Transition from child and adolescent mental health care to adult services for young people with Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) in Europe: Barriers and recommendations.

Transition in mental health care is the process ensuring continuity of care of a young patient arriving at the CAMHS (Child and Adolescent Mental Health Service) age boundary within mental health services. Transition refers to a transfer to an adult mental health service (AMHS), to private care or other mental health community services. A transition plan can also lead to a managed end of specialized care with involvement of a general practitioner or social services. For young people with a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) or ASD (Autism Spectrum Disorder), two disorders that persist into adulthood, an optimal transition would ensure continuity of care or facilitate access to specialized care in the case of a discharge. Transition typically occurs during adolescence, a known sensitive period when young people may experience major changes at several levels: physiological, psychological and social. Any barrier in the transition process resulting in discontinuity of care may worsen the symptoms of ADHD or ASD and can ultimately adversely affect the global mental health of young people with such neurodevelopmental disorders. The objectives of this narrative review are: 1/to identify the barriers in the transition process in mental health services often faced by young people with these two disorders; 2/to highlight specific recommendations for strengthening the CAMHS-AMHS interface that have been proposed by various countries in Europe.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services.

PURPOSE: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS. METHODS: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations. RESULTS: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. CONCLUSION: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide.

BACKGROUND: The painful experience of mourning after suicide can be further complicated by the stigma surrounding suicide survival. We investigated how grief and depression influence the perception of stigma towards survivors in a sample of help-seeking persons bereaved through suicide. METHODS: Cross-sectional design. Information on sociodemographic variables and responses to the Stigma of Suicide Survivor Scale, Beck Depression Inventory (BDI) and Inventory of Complicated Grief (ICG) was collected from 240 people bereaved through suicide who consecutively accessed an online support initiative. RESULTS: Despite the strong correlation between ICG and BDI scores, the intensity of depressive but not of grief symptoms was related to perceived stigma towards survivors. Time since loss was also positively related to levels of perceived stigma against survivors. The links between depression and perceived stigma persisted after taking into account relationship with the deceased and other sociodemographic factors. LIMITATIONS: The main study limitations are the cross-sectional design, reliance on self-report measures, and the self-selection of the sample of people bereaved through suicide, seeking help through a website. Social support was not measured and the sample included a large proportion of women. CONCLUSIONS: Specific interventions designed for persons bereaved by suicide should consider that psychological distress and mourning are qualitatively different reactions to a suicide loss. The relationship among perceived stigma, depressive suffering and time elapsed since the suicide loss suggests the usefulness of closely investigating the experience of stigma in all people bereaved through suicide with depressive symptoms, even long after the event.

Gut complex carbohydrates and intestinal microflora in broiler chickens fed with oregano (Origanum vulgare L.) aqueous extract and vitamin E.

One hundred and seventy one-day-old female broiler chicks were randomly divided into three groups fed with different dietary treatments: basal control diet (C); C supplemented (2 g/kg) with an oregano aqueous extract (O); C supplemented (150 mg/kg) with vitamin E (E). Growth performance was evaluated at 21 (T1) and 42 days (T2). On the same days, morphological, histochemical and microbiological analyses were performed. The O group showed the highest (p < 0.01) body weight at T1, while no differences were observed at T2. Light microscopic observation and conventional histochemistry showed no differences with regard to the two sampling times, whereas significant differences emerged among the treatments. The O treatment generally enhanced goblet cell reactivity more than both the C and E treatments. Coliform count was lower in the ileum tract of the O group at both T1 and T2 (p < 0.05) and increased with age in all groups. Escherichia coli showed the lowest values in the caecum of the O group (p < 0.001) at both sampling times. Enterococci, lactobacilli and staphylococci populations showed no differences among the different experimental groups in the caecum. In the ileum, the O group did not exhibit the sharp decline (p < 0.001) in the lactic acid bacteria population observed in the other two experimental groups. In conclusion, oregano aqueous extract supplementation seemed to elicit the best response among treatments, enabling better growth performance, enhancing both the quantity and quality of glycoconjugates involved in indirect defence actions and significantly reducing both the coliform and E. coli counts.

Unaltered Oxytocin and Vasopressin Plasma Levels in Patients with Schizophrenia After 4 Months of Daily Treatment with Intranasal Oxytocin.

The neuropeptide oxytocin (OXT) has been proposed as a treatment for a number of neuropsychiatric disorders characterised by impaired social behaviour, including schizophrenia. Although several studies have reported the chronic administration of OXT to be safe and tolerable, its effects on circulating levels of OXT, as well as the related neuropeptide arginine vasopressin (AVP), have not been assessed. In the present study, in a within-subjects cross-over, double-blind, randomised controlled trial, we assayed the plasma levels of OXT and AVP in 31 patients with schizophrenia who were treated daily for 4 months with 40 IU of intranasal OXT or placebo. Our data indicate a mean ± SD baseline OXT concentration of 1.62 ± 0.68 pg/ml, as determined by radioimmunoassay, which did not display any significant variation after chronic treatment with OXT or placebo. Similarly, the mean ± SD baseline AVP value of 2.40 ± 1.26 pg/ml remained unchanged. The present study also assessed cardiovascular and body fluid indicators (osmolality, plasma sodium concentration and systolic blood pressure), as well as a parameter for food intake (body mass index), with all observed to remain stable. By reporting that daily treatment with 40 IU of intranasal OXT or placebo for 4 months does not impact on OXT and AVP plasma levels, nor on cardiovascular, body fluids and food intake parameters, the present study represents an important step towards developing OXT as a safe treatment.

Treatment-emergent suicidal ideation during 4 months of acute management of unipolar major depression with SSRI pharmacotherapy or interpersonal psychotherapy in a randomized clinical trial.

BACKGROUND: To date, few randomized controlled trials (RCTs) of major depression have examined suicidal ideation as an outcome measure. Our aim is to determine the incidence of treatment-emergent suicidal ideation (ESI) and behaviors during the acute phase of treatment with an SSRI antidepressant or interpersonal psychotherapy (IPT) in patients with unipolar major depression. METHODS: In a two-site RCT, 291 adult outpatients with nonpsychotic major depression and a Hamilton Depression Rating Scale (HDRS) score ≥15 were randomly allocated to IPT or SSRI. Participants who did not remit with monotherapy received augmentation with the other treatment. ESI was defined as a post-baseline HDRS suicidality item score ≥2 or a post-baseline Quick Inventory of Depressive Symptomatology (QIDS) score ≥2 in patients with a baseline score ≤1. RESULTS: Of the 231 participants who had no suicidal ideation at baseline, 32 (13.8%) subsequently exhibited ESI on at least one post-baseline visit. Time to suicidal ideation was significantly longer in patients allocated to SSRI compared to those allocated to IPT (HR = 2.21, 95% CI 1.04-4.66, P = .038), even after controlling for treatment augmentation, benzodiazepine use, and comorbidity with anxiety disorders. Worsening of suicidal ideation occurred in 7/60 patients who had suicidal ideation at baseline. In the large majority of cases, suicidal ideation was successfully managed with the study protocol. CONCLUSIONS: In the context of careful monitoring and frequent contact, selective serotonin reuptake inhibitor (SSRI) was associated with a lower risk of ESI than IPT and both SSRI and IPT appeared to be safe treatments for patients with past suicide attempts, none of whom exhibited ESI during the study.

Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy.

BACKGROUND: Although many studies suggest that, on average, depression-specific psychotherapy and antidepressant pharmacotherapy are efficacious, we know relatively little about which patients are more likely to respond to one versus the other. We sought to determine whether measures of spectrum psychopathology are useful in deciding which patients with unipolar depression should receive pharmacotherapy versus depression-specific psychotherapy. METHOD: A total of 318 adult out-patients with major depression were randomly assigned to escitalopram pharmacotherapy or interpersonal psychotherapy (IPT) at academic medical centers at Pittsburgh, Pennsylvania and Pisa, Italy. Our main focus was on predictors and moderators of time to remission on monotherapy at 12 weeks. RESULTS: Participants with higher scores on the need for medical reassurance factor of the Panic-Agoraphobic Spectrum Self-Report (PAS-SR) had more rapid remission with IPT and those with lower scores on the psychomotor activation factor of the Mood Spectrum Self-Report (MOODS-SR) experienced more rapid remission with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Non-specific predictors of longer time to remission with monotherapy included several panic spectrum and mood spectrum factors and the Social Phobia Spectrum (SHY) total score. Higher baseline scores on the 17- and 25-item Hamilton Depression Rating Scales (HAMD-17 and HAMD-25) and the Work and Social Adjustment Scale (WSAS) also predicted a longer time to remission, whereas being married predicted a shorter time to remission. CONCLUSIONS: This exploratory study identified several non-specific predictors but few moderators of psychotherapy versus pharmacotherapy outcome. It offers useful indicators of the characteristics of patients that are generally difficult to treat, but only limited guidance as to who benefits from IPT versus SSRI pharmacotherapy.

Parental psychopathology and the risk of suicidal behavior in their offspring: results from the World Mental Health surveys.

Previous research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive aggression (for example, antisocial personality) and anxiety/agitation (for example, panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55 299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (that is, time since most recent episode controlling for age of onset and time since onset) of subsequent suicidal behavior (suicide ideation, plans and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental antisocial personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt was also found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of intergenerational transmission of suicidal behavior.

Immunohistochemical evidence of Orexin-A in the pancreatic beta cells of domestic animals.

A large body of information proves that Orexin-A is present in the pancreatic endocrine cells of humans and laboratory animals; more detailed studies identify Orexin-A-immunopositive cells as beta cells. Because no data have been reported on the pancreas of domestic animals, we investigated the presence and the distribution of cells containing Orexin-A in the pancreas of cattle, sheep and pigs by means of immunohistochemical techniques. Using a polyclonal antibody against Orexin-A, the immunopositive reaction was identified in the cytoplasm of many insular cells in the three species studied. Double immunohistochemical staining, using a polyclonal anti-insulin antibody, showed that Orexin-A is co-expressed with insulin. Our results, besides showing the presence of Orexin-A in the endocrine pancreas of domestic animals, together with data present in the literature, could contribute to the understanding of complex mechanisms regulating the functionality of the endocrine pancreas in domestic animals.

Identification of orexin A- and orexin type 2 receptor-positive cells in the gastrointestinal tract of neonatal dogs.

The presence and distribution of cells positive to orexin A (OXA) and to orexin type 2 receptor (OX2R) were investigated in the gastrointestinal tract of neonatal dogs by means of immunohistochemical techniques. The orexin A-positive cells were identified with some of the endocrine cells in the stomach and in the duodenum; they were both of the open and closed type and were lacking in the large intestine. In the stomach, a large subset of orexin A-positive cells also showed gastrin-like immunoreactivity while, in the duodenum, many of them seemed to store serotonin. The orexin type 2 receptor-positive cells were evidenced all along the gastrointestinal tract examined, also in the large intestine, and they showed the same morphological characteristics as those positive to orexin A. Moreover, the immunohistochemical techniques revealed intense positivity for both orexin A and orexin type 2 receptor in the neurons and fibers of the enteric nervous system. A large subset of orexin A-positive neurons seemed to store substance P.

Interpersonal problem areas and onset of panic disorder.

BACKGROUND: Numerous studies indicate that stressful life events are key precipitants of psychological disturbances. Severe stress often precedes the onset or exacerbation of illness in vulnerable individuals and may be of primary importance in the genesis of some mental disorders. Several authors have suggested that major life events play a role in the development of panic-related symptoms. The aim of this study was to examine the presence of stressful life events, in particular events focused in the interpersonal psychotherapy problem areas (grief, role disputes, role transitions, interpersonal deficits), in patients suffering from panic disorder. METHODS: We interviewed 55 patients suffering from panic disorder, with or without agoraphobia, in accordance with the diagnostic criteria specified in MINI PLUS. The panic attack profile was evaluated with the Panic Attack and Anticipatory Anxiety Scale. We assessed the ability to adapt to and derive satisfaction from the social environment with the Social Adjustment Scale Self Report and interpersonal problems with Interpersonal Questionnaire. RESULTS: Using the Interpersonal Questionnaire we found that all subjects had had relevant interpersonal problems in the year preceding the onset of PD: 92.7% had experienced a role transition, 85.5% interpersonal deficits, 74.5% a role dispute and 38.2% had suffered the loss of a relative or significant other. These results were confirmed by Paykel's scale, on which the whole sample reported a high frequency of life events in the 6 months before onset of illness. These preliminary data suggest a rationale for the therapeutic strategies of interpersonal psychotherapy in individuals with panic disorder.

Equine mandibular gland: in situ characterisation of sialoderivatives.

REASONS FOR PERFORMING STUDY: Sialic acids modulate the metabolite transport across membranes and may be involved in protection against pathogenic agents. The presence of sialoderivatives in the equine mandibular gland requires further study. OBJECTIVE: To biochemically visualise in situ the presence of sialoderivatives, by means of mild and strong periodate oxidation and alcoholic saponification, combined with lectin histochemistry and sialidase digestion in order to hypothesise roles for detached sialoderivatives. METHODS: Mandibular glands were removed from 8 mature horses of both sexes and subjected to histochemical procedures, including periodate oxidation, saponfication and lectin staining. Controls were based upon the omission of peroxidase-conjugated lectins and respective enzyme-free buffers. RESULTS: The reactivities of PNA and RCA I lectins were affected by sialidase treatment, whether preceded by saponification or not, showing that the dimer N-acetyl-sialic acid-beta-Gal was linked (1-3)GalNAc and (1-4)GlcNAc. In acinar cells the sequence sialic acid-beta-Gal(1-3)GalNAc showed sialic residues acetylated at C4 only and at C4 and C7 and/or C8 and/or C9(alpha2-6Gal) in both sexes, while in female mandibular gland also C4 and C9(alpha2-3Gal) acetylated residues were present. Sialic acid linked to beta-Gal(1-4)GlcNAc was prevalently C4 and C7 and/or C8 and/or C9(alpha2-6Gal and alpha2-3Gal) acetylated, whereas only a minor quantity showed acetyl groups at C7 and/or C8 and/or C9(alpha2-6Gal) in the acinar cells of both sexes. CONCLUSIONS: The great variety of sialic acid residues expressed by equine mandibular gland could assume an important role in the defensive mechanisms towards pathogen agents and, compared with those of cattle, probably represents an example of molecular species-specificity related to different alimentary habits.

SOPRoxi: a research-intervention project for suicide survivors.

In Italy, postvention models specifically designed for people surviving the suicide of a loved one are very scarce. The SOPRoxi project was developed to respond to this particular lack. By involving different professional and nonprofessional figures (GPs, mental health professionals, social workers, volunteers, etc), the SOPRoxi project aims to remove the stigma associated with this condition and to offer adequate, multifaceted help to survivors.

Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study.

The aim of this study was to assess any predictive factors for repeated attempted suicide and completed suicide in a 1-year follow-up on a sample of elderly European suicide attempters (60 years and over). From 1990 to 1993, 63 subjects completed the first interview and were recontacted after 1 year. At follow-up, eight subjects (12.7%) had taken their lives and seven (11.1%) had repeated at least one suicide attempt. On comparison of repeaters and non-repeaters, differences emerged in terms of death of the father in childhood and for mean Suicidal Intent Score. At the end of follow-up period, repeaters reported a more frequent desire to repeat suicidal behaviour and judged their mental health and social assistance received to be worse. Suicides and non-repeaters differed especially in relation to death of father during childhood and number of contacts with General Practitioner. Interpretation of the results must take into account the smallness of the test sample, the difficulties in obtaining complete data for the follow-up interview, the lack of a control group and a diagnosis formulated in a hospital consultation setting. The study confirms, however, the high risk of repetition of suicidal behaviour in the elderly. In old age suicidal ideation is often sustained over long periods of time and requests for help are addressed to relatives and GPs. An interesting finding is the more frequent death of the father during childhood among repeaters.

One-year prevalence of death thoughts, suicide ideation and behaviours in an elderly population.

BACKGROUND: Suicidality is constituted by all those phenomena that are apparently positioned along a continuum, with the two extremes represented by death wishes and completed suicide. OBJECTIVES: The aim of this paper is to show the one-year prevalence of the phenomena constituting this possible continuum in the elderly population (aged 65 years and over) of a northern Italian city and to evaluate the relationship between some of these phenomena with psychological suffering. METHOD: Emotional feelings and suicidal thoughts have been investigated by an epidemiological survey conducted in a central quarter of that city. Data on attempted and completed suicide derived from the data bank of the Padua's WHO Collaborating Centre for Research and Training in Suicide Prevention that monitors these phenomena since 1989. RESULTS AND CONCLUSIONS: Results suggest the existence of some continuity in suicidal phenomena, where prevalence decreases from those of emotional/ideational nature to most extreme behaviour. Subjects presenting with more severe suicidal ideation were those also obtaining highest scores in a number of sub-scales of the Brief Symptom Inventory.

Hostility as a feature of elderly suicidal ideators.

Literature suggests that suicidal feelings are relatively rare in mentally healthy older adults. This research investigated the presence of death or suicidal ideation in a group of home-dwelling elderly people (N = 611, M age = 75.7 yr., SD = 7.2), taking into account their psychopathological profiles assessed by means of the Brief Symptom Inventory. Suicidality was investigated by the Italian translation of the 1974 questions from Paykel, Myers, Lindenthal, and Tanner. Elderly with death or suicidal ideation manifested depressive and anxious symptoms on the Brief Symptom Inventory. This psychopathological profile, which has been reported for these subjects in various contributions to the literature, was also characterized by the presence of hostility. The correlation with higher scores on the hostility scale is difficult to interpret, although these feelings are often accompanied by failure to control impulses, which is an essential characteristic in suicidal behaviour.

Carbohydrate histochemistry of lamb duodenum.

In order to elucidate the carbohydrate profile of the mucosa of lamb duodenum, conventional histochemical methods and a panel of 7 labelled lectins were used. In some cases, treatment with sialidase preceeded lectin staining. Carbohydrate histochemistry revealed the presence of sugar residues in the brush border of enterocytes, goblet cells and duodenal glands. All sites contained neutral and acid glycoconjugates. The presence of sulphomucins in goblet and duodenal gland cells was age-dependent. Enterocytes and duodenal gland cells contained abundant amounts of oligosaccharides with terminal sialic acid-galactosyl(beta1 --> 3)N-acetylgalactosamine, whereas goblet cells contained the penultimate N-acetylgalactosamine residue linked to sialic acid. These findings were not age-dependent, whereas scarce amounts of fucose were found in all sites especially in young animals. The findings obtained in the present study serve as a basis for future pathological studies in lamb and sheep.

Death ideation and its correlates: survey of an over-65-year-old population.

The presence of dissatisfaction with life or thoughts of death or suicide has been variously surveyed in adolescent samples and in the general population, but there is a paucity of research on the elderly. The aim of this study was to assess, in an elderly community-dwelling population: a) the prevalence of death and/or suicidal feelings and thoughts and any attempted suicides; and b) factors associated with these experiences. A total of 611 over-65-year-old subjects were interviewed at home. Seventeen percent of the total (F:M = almost 2:1) responded affirmatively to at least one of the questions on suicidality. Elderly people reporting suicidal feelings presented markedly higher levels of physical and psychological distress, such as depression, anxiety, and hostility. Results indirectly confirm that depressive symptomatology is not adequately treated. Greater attention is warranted in psychological evaluation of the elderly to take into account those risk factors that, if identified and managed, could reduce the frequency of suicidal thoughts and, probably, associated actions.

Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour.

OBJECTIVE: The authors present an analysis of findings for the 65 years and over age group from the WHO/EURO Multicentre Study of Suicidal Behaviour (1989-93). METHODS: Multinational data on non-fatal suicidal behaviour is derived from 1518 subjects in 16 European centres. Local district data on suicide were available from 10 of the collaborating centres. RESULTS: Stockholm (Sweden), Pontoise (France) and Oxford (UK) had the highest suicide attempts rates. In most centres, the majority of elderly who attempted suicide were widow(er)s, often living alone, who used predominantly voluntary drug ingestion. Non-fatal suicidal behaviour decreased with increasing age, whereas suicide rates rose. The ratio between fatal and non-fatal behaviours was 1:2, that for males/females almost 1:1. In the years considered, substantial stability in suicide and attempted suicide rates was observed. As their age increased, suicidal subjects displayed only a limited tendency to repeat self-destructive acts. Moreover, there was little correlation between attempted suicide and suicide rates, which carries different clinical implications for non-fatal suicidal behaviour in the elderly compared with younger subjects in the same WHO/EURO study.

Origin of enzootic intranasal tumor in the goat (Capra hircus): a glycohistochemical approach.

Enzootic intranasal tumor (EIT) appears glandular in type and has recently been classified as an adenocarcinoma of low malignancy. The aim of this study was to characterize the secretion of surface glycoconjugates (GCs) in EIT and in normal respiratory and olfactory mucosae of the goat by means of conventional and lectin histochemistry, in order to shed light on the histogenesis of EIT. Morphologic and ultrastructural investigations showed two growth types of EIT: i.e., tubular and papillary patterns. Conventional histochemistry revealed the presence of neutral and carboxylated GCs in the olfactory glands and in the tubular part of EIT, as well neutral and sulphated GCs in the respiratory glands and in the papillary part of EIT, suggesting that the papillary pattern tumor arises from the respiratory glands, whereas the tubular portion of EIT arises from the olfactory glands. Lectin histochemistry gave further information on the expressed GCs.