.981; p = 0.026), whereas being prescribed olanzapine LAI was associated with increased discontinuation risk compared with being prescribed paliperidone LAI (HR 2.156; 95% CI 1.003-4.634; p = 0.049). CONCLUSIONS: Clinicians should be aware that LAI discontinuation is a frequent occurrence. LAI choice should be carefully discussed with the patient, taking into account individual characteristics and possible obstacles related to the practicalities of each formulation.

Long-acting second-generation and oral antipsychotics for substance use disorders and psychotic symptoms: Prescribing attitudes among Italian psychiatrists.

PURPOSE: To explore Italian psychiatrists' attitudes toward the off-label use of second generation antipsychotics (SGAs) in patients with substance use disorder and psychotic symptoms. DESIGN AND METHODS: A sample of 300 Italian psychiatrists associated with the Italian Society of Neuropsychopharmacology was randomly selected to complete a survey about the off-label prescription of SGAs. FINDINGS: Oral aripiprazole (32.7%), olanzapine (30.2%), and quetiapine (25.2%) were considered "appropriate." Long-acting antipsychoticss were generally considered "inappropriate." PRACTICE IMPLICATIONS: Our findings reflect a substantial level of uncertainty and a lack of coherent clinical guidance within the realm of dual diagnosis treatment. Therefore, they emphasize the need to develop specific guidelines to improve the management of pharmacotherapy among this population.

Body-environment integration: Temporal processing of tactile and auditory inputs along the schizophrenia continuum.

According to the dimensional approach to psychosis, there is a continuum from low schizotypy to schizophrenia patients. The temporal aspect of sensory processing seems to be compromised across such continuum, as suggested by different studies separately investigating unisensory or multisensory domains. Most of these studies have so far focused primarily on the temporal processing of visual and auditory stimuli, either in schizotypy or schizophrenia, while leaving the tactile domain and the integration of touch with other senses mostly unexplored. Given the relevance of body-related perceptual abnormalities for psychosis proneness, we aimed at filling this gap in the literature across two studies. We asked participants with increasing levels of schizotypy (study 1) and schizophrenia patients (study 2) to perform three simultaneity judgement tasks: a unimodal tactile task, a unimodal auditory task and a bimodal audio-tactile task. Each task allowed estimating a simultaneity range (SR), as a proxy of the individual tolerance to asynchronies in the tactile, auditory and audio-tactile domains, respectively. Results showed larger SRs as the level of schizotypy increases. Specifically, the linear effect of schizotypy levels on the audio-tactile task was stronger than on the auditory task, which in turn was greater than the effect on the tactile task (study 1). Differently, schizophrenia patients showed larger SRs than controls in all the three tasks (study 2). The current study is the first empirical investigation across the continuum from low schizotypy to schizophrenia of the tolerance to asynchronies in the processing of external (auditory) and body-related (tactile) inputs.

Off-Label Use of Second-Generation Antipsychotics in Borderline Personality Disorder: A Survey of Italian Psychiatrists.

The guidelines for borderline personality disorder (BPD) treatment suggest non-pharmacological treatment as the first option, but second-generation antipsychotics (SGAs) are among the overprescribed medications. This study aimed to explore Italian psychiatrists' attitudes toward off-label use of SGAs in BPD. A randomly selected sample of Italian psychiatrists completed a questionnaire regarding off-label prescription of SGAs. Most respondents reported the off-label use of SGAs. Among the reasons supporting the prescription of SGAs, the presence of strong published data was the most determining factor (51.5%). The SGA olanzapine is considered the most appropriate, followed by quetiapine and aripiprazole. Although off-label prescription of SGAs represents a common clinical practice in accordance with a worldwide trend, the use of long-acting injection formulations was considered inappropriate by 69% of psychiatrists in our sample. Our results reiterate the discrepancy between everyday clinical practice and international recommendations, and show how relevant the literature is in off-label drug prescription.

Psychopathological Burden and Quality of Life in Substance Users During the COVID-19 Lockdown Period in Italy.

BACKGROUND: Following the development of the COVID-19 pandemic, a rigid public health strategy of reduced social contact and shelter-in-place has been adopted by the Italian Government to reduce the spread of the virus. In this paper, we aim at evaluating the impact that the COVID-19 pandemic, and the relative containment measures, have had on a real-life sample of patients suffering from substance use disorders (SUDs) and/or behavioral addictions. METHODS: An anonymous questionnaire was filled out by 153 addicted patients, both outpatients and residential inpatients, recruited across Italy and highly representative of the current Italian population suffering from addictions. Psychopathological burden (anxiety and depressive symptomatology, somatization, irritability, and post-traumatic symptoms), quality of life, and craving changes in daily habits were assessed. RESULTS: In our sample, we found moderate rates of depression (22.9%), anxiety (30.1%), irritability (31.6%), and post-traumatic stress (5.4%) symptoms. Psychopathological burden was globally higher among residential patients. Reported levels of craving were generally low. DISCUSSION: This study is the first attempt to collect Italian data regarding the effects of the rigid quarantine period, during the COVID-19 pandemic, on patients suffering from a SUD and/or behavioral addictions. The presence of a moderate psychopathological burden correlated to poor quality of life and low craving scores represented the main outcomes. Long-term studies, with follow-up after the end of the restrictive measures, should be considered to implement our findings.

Clinical correlates of paliperidone palmitate and aripiprazole monohydrate prescription for subjects with schizophrenia-spectrum disorders: findings from the STAR Network Depot Study.

This study, based on the 'Servizi Territoriali Associati per la Ricerca' (STAR) Network Depot Study nationwide baseline data, explored whether individual symptoms severity and clusters might influence the prescription of paliperidone palmitate 1-month (PP1M) vs. aripiprazole monohydrate. The Brief Psychiatric Rating Scale (BPRS) was used to assess psychopathology and relevant symptoms clusters. Drug Attitude Inventory, 10 items, was used to test attitude towards medications. Adherence to treatments was rated according to the Kemp seven-point scale. We assessed for eligibility 451 individuals and, among them, we included 195 subjects (n = 117 who started PPM1 and n = 78 aripiprazole monohydrate). Individuals were comparable in terms of age, gender, treatment years, recent hospitalizations, previous long-acting injectable antipsychotic treatments, additional oral treatments, attitude toward drugs, medication adherence, and alcohol/substance-related comorbidities. Subjects starting PP1M presented higher BPRS overall (P = 0.009), positive (P = 0.015), and negative (P = 0.010) symptom scores compared to subjects starting aripiprazole monohydrate. Results were confirmed by appropriate regression models and propensity score matching analysis. No differences were found comparing the other BPRS subscale scores: affect, resistance, and activation. Clinicians may be more prone to prescribe PPM1, rather than aripiprazole monohydrate, to subjects showing higher overall symptom severity, including positive and negative symptoms. No additional clinical factors influenced prescribing attitudes in our sample.

Prescription Drug Misuse in "Clubbers" and Disco Goers in Ibiza.

Background: Prescription drug misuse and its related risks are considered a worldwide public health issue. Current trends show that the extent of such phenomenon may not be limited to subjects with psychiatric disorders, as it also spreads to dance party and nightclub attendees, who often consume prescription drugs in combination with alcohol and psychoactive substances. This study aims to report the sociodemographic data and the psychiatric and clinical features of a sample of clubbers reporting prescription drugs use. Methods: Patients admitted to the psychiatry ward of the Can Misses Hospital in Ibiza were recruited for the study during a span of four consecutive years (2015-2018). The inclusion criteria were age 18-75 years old and the intake of psychoactive substances or more than five alcohol units during the previous 24 h. Substance use habits, psychopathological features, and use of unprescribed pharmaceuticals were investigated. Urine samples were collected and analyzed using gas chromatography/mass spectrometry. Results: A total of 110 subjects with psychoactive substance intoxication were recruited for the study. Among these, 37 (40%) disclosed the use of prescription drugs without medical supervision. The most common compounds were benzodiazepines (66%), antiepileptic drugs (8%), antidepressants (6%), opioids (6%), antipsychotics (6%), stimulants (6%), and non-steroidal anti-inflammatory drugs (NSAIDs, 2%). Prescription drug misuse was negatively associated with the use of psychodysleptics (two-tailed Fisher's exact test p = 0.018, ρ = -0.262). Conclusions: The use of prescription drugs is also common among clubbers, usually characterized by low propensity to be prescribed benzodiazepines, antipsychotics, or antidepressants. Prescription drugs may be an alternative to classic and novel psychoactive compounds or may be used to tamper and self-medicate the effects determined by the use of substances. Party goers should be adequately informed about possible risks of co-intake of psychoactive substances and prescription drugs to prevent serious medical and psychiatric consequences.

Off-Label Use of Second-generation Antipsychotics in Bipolar Disorder: A Survey of Italian Psychiatrists.

Bipolar disorder (BD) is characterized by recurrent depressive and manic episodes. Lithium, valproate, lamotrigine, and some second-generation antipsychotics (SGAs) are the most typical pharmacological treatments for BD, the main goal being mood stabilization. However, despite these treatments, most patients continue to experience recurrent mood episodes and residual symptoms. Findings from several studies suggest that some SGAs may be beneficial beyond approved indications. The goal of the survey presented in this article was to examine Italian psychiatrists' attitudes concerning the off-label use of SGAs in depressive and maintenance phases of BD. A questionnaire about the off-label prescription of SGAs was e-mailed to 300 psychiatrists from Northern, Central, and Southern Italy affiliated with the Italian Society of Psychopharmacology (SINPF) to investigate the frequency of and motivation for off-label use of SGAs and evaluate the psychiatrists' attitude toward use of specific SGAs in BD; 202 questionnaires were completed. The respondents were equally distributed in terms of sex, and the mean age of respondents was 44.1 years. The majority of the sample reported use of SGAs for off-label indications either very often (16.7%), often (33.7%), or occasionally (34.7%). The main motivation for off-label use of the SGAs was the presence of published evidence (51.5%), followed by patients' nonresponse to previous treatment (37.1%). With regard to the use of specific SGAs in BD, off-label aripiprazole was considered appropriate for depressive episodes by 46% of the psychiatrists, followed by olanzapine which was considered appropriate by 33.7%. For maintenance treatment of BD, off-label asenapine was considered appropriate by 45% of the psychiatrists, followed by long-acting aripiprazole and olanzapine pamoate, which were considered appropriate by 37.1% and 23.8%, respectively. In summary, ~50% of Italian psychiatrists frequently (very often or often) prescribe SGAs for off-label indications. Given the relatively limited number of indicated effective treatments for BD, the use of some SGAs off-label may be considered appropriate when dealing with patients whose BD is resistant to medications with labeled indications for BD.

Factors associated with first- versus second-generation long-acting antipsychotics prescribed under ordinary clinical practice in Italy.

BACKGROUND: For many years, long-acting intramuscular (LAI) antipsychotics have been prescribed predominantly to chronic and severe patients, as a last resort when other treatments failed. Recently, a broader and earlier use of LAIs, particularly second-generation LAIs, has been emphasized. To date, few studies attempted to frame how this change in prescribing took place in real-world practice. Therefore, this study aimed to describe the clinical features of patients prescribed with LAIs, and to explore possible prescribing differences between first- and second-generations LAIs under ordinary clinical practice in Italy. METHODS: The STAR Network "Depot" Study is an observational, longitudinal, multicenter study involving 35 centers in Italy. In the cross-sectional phase, patients prescribed with LAIs were consecutively recruited and assessed over a period of 12 months. Descriptive statistics and multivariable logistic regression analyses were employed. RESULTS: Of the 451 recruited patients, 61% were males. The level of social and working functioning was heterogeneous, as was the severity of disease. Seventy-two per cent of the patients had a diagnosis of the schizophrenia spectrum. Seventy per cent were prescribed with second-generation antipsychotic (SGA) LAIs (mostly paliperidone, aripiprazole and risperidone). Compared to first-generation antipsychotic (FGA) LAIs, patients prescribed with SGA LAIs were more often younger; employed; with a diagnosis of the schizophrenia spectrum or bipolar disorder; with higher levels of affective symptoms; with fewer LAI prescriptions in the past. DISCUSSION: LAIs' prescribing practices appear to be more flexible as compared to the past, although this change is mostly restricted to SGA LAIs.

Substance-related psychopathology and aggressiveness in a nightlife holiday resort: Results from a pilot study in a psychiatric inpatient unit in Ibiza.

OBJECTIVES: We aimed to describe a sample of subjects admitted to a psychiatric unit after the intake of psychoactive substances for recreational purposes. METHODS: Between June and September 2015, 49 subjects were included. Sociodemographic characteristics and psychopathological aspects were investigated, and urine samples for further analysis were collected. Three subgroups (cannabinoids, stimulants, and depressors users) were identified, according to the structured interview regarding substance use and urinalysis. RESULTS: Level of aggressiveness was found to be significantly higher (p < .05) in the cannabinoids subgroup. Self-reported symptom severity was comparable among groups, but trends could be identified: SCL-90 results showed a prevalence of anxiety symptoms among depressors users, hostility or aggression in the tetrahydrocannabinol subgroup, and psychoticism in the stimulants subgroup. CONCLUSIONS: The use of psychoactive substances was be characterised by poly-use of both traditional and novel substances. The presence of aggressiveness emerged as a main feature associated with the use of cannabis and other cannabinoids. Binge drinking and sleep deprivation also represented a relevant component in almost all the evaluated subjects.

Psychotropic drugs and ventricular repolarisation: The effects on QT interval, T-peak to T-end interval and QT dispersion.

OBJECTIVE: We aimed to investigate in a clinical setting, the effects of different classes of psychotropic drugs on cardiac electrophysiological measures linked with an increased risk of sudden cardiac death. METHODS: We conducted a cross-sectional study in a population of 1059 psychiatric inpatients studying the effects of various psychotropic drugs on the T-peak to T-end (TpTe) interval, QT dispersion and QT interval. RESULTS: Methadone use showed a strong association with TpTe prolongation (odds ratio (OR)=12.66 (95% confidence interval (CI), 3.9-41.1), p<0.001), an effect independent from action on QT interval. Mood stabilisers showed significant effects on ventricular repolarisation: lithium was associated with a TpTe prolongation (OR=2.12 (95% CI, 1.12-4), p=0.02), while valproic acid with a TpTe reduction (OR=0.6 (95% CI, 0.37-0.98), p=0.04). Among antipsychotics, clozapine increased TpTe (OR=9.5 (95% CI, 2.24-40.39), p=0.002) and piperazine phenothiazines increased QT dispersion (OR=2.73 (95% CI, 1.06-7.02), p=0.037). CONCLUSIONS: Treatment with psychotropic drugs influences TpTe and QT dispersion. These parameters might be considered to better estimate the sudden cardiac death risk related to specific medications. Beyond antipsychotics and antidepressants, mood stabilisers determine significant effects on ventricular repolarisation.