[Do clothes make the psychiatrist? Psychiatrists and patients on psychiatrists' dress style and form of address]. / Maken de kleren de psychiater? Psychiaters en patiënten over kleding en aanspreekvorm.

BACKGROUND: Both the way a psychiatrist dresses and the way he gets addressed can have an impact on the therapeutic relationship. Most psychiatrists have stopped wearing white coats and dress less formally than before. AIM: To identify psychiatrists’ and patients’ preferences regarding psychiatrists’ style of dress and form of address. To test if certain styles of dress are linked to competence or accessibility. METHODS: A total of 143 respondents, of which 35 psychiatrists and 108 patients, filled out structured questionnaires with pictures. RESULTS: Psychiatrists, and both minor and adult patients, preferred psychiatrists to dress formally while elderly patients prefer them to wear white coats. The formal dress style and white coat were perceived as more competent than the informal style. Psychiatrists thought a white coat is regarded less accessible than a formal dress style and a formal dress style less accessible than an informal one. Adult patients regarded a white coat as less accessible than formal and informal dress styles. In elderly and minor patients no differences were seen in perceived accessibility for the three dress styles. Both psychiatrists and patients preferred a psychiatrist to be addressed with ‘doctor’ and a patient with his/her first name. CONCLUSIONS: It seems a good choice for a psychiatrist to go formally dressed, let them be addressed by their title, and address patients by their first name.

A longitudinal study of the association between basal ganglia volumes and psychomotor symptoms in subjects with late life depression undergoing ECT.

Psychomotor dysfunction (PMD) is a core element and key contributor to disability in late life depression (LLD), which responds well to electroconvulsive therapy (ECT). The neurobiology of PMD and its response to ECT are not well understood. We hypothesized that PMD in LLD is associated with lower striatal volume, and that striatal volume increase following ECT explains PMD improvement. We analyzed data from a two-center prospective cohort study of 110 LLD subjects (>55 years) receiving ECT. Brain MRI and assessment of mood, cognition, and PMD was performed 1 week before, 1 week after, and 6 months after ECT. Volumetry of the caudate nucleus, putamen, globus pallidus, and nucleus accumbens was derived from automatically segmented brain MRIs using Freesurfer®. Linear multiple regression analyses were used to study associations between basal ganglia volume and PMD. Brain MRI was available for 66 patients 1 week post ECT and in 22 patients also six months post ECT. Baseline PMD was associated with a smaller left caudate nucleus. One week after ECT, PMD improved and volume increases were detected bilaterally in the caudate nucleus and putamen, and in the right nucleus accumbens. Improved PMD after ECT did not relate to the significant volume increases in these structures, but was predicted by a nonsignificant volume change in the right globus pallidus. No volume differences were detected 6 months after ECT, compared to baseline. Although PMD is related to lower striatal volume in LLD, ECT-induced increase of striatal volume does not explain PMD improvement.

Understanding electroconvulsive therapy-related anxiety: a prospective study.

AIMS OF STUDY: Although electroconvulsive therapy (ECT)-related anxiety is experienced by a significant proportion of patients, it remains understudied. Our aim was to study the course of ECT-related anxiety during ECT. METHODS: Seventy-four patients with unipolar or bipolar depression, referred for ECT, were included. ECT-related anxiety was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ). RESULTS: Female patients reported more anxiety than men (F(1,64.6) = 3.95, P = 0.05). Patients with a psychotic depression were more anxious before the start of ECT (F(64.8) = 4.57, P = 0.04), but experienced a significant decrease in ECT-related anxiety (t(63.9) = -3.63, P = 0.0006), whereas patients with a non-psychotic depression remained stable on anxiety during their ECT course (t(63,9) = 0.76, P = 0.45). In addition, we found a significant correlation between the decrease of ECT-related anxiety and the decrease of depression-severity (r = 0.35; P = 0.04). CONCLUSION: There are individual differences in ECT-related anxiety trajectories during ECT. Both female patients and patients with psychotic depression experienced more ECT-related anxiety before the start of ECT. The severity of ECT-related anxiety decreased significantly in patients with a psychotic depression, but remained stable in patients without a psychotic depression during ECT. In addition, patients who showed a stronger decrease in depression-severity also showed a stronger decrease in ECT-related anxiety. A better understanding of ECT-related anxiety trajectories can help in designing anxiety-reducing interventions.

Association between hippocampal volume change and change in memory following electroconvulsive therapy in late-life depression.

OBJECTIVE: Electroconvulsive therapy (ECT)-induced hippocampal volume change (HVC) has been repeatedly described in recent years. The similar time course of HVC and ECT-related cognitive effects suggest a relation, that is to date, understudied. This study investigates whether HVC following ECT predicts the change in memory performance six months after the end of the ECT treatment. METHODS: Hippocampal volume (HV) was measured via high-resolution 3D T1-weighted images in 88 patients with late-life depression, within 1 week before and after ECT. Memory performance was assessed before and six months after ECT. Multiple linear regression was used to examine whether change in memory performance could be predicted based on ECT-induced changes in HV. RESULTS: Larger right absolute HVC predicts less pronounced improvement on the VAT (visual memory) in the whole sample. For the 8-Word Test (verbal memory), Category Fluency Test (semantic memory), and MMSE, the effect is only present in patients who switched from right unilateral to bitemporal stimulation after six ECT sessions. Absolute HVC in the left hemisphere was not significantly related to cognitive change. CONCLUSION: A larger absolute change in right HV during ECT is associated with less improvement in memory performance up to 6 months post-ECT.

Long-term neurocognitive functioning after electroconvulsive therapy in patients with late-life depression.

OBJECTIVE: There is ongoing concern about the possible negative impact of ECT on neurocognitive functioning in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression, using an extensive neuropsychological battery. METHODS: A total of 110 patients aged 55 years and older with unipolar depression, referred for ECT were included. The neuropsychological test battery was assessed prior to ECT and 6 months after the last ECT session. RESULTS: There were no statistically significant group-level changes from baseline to 6 months post-ECT in any of the neuropsychological measurements. Individual differences in cognitive performance were detected using the Reliable Change Index. CONCLUSION: Patients with late-life depression do not show deleterious cognitive effects 6 months following an ECT index course, although there are considerable differences at an individual level. Clinicians should not hesitate to prescribe ECT in older patients, as most of these patients will tolerate the treatment course and a small group will even experience a cognitive enhancement. However, clinicians should be aware that a small group of patients can experience cognitive side-effects. Further study is needed to predict which patients have a higher risk of developing cognitive side-effects.

[ResPECT - a decade of Flemish-Dutch ECT research]. / ResPECT ­ een decennium Vlaams-Nederlands onderzoek naar elektroconvulsietherapie.

BACKGROUND: There is increasing clinical and scientific interest in electroconvulsive therapy (ECT). AIM: To provide an overview of the main research findings of the Flemish-Dutch research consortium ResPECT. METHOD: We report on our review of the relevant literature. RESULTS: Our studies confirm that ECT is one of the most efficient treatments for depression in later life and for depression with psychotic features. Older people with age-related brain pathology can respond well to ECT. It is still preferable to apply a standard pulse-width because this increases the efficacy of the treatment and minimises the cognitive impact. Even vulnerable older people can react favourably to ECT. CONCLUSION: Recent findings of the ResPECT consortium are providing new insights that are applicable in daily clinical practice. Research into mechanisms of action can also increase our understanding of the pathophysiology of severe depression.

Long-term electrical stimulation of bed nucleus of stria terminalis for obsessive-compulsive disorder.

We previously reported that bilateral electrical stimulation in the anterior limb of the internal capsule/bed nucleus of the stria terminalis (IC/BST) effectively reduces symptoms in severe treatment-resistant obsessive-compulsive disorder (OCD) patients. Here we used a linear mixed model to investigate the evolution of symptomatic and functional status of our patients (n=24) and examined if baseline variables could predict this evolution. Data were collected during routine, clinical psychiatric visits. Our analysis showed a long-term, sustained effect of electrical stimulation in the IC/BST. After a fast initial decline of OCD symptoms, these symptoms remain relatively stable. In addition, we found a strong ON/OFF effect of stimulation (e.g., due to battery depletion). Our data also show that it is not the surgical procedure but rather the electrical stimulation that drives the improvement in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores. The Beck Depression Inventory (BDI) at baseline was the only predictor significantly related to the evolution of the Y-BOCS. A higher BDI at baseline seemed to be related to a smaller decrease of the Y-BOCS over time. In conclusion, electrical stimulation in the IC/BST has a fast and sustained effect on OCD and comorbid symptoms and functional status of patients.

DNA methylation in imprinted genes IGF2 and GNASXL is associated with prenatal maternal stress.

Epigenetic regulation of imprinted genes during embryonic development is influenced by the prenatal environment. Our aim was to examine the effect of maternal emotional stress and cortisol levels during pregnancy on methylation of imprinted genes, insulin-like growth factor 2 (IGF2) and guanine nucleotide-binding protein, alpha stimulating extra-large (GNASXL), using umbilical cord blood DNA. Maternal depressed mood (Edinburgh Depression Scale; EDS), pregnancy-related anxiety questionnaire (PRAQ) and cortisol day profiles were assessed throughout pregnancy. At birth, a cord blood sample (n = 80) was taken to study DNA methylation of IGF2 DMR0 (differentially methylated region), IGF2 anti-sense (IGF2AS) and GNASXL using Sequenom EpiTYPER. Linear mixed models were used to examine the relationship between DNA methylation and maternal stress, while correcting for confounders. We also studied the association of DNA methylation with the child ponderal index at birth. We found a cytosine-guanine dinucleotide (CpG)-specific association of PRAQ subscales with IGF2 DMR0 (CpG5, P < 0.0001) and GNASXL (CpG11, P = 0.0003), while IGF2AS was associated with maternal EDS scores (CpG33, P = 0.0003) and cortisol levels (CpG33, P = 0.0006; CpG37-38, P = 0.0005). However, there was no association of methylation with ponderal index at birth. In conclusion, maternal stress during pregnancy, as defined by cortisol measurements, EDS and PRAQ scores, is associated with DNA methylation of imprinted genes IGF2 and GNASXL. Our results provide further evidence that prenatal adversity can influence imprinted gene methylation, although future studies are needed to unravel the exact mechanisms.

Yoga in schizophrenia: a systematic review of randomised controlled trials.

OBJECTIVE: The objective of this systematic review was to assess the effectiveness of yoga as a complementary treatment on general psychopathology, positive and negative symptoms and health-related quality of life (HRQL) for people with schizophrenia. METHOD: Randomised controlled trials (RCTs) were considered whether they investigated a yoga intervention in patients with schizophrenia. The selection of studies, data extraction and quality assessment were performed independently by two reviewers. RESULTS: Only three RCTs met the inclusion criteria. Lower Positive and Negative Syndrome Scale (PANSS) total scores and subscale scores for positive and negative symptoms were obtained after yoga compared with exercise or waiting list control conditions. In the same way, the physical, psychological, social and environmental HRQL as measured with the abbreviated version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) increased more significantly after yoga than after exercise or waiting list control conditions. None of the RCTS encountered adverse events. Dose-response relationships could, however, not be determined. CONCLUSION: Although the number of RCTs included in this review was limited, results indicated that yoga therapy can be an useful add-on treatment to reduce general psychopathology and positive and negative symptoms. In the same way, HRQL improved in those antipsychotic-stabilised patients with schizophrenia following yoga.

A prospective, multicentre, open-label study to evaluate the effectiveness of aripiprazole in the treatment of a broad range of patients with schizophrenia.

PURPOSE: The aim of this study is to evaluate the effectiveness of 12-week treatment with aripiprazole in a broad range of patients suffering from schizophrenia by using a variety of physicians, caregivers and patients scales. SUBJECTS AND METHODS: A total of 361 in- or outpatients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for schizophrenia received open-label aripiprazole (10-30 mg per day) in this 12-week, prospective, multicentre, uncontrolled study. The primary endpoint was the Clinical Global Impression-Improvement (CGI-I) scale which measured effectiveness of study medication, including efficacy, safety and tolerability. A variety of physician-, patient- and caregiver-rated parameters were measured to gain a complete view of the effectiveness of aripiprazole. RESULTS: The effectiveness of aripiprazole treatment was demonstrated in a broad range of schizophrenia patients (CGI-I score of 3.0; 95% confidence interval: 2.8, 3.2: last observation carried forward [LOCF]) as the upper bound of the 95% CI was less than 4 (score of "no change"). Both patient and caregiver PGI-I scores (LOCF: 95% CI: 2.79, 3.09 and, 95% CI: 2.74, 3.17, respectively) corroborate this finding. Aripiprazole had a positive effect on disease severity by study end, as assessed by an increase of the (physician-rated) CGI-S scores, with 57.3% of patients having improved disease, one-third maintaining their condition (30.8%) and 11.3% with worsening symptoms (LOCF). The Investigator Assessment Questionnaire (IAQ) showed a great improvement (>50% of patients). Patients reported significantly improved quality of life and overall, 71% of patients and 67% of caregivers preferred aripiprazole to their previous antipsychotic medication (LOCF; P<0.0001 over time). CONCLUSION: Aripiprazole was effective in a broad range of patients with schizophrenia.

[Validity of nonaffective functional psychosis of the DSM IV in a Congolese population. A transversal clinical trial]. / Validité des psychoses fonctionnelles non affectives du DSM IV dans une population congolaise. Une étude clinique transversale.

BACKGROUND: The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM IV) distinguishes schizophrenia, schizophreniform disorder and brief psychotic disorder only according to the duration of the illness. Thus, the validity of these nosological concepts sounds uncertain. AIM: The aim of this study was to evaluate the validity of the DSM IV concepts schizophrenia, schizophreniform disorder and brief psychotic disorder. POPULATION AND METHODS: Seventy schizophrenics, 68 patients with brief psychotic disorder and 50 with schizophreniform disorder, all Congolese people, selected from the 'Telema' Mental Health Centre and the 'Neuropsychopathological centre of the University of Kinshasa, from 5(th) August 2003 to 14(th) March 2005 were compared with respect to the following clinical parameters: family schizophrenia and brief psychoses history, precipitating psychosocial factors, mode of onset of the disease, clinical syndromes linked to psychoses and general functioning. Statistical analyses included analysis of variances 'one way' (Anova), post hoc Tukey's test, discriminant analysis, and analysis of covariances. RESULTS: Brief psychotic disorder differed from schizophrenia and schizophreniform Disorder in respect with positive syndrome (F=8.76, df=2; 179, p=0.0002), cognitive syndrome (F=3.79, df=2; 179, P=0.024), syndrome of excitement (F=3.23, df=2; 179, P=0.042), general functioning (F=13.73, df=2; 179, P<0.0001), family history of schizophrenia (χ(2)=8.65; P=0.013), precipitating psychosocial factors (χ(2)=19.82; P<0.0001), and mode of onset of the disease (χ(2)=91.3; P<0.0001). Schizophreniform disorder differered from schizophrenia only by a more frequent acute onset and a better general functioning. Two nosological realities were thus distinguishable: brief psychotic disorder and schizophrenia-schizophreniform disorder complex. Surprisingly, negative syndrome could not distinguish brief psychotic disorder from schizophrenia and schizophreniform (F=2.80, df=2; 179, P=0.063). Data of the discriminant analysis based on scores on general functioning, positive, negative, depressive, cognitive and excitement syndromes was conclusive (F=6.41, df=2; 185, P<0.0001) and allowed correct classification rates of 75% for brief psychotic disorder, 48% for schizophreniform disorder, 54% for schizophrenia. Schizophreniform disorder was thus the less distinguishable group; this is in the line with longitudinal studies, which demonstrated the lowest diagnostic stability of this affection, compared with the two other diseases. Total error rate was 41%. CONCLUSIONS: Brief psychotic disorder could constitute a distinct affection from schizophrenia and schizophreniform disorder, whereas schizophreniform disorder and schizophrenia could be the same affection; the first being an acute and "good functioning" form of the second. However, these viewpoints need to be confirmed by data on long-term course. The data of this study validate ultimately a binary model of the major nonaffective functional psychoses, like that of the tenth edition of the International classification of mental and behavioural disorders (ICD-10).

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects.

OBJECTIVE: The cognitive side-effects of bifrontal (BF) and right unilateral (UL) ultra-brief pulse (0.3 ms) electroconvulsive therapy (ECT) were compared, in the treatment of patients with a depressive episode. METHOD: Neuropsychological functioning in patients with a medication refractory depressive episode, that were treated with a course of BF ultra-brief ECT at 1.5 times seizure threshold (ST) or UL ultra-brief ECT at 6 times ST, by random assignment, was assessed before treatment, and 1 and 6 weeks after the treatment course, by a blinded rater. RESULTS: Of the 64 patients that were included, 32 (50%) received BF ECT, and 32 (50%) received UL ECT, by random assignment. Neuropsychological testing 1 and 6 weeks after treatment was performed by 30 (93.75%) and 19 (59.37%) patients, respectively, in the BF-group and 29 (90.62%) and 20 (62.50%), respectively, in the UL-group. There was no deterioration in any of the neuropsychological measures. Patients rated their memory as clearly improved after treatment. There were no significant differences between the patients given BF ECT and those given UL ECT. CONCLUSIONS: Ultrabrief pulse ECT, used either in combination with a UL electrode position and a stimulus of 6 times ST, or a BF electrode position with a stimulus of 1.5 times ST, are effective antidepressant techniques, that do not have a deleterious effect on cognitive function.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: clinical efficacy.

BACKGROUND: It has been suggested that electroconvulsive therapy (ECT) with an ultra-brief pulse width in combination with a bilateral electrode placement has diminished antidepressive efficacy, as compared to unilateral ultra-brief pulse ECT. OBJECTIVE: The antidepressive efficacy of bifrontal and right unilateral ultra-brief pulse (0.3 ms) ECT were compared. METHOD: Eighty-one patients with a medication refractory depressive episode were treated with a course of bifrontal ultra-brief pulse ECT at 1.5 times seizure threshold or unilateral ultra-brief pulse ECT at 6 times seizure threshold by random assignment. The 17 item-Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory, Clinical Global Impression and Patient Global Impression were administered at baseline and repeated weekly during and 1 and 6 weeks after the course, by a blinded rater. RESULTS: 64/81 patients (79%) completed the study, half of which were treated with bifrontal ECT. At the end of the course, 78.1% of the BF group and 78.1% of the UL group responded, whereas, 34.38% (N=11) of the BF group and 43.75% (N=14) of the UL group achieved strict remission criteria (HRSD-score < or = 7). There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT, although patients receiving unilateral ECT achieved response/remission-criteria after a smaller number of treatments. LIMITATIONS: Relatively small number of subjects. CONCLUSIONS: Using an ultra-brief pulse width, both BF and UL-ECT are efficacious, although patients receiving UL-ECT achieve response/remission-criteria after a smaller number of treatments. TRIAL REGISTRY: http://www.controlled-trials.com/ REGISTRATION NUMBER: ISRCTN56570426.

[Increase in the percentage of female authors in the international psychiatric literature since 1970]. / Toename van het percentage vrouwelijke auteurs in de internationale psychiatrische vakliteratuur sinds 1970.

BACKGROUND: The participation of women in medicine and psychiatry is increasing. AIM: To find out whether this trend is also reflected in the international psychiatric literature. METHOD: We took steps to discover the gender of the first and the last author as listed below the title of 290 articles sampled at random from three leading psychiatric journals published between 1970 and 2007. results Women turned out to be underrepresented as the first or last author of these psychiatric articles; this conclusion was also found to apply to the first and last authors who were medical authors. Whereas the proportion of female first authors had increased significantly since 1970 and had reached almost 50% in 2007, there had been no such increase as far as last authors were concerned. CONCLUSION: In the psychiatric literature studied, the proportion of female first authors rose to almost 50%.

Une batterie de tests pour l'evaluation neuropsychologique des psychoses fonctionnelles non affectives chez le congolais

Contexte. Il n'existe pas, à ce jour, un modèle de batterie de tests destiné à l'exploration des troubles neuropsychologiques (cognitifs) des psychoses fonctionnelles non affectives en Afrique ; il n'y a que des batteries neuropsychologiques pour les schizophrènes occidentaux Objectif. L'objectif de cette étude est de déterminer, au sein d'une batterie neuropsychologique pour schizophrènes occidentaux, les tests recommandables à l'étude des troubles cognitifs des psychoses fonctionnelles non affectives dans le contexte culturel congolais. Sujets et méthodes. Les performances cogrutrves de 188 patients congolais présentant les psychoses fonctionnelles non affectives des types schizophrénie, trouble schizophréniforme et trouble psychotique bref, recrutés au centre de santé mentale 'TELEMA' et au Centre Neuro-Psychopathologique (CNPP) de l'Université de Kinshasa ont été comparées à celles de 152 sujets congolais de contrôle. L'analyse des variances 'one way' (ANOVA) et l'analyse des covariances (ANCOVA) ont été appliquées Résultats. Tous les tests utilisés et 90% des variables neuropsychologiques étudiées ont pu faire ressortir l'infériorité cognitive des patients. En plus, ces derniers ont affiché un déficit cognitif diffus, à l'image de celui des schizophrènes. Conclusions. Les différents tests neuropsycho-logiques utilisés sont suffisamment sensibles aux psychoses fonctionnelles non affectives chez les congolais ; ils sont recommandables dans l'exploration neuropsychologique desdites psychoses au sein du contexte culturel congolais. La question de la parenté neuropsychologique des psychoses abordées requiert une étude approfondie

The usefulness of experience sampling in understanding the urge to move in anorexia nervosa.

BACKGROUND: Physical hyperactivity has often been described in anorexia nervosa (AN) patients but up until now in-depth research has been scarce. Experience sampling methodology (ESM), a structured diary technique assessing momentary mental state at random times during the day, may be useful in studying hyperactivity in AN. METHODS: In two single case reports, ESM was used to investigate the variation across time of the urge to move in relation to potentially relevant eliciting conditions such as positive and negative emotions, weight preoccupation and attractiveness. RESULTS: Frequency distribution of the involved variables indicated substantial individual differences between patients. While both patients' tendency to be hyperactive was positively related to their weight preoccupation and negative emotions, in only one patient, the urge to move turned out to be significantly related to (the absence of) positive emotions. CONCLUSIONS: ESM can be useful to test whether general theories of psychopathology apply to specific patients, and it may be conceived as an individually tailored approach to self-monitoring. As such, it may guide the clinician to devise therapeutic interventions in particular patients.