The relative efficiency of schizophrenia health care systems: an international comparison using data envelopment analysis.

AIM: To compare the health economic efficiency of health care systems across nations, within the area of schizophrenia, using a data envelopment analysis (DEA) approach. METHODS: The DEA was performed using countries as decision-making units, schizophrenia disease investment (cost of disease as a percentage of total health care expenditure) as the input, and disability-adjusted life years (DALYs) per patient due to schizophrenia as the output. Data were obtained from the Global Burden of Disease 2017 study, the World Bank Group, and a literature search of the PubMed database. RESULTS: Data were obtained for 44 countries; of these, 34 had complete data and were included in the DEA. Disease investment (percentage of total health care expenditure) ranged from 1.11 in Switzerland to 6.73 in Thailand. DALYs per patient ranged from 0.621 in Lithuania to 0.651 in Malaysia. According to the DEA, countries with the most efficient schizophrenia health care were Lithuania, Norway, Switzerland and the US (all with efficiency score 1.000). The least efficient countries were Malaysia (0.955), China (0.959) and Thailand (0.965). LIMITATIONS: DEA findings depend on the countries and variables that are included in the dataset. CONCLUSIONS: In this international DEA, despite the difference in schizophrenia disease investment across countries, there was little difference in output as measured by DALYs per patient. Potentially, Lithuania, Norway, Switzerland and the US should be considered 'benchmark' countries by policy makers, thereby providing useful information to countries with less efficient systems.

Neuroanatomical Correlates of Impulsive Action in Excoriation (Skin-Picking) Disorder.

Excoriation (skin-picking) disorder (SPD) has similarities to obsessive-compulsive disorder (OCD) and is included within the obsessive-compulsive and related disorders (OCRD) diagnostic class in DSM-5. Separate neuroimaging and neurocognitive studies suggest that people affected by SPD find it difficult to inhibit dominant motor responses due to a failure of "top-down" control mechanisms. No study has examined the neural correlates of SPD in participants with varying degrees of impulsive motor behavior. This study correlated cortical thickness and volumes of selected subcortical structures with stop-signal task performance in participants with SPD (N=15) and in healthy control subjects (N=8). All participants were free from current psychiatric comorbidity, including OCD. In volunteers with SPD, longer stop-signal reaction times were correlated with cortical thinning in the right insula and right-inferior parietal lobe and with increased cortical thickness in the left-lateral occipital lobe, though these findings did not withstand correction for multiple comparisons. There were no significant correlations between cortical thickness in these three structures and stop-signal reaction times in the control group. This study suggests that structural abnormalities in the insular cortex and parietal and occipital regions may play a role in the pathophysiology of SPD. Further neuroimaging research is needed to understand the neurobiology of SPD and its relationship with other putative OCRDs.

Cognitive inflexibility in a young woman with pyromania.

Background Pyromania is a rare disorder that is characterized by multiple episodes of deliberate and purposeful fire-setting. It is typically associated with significant psychosocial dysfunction and legal problems. Even so, little research has examined cognitive aspects of the disorder. Case presentation/study In this study, we compared a 24-year-old woman with pyromania with 19 age- and gender-matched healthy controls using a battery of computerized neurocognitive tasks. Our participant affected by pyromania showed impaired cognitive flexibility but intact functioning on measures of impulsive action and decision-making. Discussion Although pyromania shares phenomenological similarities with other urge-driven disorders, our results suggest that pyromania may have features of compulsivity as well. Conclusions Pyromania is relatively understudied from a neurobiological perspective. Further research is needed to understand the pathophysiology, classification, and treatment of pyromania.

Stealing behavior and impulsivity in individuals with kleptomania who have been arrested for shoplifting.

OBJECTIVES: Kleptomania is characterized by strong urges to steal and is one of only a few psychiatric disorders defined by illegal behaviors, but the clinical characteristics of individuals with kleptomania who have faced legal consequences due to their behavior are poorly understood. METHOD: From 2001 to 2012, we recruited 107 adult participants with DSM-IV kleptomania. Participants with a history of shoplifting-related arrest (N=82) were compared with those who had no such history (N=25) on demographics, clinical features, and a self-report measure of impulsivity. RESULTS: Participants whose shoplifting had resulted in arrest had higher self-rated impulsivity on a weak trend level (Eysenck Impulsiveness Questionnaire), with large to very large effect size (Cohen's d=1.12). Group comparisons showed no significant differences in terms of overall functioning (d=0.60), time spent stealing (d=0.73), frequency of stealing behavior (d=0.33), psychiatric comorbidity, or severity of kleptomania symptoms. CONCLUSIONS: Legal problems in kleptomania may be associated with generalized deficits in inhibitory control independent of kleptomania symptom severity. These findings emphasize the need for treatment to improve functional status in individuals with kleptomania and reduce the social and economic costs associated with reoffending.

A structural MRI study of excoriation (skin-picking) disorder and its relationship to clinical severity.

Excoriation (skin-picking) disorder (SPD) shares symptomology with other obsessive-compulsive and related disorders. Few studies, however, have examined the neurological profile of patients with SPD. This study examined differences in cortical thickness and basal ganglia structural volumes between 20 individuals with SPD and 16 healthy controls using magnetic resonance imaging (MRI). There were no significant differences in demographic variables (age, gender, education and race) between groups. All subjects completed a structural MRI scan and completed a battery of clinical assessments focusing on SPD symptom severity, depression and anxiety symptoms, and quality of life. No statistically significant differences in basal ganglia (caudate, putamen, and nucleus accumbens) structural volumes were found between groups. In individuals with SPD, increasing impulsiveness correlated positively with increased cortical thickness in the left insula, and skin picking severity correlated negatively with cortical thickness in the left supramarginal gyrus and a region encompassing the right inferior parietal, right temporal and right supramarginal gyrus. This study suggests similarities and differences exist in symptomology between SPD and the other obsessive-compulsive and related disorders. Additional neuroimaging research is needed to better delineate the underlying neurobiology of SPD.

Placebo response in trichotillomania.

Trichotillomania is a functionally impairing, often overlooked disorder with no Food and Drug Administration-approved medications indicated for its treatment. The ability of clinical trials to detect the beneficial effects of pharmacologic treatment in trichotillomania has been hampered by the high placebo response rate. Very little is known about baseline demographic and clinical characteristics that may be predictive of placebo response in such patients. Overall, 104 participants assigned to placebo were pooled from five double-blind trials conducted at three sites in the USA and Canada. Participants were classified as placebo responders or nonresponders on the basis of a cutoff of a 35% reduction in symptom severity on the Massachusetts General Hospital Hair Pulling Scale. Baseline group differences were characterized using t-tests and equivalent nonparametric tests as appropriate. Thirty-one percent of individuals assigned to placebo treatment showed a significant clinical response to placebo. Placebo responders (n=32) and nonresponders (n=72) did not differ significantly on any demographic or clinical variable. Predictors of placebo response for trichotillomania remain elusive and do not appear to be similar to those reported for other mental health disorders.

Trichotillomania and its clinical relationship to depression and anxiety.

OBJECTIVE: Trichotillomania (TTM) is associated with high rates of co-occurring depression and anxiety disorders. What the co-occurrence of TTM, depression or anxiety disorders means clinically and cognitively, however, has garnered little research attention. METHODS: About 530 adults with TTM were examined on a variety of clinical measures including symptom severity, psychosocial measures of functioning, psychiatric comorbidity and neurocognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between TTM patients with current comorbid major depressive disorder (MDD), a current anxiety disorder, both MDD and an anxiety disorder, or neither. RESULTS: Of 530 participants, 58 (10.3%) had MDD only, 97 (18.3%) had an anxiety disorder only, 58 (10.3%) had both MDD and an anxiety disorder, and 317 (59.8%) had neither. For almost all clinical measures, those with MDD only reported worse symptoms than those with an anxiety disorder only, and the combination of MDD and an anxiety disorder reported the worst level of symptom severity. CONCLUSIONS: These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical differences. The clinical differences may also have treatment implications.

Latent class analysis of gambling subtypes and impulsive/compulsive associations: Time to rethink diagnostic boundaries for gambling disorder?

BACKGROUND: Gambling disorder has been associated with cognitive dysfunction and impaired quality of life. The current definition of non-pathological, problem, and pathological types of gambling is based on total symptom scores, which may overlook nuanced underlying presentations of gambling symptoms. The aims of the current study were (i) to identify subtypes of gambling in young adults, using latent class analysis, based on individual responses from the Structured Clinical Interview for Gambling Disorder (SCI-GD); and (ii) to explore relationships between these gambling subtypes, and clinical/cognitive measures. METHODS: Total 582 non-treatment seeking young adults were recruited from two US cities, on the basis of gambling five or more times per year. Participants undertook clinical and neurocognitive assessment, including stop-signal, decision-making, and set-shifting tasks. Data from individual items of the Structured Clinical Interview for Gambling Disorder (SCI-GD) were entered into latent class analysis. Optimal number of classes representing gambling subtypes was identified using Bayesian Information Criterion and differences between them were explored using multivariate analysis of variance. RESULTS: Three subtypes of gambling were identified, termed recreational gamblers (60.2% of the sample; reference group), problem gamblers (29.2%), and pathological gamblers (10.5%). Common quality of life impairment, elevated Barratt Impulsivity scores, occurrence of mainstream mental disorders, having a first degree relative with an addiction, and impaired decision-making were evident in both problem and pathological gambling groups. The diagnostic item 'chasing losses' most discriminated recreational from problem gamblers, while endorsement of 'social, financial, or occupational losses due to gambling' most discriminated pathological gambling from both other groups. Significantly higher rates of impulse control disorders occurred in the pathological group, versus the problem group, who in turn showed significantly higher rates than the reference group. The pathological group also had higher set-shifting errors and nicotine consumption. CONCLUSIONS: Even problem gamblers who had a relatively low total SCI-PG scores (mean endorsement of two items) exhibited impaired quality of life, objective cognitive impairment on decision-making, and occurrence of other mental disorders that did not differ significantly from those seen in the pathological gamblers. Furthermore, problem/pathological gambling was associated with other impulse control disorders, but not increased alcohol use. Groups differed on quality of life when classified using the data-driven approach, but not when classified using DSM cut-offs. Thus, the current DSM-5 approach will fail to discriminate a significant fraction of patients with biologically plausible, functionally impairing illness, and may not be ideal in terms of diagnostic classification. Cognitive distortions related to 'chasing losses' represent a particularly important candidate treatment target for early intervention.

Gambling disorder, DSM-5 criteria and symptom severity.

INTRODUCTION: Gambling disorder (GD) is a prevalent psychiatric condition whose severity is typically defined by the number of DSM-5 criteria met out of a maximum of nine. The relationships between the levels of gambling severity, thus defined, and other measures of psychopathology and everyday functioning are clinically important. METHODS: Baseline data were collected in patients with GD, conducted from 2001 to 2016. Participants completed clinical interviews and questionnaires. The impact of disease severity (mild, moderate, and severe) on clinical measures was characterized using analysis of variance models. RESULTS: The sample included 574 adults with GD, of whom 73 (12.7%) had mild, 184 (32.1%) moderate, and 317 (55.2%) severe GD. The moderate and severe cases, compared to mild severity group tended be older, had later age of onset, lost more money to gambling in the preceding year, had worse quality of life, had higher state anxiety and depressive scores, consumed more nicotine via smoking per day, and had lower venturesomeness scores. The moderate and severe groups did not differ significantly on these measures, however. The Yale-Brown Obsessive Compulsive Scale modified for Pathological Gambling (PG-YBOCS) discriminated significantly between all three groups. CONCLUSIONS: Several measures of psychopathology and functional impact of gambling symptoms appear similar between moderate and severe GD cases, while mild cases are clearly differentiated from moderate and severe cases. Thus, the current working definition of GD symptom severity boundaries has important limitations in terms of potential clinical utility.

The Young and the Stressed: Stress, Impulse Control, and Health in College Students.

High levels of stress are common among young adults, particularly those enrolled in college. These degrees of stress have shown numerous deleterious effects across both academic and health variables. Findings regarding the role of stress in the presentation of impulse control disorders, particular among college students, are limited. This study examined potential associations between perceived stress, academic achievement, physical/mental health, and impulse control disorders in young adults. A total of 1805 students completed an online survey and were included in the analysis. Responders were grouped by their overall score on the Perceived Stress Scale into mild, moderate, or severe. Severe perceived stress was associated with worse academic achievement and worse physical health, as well as higher rates of psychiatric and impulsive disorders. These findings may suggest associations between stress and numerous aspects of mental/physical health in young adults, which could be an important consideration for individuals working with college students.

Does comorbidity matter in body-focused repetitive behavior disorders?

BACKGROUND: Trichotillomania (TTM) and skin-picking disorder (SPD) have been characterized as body-focused repetitive behavior disorders (BFRBs). Because BFRBs frequently co-occur, we sought to discover the similarities and differences for individuals having both TTM and SPD as opposed to 1 of these disorders. METHODS: Participants with primary TTM (N = 421) were evaluated regarding the comorbidity of SPD, and participants with primary SPD (N = 124) were evaluated regarding the comorbidity of TTM. The effects of comorbidity overlap on demographic and clinical measures were evaluated. RESULTS: Of the 421 participants with primary TTM, 61 (14.5%) had co-occurring SPD. Of 124 participants with primary SPD, 21 (16.9%) had comorbid TTM. Participants with primary TTM and comorbid SPD had significantly more severe trichotillomania symptoms and were more likely to have major depressive disorder than those with TTM alone. Participants with primary SPD and comorbid TTM reported significantly more severe skin-picking symptoms than those who had only SPD. CONCLUSIONS: Individuals with co-occurring TTM and SPD may have more problematic symptoms with the primary repetitive behavior. Hair pullers with comorbid SPD were more likely to have comorbid depression. Evaluating patients for multiple BFRBs may be important to assess the severity of symptoms and may have treatment implications.

Racial-ethnic related clinical and neurocognitive differences in adults with gambling disorder.

Recent epidemiological data suggest that the lifetime prevalence of gambling problems differs depending on race-ethnicity. Understanding variations in disease presentation in blacks and whites, and relationships with biological and sociocultural factors, may have implications for selecting appropriate prevention strategies. 62 non-treatment seeking volunteers (18-29 years, n=18 [29.0%] female) with gambling disorder were recruited from the general community. Black (n=36) and White (n=26) participants were compared on demographic, clinical and cognitive measures. Young black adults with gambling disorder reported more symptoms of gambling disorder and greater scores on a measure of compulsivity. In addition they exhibited significantly higher total errors on a set-shifting task, less risk adjustment on a gambling task, greater delay aversion on a gambling task, and more total errors on a working memory task. These findings suggest that the clinical and neurocognitive presentation of gambling disorder different between racial-ethnic groups.

A comparison of clinical vs subclinical skin pickers in Israel.

BACKGROUND: Skin-picking disorder (SPD) was recognized as its own entity for the first time in DSM-5. The existing SPD literature is limited and, to date, no study has examined the differences between clinical and sub- clinical SPD. Identifying differences between these 2 groups may improve diagnostic accuracy, treatment, and prevention efforts. METHODS: Israeli adults (N = 4,325) from 2 previous studies were examined for the presence of clinical and subclinical SPD. Individuals with clinical SPD (n = 150) vs subclinical SPD (n = 219) were compared on skin-picking characteristics, psychological phenomena, and clinical correlates. RESULTS: There were many similarities between clinical and subclinical skin pickers. Individuals with clinical SPD, however, had more severe skin picking, greater associated functional impairment, greater perceived stress, and greater depressive and obsessive-compulsive symptoms, and were also more likely to have a first-degree relative with SPD. CONCLUSIONS: This study suggests that although there are some similarities between clinical and subclinical SPD, there also are distinct differences in the clinical presentation. Understanding these differences may be an important factor in treatment and prevention planning.

Psychosocial dysfunction associated with skin picking disorder and trichotillomania.

Skin picking disorder (SPD) and trichotillomania (TTM) are common and oftentimes disabling disorders. 125 Participants with SPD and 152 with TTM undertook clinical and neurocognitive evaluation, and were grouped according to mild, moderate, or severe levels of psychosocial dysfunction. Relationships between functional impairment and other variables were explored using linear regression and categorical analyses. Greater functional impairment was associated with worse disease severity in both groups, and by later symptom onset and lower quality of life in TTM subjects. These results indicate that levels of self-reported psychosocial dysfunction have a strong association with specific clinical aspects of SPD and TTM.

N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial.

IMPORTANCE: Excoriation (skin-picking) disorder (SPD) is a disabling, underrecognized condition in which individuals repeatedly pick at their skin, leading to noticeable tissue damage. To date, there has been no clearly effective pharmacologic or psychological treatment for SPD. OBJECTIVE: To determine whether N-acetylcysteine, an amino acid that appears to restore extracellular glutamate concentration in the nucleus accumbens, will be more effective than placebo in reducing compulsive picking behavior. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind trial was conducted at ambulatory care centers at the University of Minnesota (September 12, 2011, to June 15, 2012) and the University of Chicago (December 17, 2012, to June 26, 2015) and included 66 adults with SPD. Data analysis was performed from July 16 to September 9, 2015. INTERVENTIONS: N-acetylcysteine (dosing range, 1200-3000 mg/d) or placebo was administered for 12 weeks. MAIN OUTCOMES AND MEASURES: Participants were assessed using measures of skin-picking severity, including the modified Yale-Brown Obsessive Compulsive Scale (NE-YBOCS); total scores range from 0 to 40, with higher scores reflective of greater symptom severity. Another measure of skin-picking severity was the Clinical Global Impression-Severity Scale; total scores range from 1 (normal) to 7 (among the most extremely ill patients), and improvement ratings range from 7 (very much worse) to 1 (very much improved). Selected cognitive tasks included the Intra-dimensional/Extra-dimensional Shift Task to examine cognitive flexibility, with the key outcome measures being the number of errors, and Stop-Signal Reaction Time task, which evaluates motor inhibition. Outcomes were examined using a linear mixed-effects model. RESULTS: Of the 66 participants (31 randomized to placebo and 35 to N-acetylcysteine) included in the analysis, 59 (89%) were women; mean (SD) age was 34.8 (11.0) years. Compared with placebo, N-acetylcysteine treatment was associated with significant improvements in the NE-YBOCS. At baseline, NE-YBOCS scores were 18.9 and 17.9 for the treatment and placebo groups, respectively, and at 12 weeks, the scores were 11.5 and 14.1 for the treatment and placebo groups, respectively (P = .048). For the Clinical Global Impression-Severity scale, baseline scores were 3.5 and 4.0 and 12-week scores were 3.0 and 4.2, respectively (P = .003). These effects were significant both in terms of treatment by time interactions and post hoc tests at 1 or more individual time points. At the study's end point, of the 53 participants who completed the study, 15 of the 32 participants (47%) receiving N-acetylcysteine were much or very much improved compared with 4 of the 21 participants (19%) receiving placebo (P = .03). There were no significant differences between the active and placebo arms in terms of psychosocial functioning. CONCLUSIONS AND RELEVANCE: N-acetylcysteine treatment resulted in significant reductions in skin-picking symptoms and was well tolerated. The glutamate system may prove a beneficial target in treating SPD and other compulsive behaviors. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01063348.

White matter tract integrity in treatment-resistant gambling disorder.

BACKGROUND: Gambling disorder is a relatively common psychiatric disorder recently re-classified within the DSM-5 under the category of 'substance-related and addictive disorders'. AIMS: To compare white matter integrity in patients with gambling disorder with healthy controls; to explore relationships between white matter integrity and disease severity in gambling disorder. METHOD: In total, 16 participants with treatment-resistant gambling disorder and 15 healthy controls underwent magnetic resonance imaging (MRI). White matter integrity was analysed using tract-based spatial statistics. RESULTS: Gambling disorder was associated with reduced fractional anisotropy in the corpus callosum and superior longitudinal fasciculus. Fractional anisotropy in distributed white matter tracts elsewhere correlated positively with disease severity. CONCLUSIONS: Reduced corpus callosum fractional anisotropy is suggestive of disorganised/damaged tracts in patients with gambling disorder, and this may represent a trait/vulnerability marker for the disorder. Future research should explore these measures in a larger sample, ideally incorporating a range of imaging markers (for example functional MRI) and enrolling unaffected first-degree relatives of patients.

Neural and psychological underpinnings of gambling disorder: A review.

Gambling disorder affects 0.4 to 1.6% of adults worldwide, and is highly comorbid with other mental health disorders. This article provides a concise primer on the neural and psychological underpinnings of gambling disorder based on a selective review of the literature. Gambling disorder is associated with dysfunction across multiple cognitive domains which can be considered in terms of impulsivity and compulsivity. Neuroimaging data suggest structural and functional abnormalities of networks involved in reward processing and top-down control. Gambling disorder shows 50-60% heritability and it is likely that various neurochemical systems are implicated in the pathophysiology (including dopaminergic, glutamatergic, serotonergic, noradrenergic, and opioidergic). Elevated rates of certain personality traits (e.g. negative urgency, disinhibition), and personality disorders, are found. More research is required to evaluate whether cognitive dysfunction and personality aspects influence the longitudinal course and treatment outcome for gambling disorder. It is hoped that improved understanding of the biological and psychological components of gambling disorder, and their interactions, may lead to improved treatment approaches and raise the profile of this neglected condition.

Characteristics and correlates of stealing in college students.

BACKGROUND: Stealing is a fairly common behaviour among young adults. Understanding the potential associations and characteristics of individuals who steal may help educational institutions, health services and young people themselves resolve difficulties before the behaviour impacts on their academic performance and health. AIMS: We aim to test the hypothesis that desires to steal among students would be associated with worse academic achievements and higher rates of mood and impulse control disorders. METHODS: One thousand eight hundred and five students completed the College Student Computer User Survey online and were included in this analysis at a large Midwestern United States University. Responders were grouped according to self-reported stealing urges and behaviours and were compared on measures of psychosocial function, mental health disorders and impulsivity. RESULTS: Urges to steal were associated with worse depressive symptoms, higher levels of perceived stress and a number of psychiatric disorders including bipolar disorder and multiple disorders of impulse control (kleptomania, compulsive sexual behaviour, skin picking, trichotillomania and compulsive buying). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE AND/OR FUTURE RESEARCH: These following data indicate that stealing for many college students may be considered within a spectrum of impulsive behaviours. • Illegal behaviours among students point to mental health difficulties among them. • Our findings may provide clinicians, researchers and health professionals with a clearer picture of a range of impulsive behaviours among college students and promote treatment for this group. • Our findings could also inform preventative approaches to impulsive problems in young adults.

Abnormal brain activation in excoriation (skin-picking) disorder: evidence from an executive planning fMRI study.

BACKGROUND: Excoriation (skin-picking) disorder (SPD) is a relatively common psychiatric condition whose neurobiological basis is unknown. AIMS: To probe the function of fronto-striatal circuitry in SPD. METHOD: Eighteen participants with SPD and 15 matched healthy controls undertook an executive planning task (Tower of London) during functional magnetic resonance imaging (fMRI). Activation during planning was compared between groups using region of interest and whole-brain permutation cluster approaches. RESULTS: The SPD group exhibited significant functional underactivation in a cluster encompassing bilateral dorsal striatum (maximal in right caudate), bilateral anterior cingulate and right medial frontal regions. These abnormalities were, for the most part, outside the dorsal planning network typically activated by executive planning tasks. CONCLUSIONS: Abnormalities of neural regions involved in habit formation, action monitoring and inhibition appear involved in the pathophysiology of SPD. Implications exist for understanding the basis of excessive grooming and the relationship of SPD with putative obsessive-compulsive spectrum disorders.