Improving depressive symptoms in patients with schizophrenia using bilateral bipolar-nonbalanced prefrontal tDCS: Results from a double-blind sham-controlled trial.

BACKGROUND: Treating depressive symptoms in patients with schizophrenia is challenging. While transcranical Dicrect Current Stimulation (tDCS) improved other core symptoms of schizophrenia, conflicting results have been obtained on depressive symptoms. Thus, we aimed to expand current evidence on tDCS efficacy to improve depressive symptoms in patients with schizophrenia. METHODS: A double-blind RCT was performed with patients randomized to 2 mA active-tDCS or sham-tDCS (15 daily sessions) with a bilateral bipolar-nonbalanced prefrontal placement (anode: left Dorsolateral prefrontal cortex; cathode: right orbitofrontal region). Clinical outcomes included variations of Calgary Depression Scale for Schizophrenia total score (CDSS) and of Depression-hopelessness and Guilty idea of reference-pathological guilt factors. Analysis of covariance was performed evaluating between-group changes over time. The presence/absence of probable clinically significant depression was determined when CDSS > 6. RESULTS: As 50 outpatients were included (both groups, n = 25), significant improvements following active-tDCS were observed for CDSS total score (p = 0.001), Depression-hopelessness (p = 0.001) and Guilty idea of reference-pathological guilt (p = 0.03). Considering patients with CDSS>6 (n = 23), compared to sham, active-tDCS significantly improved CDSS total score (p < 0.001), Depression-hopelessness (p = 0.001) but Guilty idea of reference-pathological guilt only marginally improved (p = 0.051). Considering response rates of clinically significant depression, important reductions of CDSS score were observed (78 % of the sample scored ≤6; active-tDCS, n = 23; sham-tDCS, n = 16; p = 0.017). Early wakening item did not significantly change in any group. LIMITATIONS: The study lacks a follow-up period and evaluation of tDCS effects on psychosocial functioning. CONCLUSIONS: Bilateral bipolar-nonbalanced prefrontal tDCS is a successful protocol for the treatment of depressive symptoms in patients with schizophrenia.

Effects of bilateral, bipolar-nonbalanced, frontal transcranial Direct Current Stimulation (tDCS) on negative symptoms and neurocognition in a sample of patients living with schizophrenia: Results of a randomized double-blind sham-controlled trial.

Negative symptoms (NS), conceived as Avolition-Apathy (AA) and Expressive Deficit (EXP) domains, and neurocognitive impairments represent unmet therapeutic needs for patients with schizophrenia. The present study investigated if bilateral bipolar-nonbalanced frontal transcranial Direct Current Stimulation (tDCS) could improve these psychopathological dimensions. This randomized, double-blind, sham-controlled study (active-tDCS versus sham-tDCS, both, n = 25) included 50 outpatients diagnosed with schizophrenia clinically stabilized. Patients received 20-min 2 mA active-tDCS or sham-tDCS (anode: left Dorsolateral Prefrontal Cortex; cathode: right orbitofrontal region). Primary outcomes included: PANSS-Negative subscale, Negative Factor (Neg-PANSS), AA and EXP domains; neurocognitive performance at Brief Assessment of Cognition in Schizophrenia. Secondary outcomes included: PANSS subscales and total score, Disorganized/Concrete (DiscC-PANSS) and Positive Factors, Clinical Global Impression (CGI) scores, clinical insight at Scale to Assess Unawareness of Mental Disorder (SUMD). Analysis of covariance (ANCOVA) was performed evaluating between-group changes over time. Significant improvements following active-tDCS were observed for all NS measures (all, p < 0.001; d > 0.8) and for working memory (p = 0.025, d = 0.31). Greater variations following to active treatment emerged also for PANSS-General Psychopathology subscale (p < 0.001; d = 0.54), PANSS total score (p < 0.001; d = 0.69), CGI indexes (all, p < 0.001; d > 0.6), DiscC-PANSS (p < 0.001; d = 0.80) and SUMD-general Unawareness index (p = 0.005; d = 0.15) but not for positive symptoms and others insight measures. Good safety/tolerability profiles were found. Bilateral bipolar-nonbalanced frontal-tDCS is a non-pharmacological approach in schizophrenia effectively improving NS, particularly the AA and EXP domains, probably acting by modulating dysfunctional cortical-subcortical networks. Preliminary results also suggest working memory improvements following tDCS. Further studies are needed to confirm the neurobiological basis of these results.

Change in core symptoms of borderline personality disorder by tDCS: A pilot study.

Borderline personality disorder (BPD) recognizes several psychopathological dimensions related to prefrontal cortex impairments. Transcranial Direct Current Stimulation (tDCS) targeting the right prefrontal dorsolateral cortex (DLPFC) positively influence cognitive functions related to impulsivity in healthy subjects. A randomized double-blind study was designed to investigate whether tDCS could modulate core dimensions (impulsivity, aggression, affective dysregulation) of BPD. Also effects on decision making process and substances craving was assessed. Patients were randomized to receive active-tDCS at 2 mA versus sham-tDCS, once a day for 15 sessions. Anode was placed on the right DLPFC (F4), cathode on the left DLPFC (F3). Impulsivity and aggression measures were significantly reduced only in patients treated with active-tDCS. Decision-making process was marginally influenced by the active current. Craving intensity was reduced only in the active-tDCS sample. Both groups showed improvements in the affective dysregulation dimension and anxious and depressive symptoms. The application of bilateral tDCS targeting right DLPFC with anodal stimulation seems to improve core dimensions of BPD (mainly impulsivity and aggression) probably by restoring prefrontal activity. tDCS might be a potential tool for preventing self-harming behaviors.

Cuidados à pessoa suspeita de COVID-19 com sinais de gravidade na Atenção Primária à Saúde / Care of suspected person of covid-19 with severe signs in primary health care

Objetivo: Descrever o processo de elaboração e a implementação de um checklist de cuidados à pessoa suspeita do novo coronavírus com sinais de gravidade na Atenção Primária à Saúde. Métodos: Relato de experiência de um Centro de Saúde da região da Grande Florianópolis, Santa Catarina, desenvolvida em duas etapas: elaboração e implementação de um checklist de cuidados para pessoas com sintomas respiratórios graves. Resultados: O checklist, elaborado coletivamente por enfermeiros e médicos em quatro versões, constituiu-se, na sua versão final dos itens: sinais vitais, ventilação, procedimentos, medicação, biossegurança, cuidados com a família, alergia medicamentosa, comunicação com outros pontos da Rede de Atenção à Urgência e observações. Implementado no atendimento a uma pessoa com sintomas respiratórios graves suspeita do novo coronavírus, o checklist proporcionou maior segurança no cuidado, acesso rápido às informações e com garantia de que nenhum dado fosse negligenciado, ademais favoreceu o diálogo entre os profissionais durante o atendimento, a comunicação com a família e com outros pontos da Rede de Atenção às Urgências. Conclusões: O checklist elaborado, claro e objetivo na sua implementação, supriu a necessidade de se garantir, na Atenção Primária à Saúde, uma assistência à pessoa suspeita do novo coronavírus com sinais de gravidade com mais qualidade e segurança. (AU)

Objective: To describe the elaboration process and implementation of a care checklist to suspected persons of the new coronavirus with severe signs in Primary Health Care. Methods: Report of experience of a health center in the region of the greater Florianópolis, Santa Catarina, developed in two phases: elaboration and implementation of a checklist for care of people with severe respiratory symptoms. Results: The checklist was elaborated collectively by nurses and physicians in four versions, and its final version consists of the items: vital signs, ventilation, procedures, medication, biosafety, family care, drug allergy, communication with other branches within the Urgent Care Network, and observations. Implemented in the care of persons with severe respiratory symptoms suspected of the new coronavirus, the checklist provided greater safety in care, quick access to information and it guaranteed that no data was neglected, in addition it facilitated the dialogue between professionals during the service, the communication with the family and with other branches within the Urgent Care Network. Conclusions: The elaborated checklist was clear and objective in its implementation, and fulfilled the need to guarantee more quality and safety in assistance of suspected person of the new coronavirus with severe signs in Primary Health Care. (AU)

Objetivo: Describir el proceso de elaboración y la implementación de un checklist de cuidados a la persona sospechosa del nuevo coronavirus con signos de gravedad en la Atención Primaria de Salud. Método: Relato de experiencia de un Centro de Salud de la región de la Grande Florianópolis, Santa Catarina, desarrollada en dos etapas: elaboración e implementación de un checklist de cuidados para personas con síntomas respiratorios severos. Resultados: El checklist elaborado colectivamente por enfermeras y médicos en cuatro versiones, consistió en su versión final de los ítems: signos vitales, ventilación, procedimientos, medicamentos, bioseguridad, cuidados con la familia, alergia a medicamentos, comunicación con otros puntos de la Red de Atención de Urgencia y observaciones. Implementado en la atención de una persona con síntomas respiratorios severos y sospechosa del nuevo coronavirus, el checklist proporcionó una mayor seguridad en el cuidado, acceso rápido a la información y garantía que ningún dato fuera desestimado. Además favorecer el diálogo entre profesionales durante la atención, la comunicación con la familia y con otros puntos de la Red de Atención de Urgencias. Conclusiones: El checklist elaborado, claro y objetivo en su implementación, cumplió la necesidad de garantizar en la Atención Primaria de Salud, la asistencia a la persona sospechosa del nuevo coronavirus con signos de gravedad con más calidad y seguridad. (AU)

Symptoms of psychosis in anorexia and bulimia nervosa.

Despite evidence from case series, the comorbidity of eating disorders with psychosis is less investigated than their comorbidity with anxiety and mood disorders. We investigated the occurrence of symptoms of psychosis in 112 female patients diagnosed with DSM-IV eating disorders (anorexia nervosa=61, bulimia nervosa=51) and 631 high school girls in the same health district as the patients: the items of the SCL-90R symptom dimensions "paranoid ideation" and "psychoticism" were specifically examined. No case of co-morbid schizophrenia was observed among patients. Compared with controls, the patients with anorexia nervosa were more likely to endorse the item "Never feeling close to another person"; the patients with bulimia nervosa were more likely to endorse the item "Feeling others are to blame for your troubles". Both groups of patients were more likely than controls to endorse the item "Idea that something is wrong with your mind". The students who were identified by the EAT and the BITE as being "at risk" for eating disorders were more likely to assign their body a causative role in their problems. Symptoms of psychosis can be observed in patients with eating disorders, but these could be better explained within the psychopathology of the disorders rather than by assuming a link with schizophrenia.

Aggressiveness, anger, and hostility in eating disorders.

OBJECTIVE: Despite evidence of a link between the behavioral and cognitive dimensions of aggressiveness and eating disorders, only few studies have tested this relation empirically. METHODS: A total of 112 female patients with anorexia nervosa (n = 61) or bulimia nervosa (n = 51) and 631 young girls attending 7 high schools in the same health district as the patients (northeast Italy) were invited to fill in a set of self-report instruments including the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, the Body Attitudes Test, and the Buss-Perry Aggression Questionnaire (AQ). RESULTS: In both healthy controls and patients, scores on the measures of eating disorder symptoms were positively related to the scores on the AQ: the strength of the association did not differ between healthy controls and patients. However, patients diagnosed with eating disorders were not more likely to disclose a propensity to aggression than the healthy controls drawn from the community: patients with anorexia nervosa scored lower than controls on the physical aggression and on the verbal aggression subscales of the AQ (P < .05). On the other hand, patients with bulimia nervosa scored higher than controls on the anger subscale of the AQ (P < .05) but did not differ from them on the other subscales of the questionnaire. CONCLUSIONS: The results confirm the higher propensity to anger in patients with bulimia nervosa; in patients with anorexia nervosa, difficulties in expressing anger and outward-directed aggressiveness can be a prevailing feature. The younger age of controls and exclusive reliance on self-report measures might have concealed some differences between patients and community subjects.

Eating disorders among professional fashion models.

Fashion models are thought to be at an elevated risk for eating disorders, but few methodologically rigorous studies have explored this assumption. We have investigated the prevalence of eating disorders in a group of 55 fashion models born in Sardinia, Italy, comparing them with a group of 110 girls of the same age and of comparable social and cultural backgrounds. The study was based on questionnaires and face-to-face interviews, to reduce the bias due to symptom under-reporting and to social desirability responding. When compared on three well-validated self-report questionnaires (the EAT, BITE, BAT), the models and controls did not differ significantly. However, in a detailed interview (the Eating Disorder Examination), models reported significantly more symptoms of eating disorders than controls, and a higher prevalence of partial syndromes of eating disorders was found in models than in controls. A body mass index below 18 was found for 34 models (54.5%) as compared with 14 controls (12.7%). Three models (5%) and no controls reported an earlier clinical diagnosis of anorexia nervosa. Further studies will be necessary to establish whether the slight excess of partial syndromes of eating disorders among fashion models was a consequence of the requirement in the profession to maintain a slim figure or if the fashion modeling profession is preferably chosen by girls already oriented towards symptoms of eating disorders, since the pressure to be thin imposed by this profession can be more easily accepted by people predisposed to eating disorders.

Seasonality of suicide: relationship with the reason for suicide.

AIMS: This study set out to test the hypothesis that the suicides that can be attributed to a psychiatric illness show a higher seasonality than the suicides due to any other reason. METHODS: All the suicides registered in Italy from 1984 to 2000 (57,796 deaths by suicide: males = 41,741, yearly rate = 11.3 per 100,000; females = 16,055, yearly rate = 4.0 per 100,000) were analyzed with circular statistic techniques, based on the maximization of mean vector length method and on the Rayleigh test. RESULTS: The suicides clearly attributed to a psychiatric illness were 35.0% among males and 51.3% among females. An economic reason for suicide was more frequently found among males; somatic illness or sentimental reasons were equally distributed in both sexes. The suicides attributable to a psychiatric illness showed a significantly higher seasonal unevenness than the suicides attributable to somatic illness and to sentimental or economic reasons. CONCLUSIONS: The main drawback of this study is that psychiatric diagnoses were not formally assessed by a forensic specialist. However, it succeeded in showing that the dynamics of suicidal behaviour are not unilineal: suicides due to psychiatric or somatic illness mainly happen in spring/summer and those due to economic difficulties mainly in December. Patients with psychiatric and/or somatic illness should be more carefully followed in spring/summer.

Eating disorders and suicide ideation: the mediating role of depression and aggressiveness.

OBJECTIVE: Symptoms of depression and aggressiveness are important antecedents and correlates of suicide ideation and completion in adolescents and adults. Among adolescents, eating disorder symptoms were also found to associate with suicidal behavior. This study was aimed at investigating the role of depression and aggressiveness as mediators in the links between eating disorder symptoms and suicide ideation among adolescents, taking into account age and sex as covariates. METHOD: Data from the Conegliano Eating Disorders Survey were used to investigate the role of depression and aggressiveness in the links between eating disorder symptoms and suicide ideation, resorting to a bootstrapped sampling distribution model. RESULTS: In a mixed male-female sample of 930 adolescents, eating disorder symptoms were positively related to suicide ideation, taking age and sex into account. Depression and aggressiveness acted as full mediators in the links between eating disorder symptoms and suicidality, and virtually abolished any direct influence of eating disorders on suicide ideation. CONCLUSION: Because of the cross-sectional nature of this study and the resorting to self-report scales, no firm statement about causal association can be made. However, both suicidal behavior and eating disorder symptoms are a rather widespread occurrence among adolescents, hence the investigation on suicidal tendencies in young people might benefit from the inclusion of measures of eating disorders to prevent the worst outcomes of minor psychological distress.

Seasonal variation in suicides and in deaths by unintentional illicit acute drug intoxications.

In order to assess whether substance-abusing people show a higher risk of dying from unintentional acute intoxication in specific periods of the year, and whether this unevenly distributed risk is subject to the same seasonal influences observed in suicide cases, we studied a total of 15,792 drug-related deaths (males=14,259; females=1533) and 20,332 deaths by suicide (males=15,571; females=4761), ascertained in Italy among 15-44-year-old people from 1984 to 2000. Distribution of deaths by month was studied with circular statistic techniques, based on the maximization of mean vector length method and the Rayleigh test. The monthly distribution of deaths over the study period followed an uneven trend that clearly differed, however, between the two time-series characterizing suicides and drug-related deaths. A clear seasonal variation was found for suicides in both genders, recurring on a significant circannual cycle. No circannual cycle was observed in the monthly distribution of drug-related deaths, which seem to be influenced by non-casual oscillations following a thrice-yearly cycle, linked to a significantly more evident 6-month recurrence. Some periods of the year, however, are clearly and consistently linked to an enhanced risk of dying by unintentional, acute intoxication by illicit drugs.

Distribution of deaths by unintentional illicit drug overdose in Italy based on periodicity over time, 1984-2000.

AIM: To assess whether substance-abusing people have a higher risk of dying from unintentional acute intoxication in specific periods of the year. METHODS: A total of 15,792 deaths (males=14,259; females=1533) were ascertained to be due to unintentional acute intoxication by illicit drugs in Italy in the study period (1984-2000). Distribution of deaths by month was studied with circular statistics techniques, based on the maximization of mean vector length (MMVL) method. The Rayleigh test was used to verify the hypothesis of uniform distribution of the events across some relevant periods. Density estimates for significant periodicities were derived with the kernel method for circular variables. RESULTS: Over the study period there was a steady increase in the number of deaths by overdose in Italy, affecting both genders, but more evident among males. The monthly distribution of deaths over the study period followed an uneven trend, with a slightly higher risk in the period between December and January, and in August, in both genders. The monthly distribution of deaths due to unintentional acute intoxication by illicit drugs appears influenced by non-casual oscillations following a thrice-yearly cycle, interlaced with a significantly more evident 6-monthly recurrence. CONCLUSIONS: There does seem to be a higher risk of dying from unintentional overdose in specific periods of the year. Better knowledge of the factors affecting the risk of mortality among substance-abusing people--due to changes in environmental or biological rhythms--could allow prediction of negative events, hence their prevention.

Suicidal ideation and aggressiveness in school-aged youths.

This study set out to explore the frequency and correlates of suicidal ideation in a community sample of school-aged adolescents living in a northeastern area of Italy. The study involved a mixed male-female sample of 1,000 adolescents, corresponding to 10% of the young population aged 15-19 in the district. We investigated psychological distress through the revised Symptom Checklist (SCL-90-R), from which we also derived our indicators on suicidality (items concerning hopelessness and suicidal ideation). Propensity to aggression was measured with an Italian version of the Aggression Questionnaire. Females scored significantly higher than males on all SCL-90-R subscales, with the exception of the hostility subscale. In our sample, 30.8% of females and 25.3% of males reported having thought about suicide; one adolescent out of 20 reported suicidal ideation of high intensity (5% out of the total sample in both genders). Males scored significantly higher than females on the Aggression Questionnaire. Both males and females who reported suicidal feelings had significantly higher scores on the Aggression Questionnaire than did those who denied suicidal ideation. Suicidal ideation is a rather widespread occurrence among adolescents and correlates with other indicators of psychological distress. Psychological distress in adolescence might also be expressed through turbulent behaviors and conduct disorders. Identification of the mental disorders underlying a higher propensity to aggression might help to prevent other negative outcomes such as suicide.

Eating disorders and suicide risk factors in adolescents: an Italian community-based study.

In a mixed male-female sample of 1000 adolescents age 15 to 19 years in a northeastern area of Italy, we investigated the links between eating disorders and suicidal tendencies by means of self-compiled measures, including the Eating Attitudes Test (EAT), the Bulimic Investigatory Test of Edinburgh (BITE), the Body Attitudes Test (BAT), and the SCL-90-R. More females than males reported abnormal eating patterns suggesting eating disorders: we found that 100 females (15.8%) and 8 males (2.8%) achieved scores above the suggested cutoff on EAT (cutoff = 30), 26 females (4.1%) and 1 male (.3%) achieved scores above the suggested cutoff on BITE (cutoff = 20), and 287 females (45.5%) and 24 males (8.6%) achieved scores above the suggested cutoff on BAT (cutoff = 36). More females than males also reported symptoms of hopelessness (44.3% vs. 30.5%) and suicidal ideation (30.8% vs. 25.3%). Both males and females reporting suicidal ideation achieved significantly higher scores on the eating disorders inventories, with no independent contribution by age, socioeconomic status, or body mass index. Although caution is required when drawing conclusions from self-reported measures, studies on mood disorders and suicidality in youth clearly need to include measures of eating disorders.

The spectrum of eating disorders: prevalence in an area of Northeast Italy.

This study aims at exploring the prevalence of eating disorders in a sample of adolescents living in a community in Northeast Italy. It takes into account age and gender differences in a mixed male-female sample of 1000 school-aged adolescents corresponding to 10% of the young population aged 15-19 years of the district. The study was based on self-reported questionnaires, including the Eating Attitudes Test (EAT), the Bulimic Investigatory Test of Edinburgh (BITE), and the Body Attitudes Test (BAT). The cases at risk were identified on the basis of the suggested validated cutoff for a clinically relevant syndrome. Females scored higher than males at all ages, body mass index levels, and socio-economic status levels. We found 100 females (15.8%) and 8 males (2.8%) scoring higher than the suggested cutoff for caseness on the EAT (cutoff=30); 26 females (4.1%) and 1 male (0.3%) scoring higher than the suggested cutoff for caseness on the BITE (cutoff=20); 287 females (45.5%) and 24 males (8.6%) scoring higher than the suggested cutoff for caseness on the BAT (cutoff=36). We did not find any gradient between age and socioeconomic status and the scores on the eating disorder inventories. BAT scores predicted with sharp precision the presence of an abnormal psychometric pattern on the EAT and the BITE. The prevalence of psychometric patterns that indicate an eating disorder seems in our adolescent sample higher than those reported in previous similar studies carried out in the North of Italy. The use of self-report inventories is a limitation in drawing definitive conclusions on the rates of eating disorder in this area; however, bodily dissatisfaction seems to be psychologically linked to abnormal eating patterns.