Bipolar II Disorder and Borderline Personality Disorder - co-morbidity or spectrum?

We assess the number of patients who we have on the Database of a Community Mental Health Team in the UK who have Bipolar Disorder and Borderline Personality Disorder. We report how many of these have been seen as having both disorders. Hence we discuss the issue as to whether Borderline Personality disorder is to be placed within the bipolar spectrum. We note the difficulties regarding the use of phenomenology alone to decide this problem, and we note the similarities in genetics, neuroimaging observations and neurobiological mechanisms among the following conditions; Bipolar Disorder, Unipolar Depression, Post-traumatic Stress Disorder, and Borderline Personality Disorder. Ethiologies such as Trauma, Abuse, Childhood adversity and exposure to War appear to influence all these conditions via epigenetic mechanisms. Hence we argue that for a spectrum to be proposed, conditions in the spectrum need to be underpinned by similar or common Neuroimaging and neurobiological mechanisms.On this basis, it may be reasonable to include Borderline Personality Disorder within a broadly described bipolar spectrum. New details of the common Neurobiological mechanisms continue to emerge.

Ketamine administration in healthy volunteers reproduces aberrant agency experiences associated with schizophrenia.

INTRODUCTION: Aberrant experience of agency is characteristic of schizophrenia. An understanding of the neurobiological basis of such experience is therefore of considerable importance for developing successful models of the disease. We aimed to characterise the effects of ketamine, a drug model for psychosis, on sense of agency (SoA). SoA is associated with a subjective compression of the temporal interval between an action and its effects: This is known as "intentional binding". This action-effect binding provides an indirect measure of SoA. Previous research has found that the magnitude of binding is exaggerated in patients with schizophrenia. We therefore investigated whether ketamine administration to otherwise healthy adults induced a similar pattern of binding. METHODS: 14 right-handed healthy participants (8 female; mean age 22.4 years) were given low-dose ketamine (100 ng/mL plasma) and completed the binding task. They also underwent structured clinical interviews. RESULTS: Ketamine mimicked the performance of schizophrenia patients on the intentional binding task, significantly increasing binding relative to placebo. The size of this effect also correlated with aberrant bodily experiences engendered by the drug. CONCLUSIONS: These data suggest that ketamine may be able to mimic certain aberrant agency experiences that characterise schizophrenia. The link to individual changes in bodily experience suggests that the fundamental change produced by the drug has wider consequences in terms of individuals' experiences of their bodies and movements.

Is family therapy the most effective treatment for anorexia nervosa?

INTRODUCTION: Anorexia nervosa is a mental health disorder characterised by deliberate weight loss (through restrictive eating, excessive exercise and/or purging), disordered body image, and intrusive overvalued fears of gaining weight. The National Institute for Clinical Excellence recommends that family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa. AIMS: To perform a literature review to assess whether family therapy is a more effective intervention than other treatments in the management of adolescents with anorexia nervosa. METHOD: Search of PubMed, The Cochrane Library and NHS Evidence for randomised controlled trials that compared a family intervention with another treatment for anorexia nervosa in adolescence. RESULTS AND DISCUSSION: This literature search revealed only six randomised controlled trials investigating the use of family therapy in the treatment of adolescents with anorexia nervosa, and these all had small sample sizes. Some, but not all, of these trials suggest that family therapy may be advantageous over individual psychotherapy in terms of physical improvement (weight gain and resumption of menstruation) and reduction of cognitive distortions, particularly in younger patients. Due to the small sample sizes and the significant risk of bias (particularly information bias) in some of the studies the evidence in favour of family therapy over individual therapy is weak. In the future, larger randomised controlled trials with long term follow-up are required to assess whether family therapy is the most effective treatment for anorexia nervosa in adolescence.

Was Cipriani right? Audits to compare discharge rates and suicidality between antidepressant monotherapies used in a British community mental health team.

INTRODUCTION: a Metanalysis by Cipriani recently showed that certain antidepressants were more effective and better tolerated than others. We wished to see whether these findings were reflected in the outcomes of depression treatment in our Community Mental Health Team (CMHT). SUBJECTS AND METHODS: we related medication choice and dosage range to outcomes of treatment as reflected by discharge rates and suicidality. RESULTS: in this paper we emphasize the relationship of Dose Range to outcome. DISCUSSION: Our results are in accord with those of Cipriani. We note that Prescription of 'the four' was associated with a greater percentage of patients discharged from the clinic than 'the others'. Sertraline was the antidepressant most likely to reduce suicidality in our sample. For patients with unipolar depression, discharge rates were higher when they were prescribed one of the four medications indicated by Cipriani and highest when prescribed escitalopram. For patients who also had other indications, discharge rates were higher for the group other than the four antidepressants identified by Cipriani and highest for fluoxetine. Regarding Dose Ranges, we note that wheras many patients had their dosage titrated upwards from the starting dose, most did not have the dosage titrated to the highest dose of the relevant medication. CONCLUSION: it does appear that the antidepressants identified by Cipriani are effective compared with other monotherapies. Medication doses need to be optimised in order to achieve optimal treatment in Depression. Our results suggest that co-morbid undiagnosed other mental illness may often be a cause of 'resistant depression'. We recommend that all CMHTs should carry out audits of their prescribing practice in order to optimise treatment outcomes.

An audit to compare discharge rates between antidepressant monotherapies prescribed for pure unipolar depression versus depression in the presence of other indications.

INTRODUCTION: It has been demonstrated that there are differences in the efficacy and acceptability of commonly prescribed antidepressants (Cipriani et al. 2009). This meta-analysis showed that escitalopram, sertraline, venlafaxine and mirtazapine were the most effective in the acute treatment of unipolar depression in adults. In this audit, these most effective antidepressants will be referred to as 'the four', whilst other antidepressants will be referred to as 'the others'. We aimed to analyse prescribing patterns of antidepressant monotherapies in Bedford East Community Mental Health Team. We also aimed to compare the efficacy of antidepressant monotherapies in patients with unipolar depression or patients with depressed mood and also other psychiatric indications within Bedford East Community Mental Health Team, using discharge rates from the out-patient clinic as the outcome measure. We aimed to compare the efficacy of 'the four' versus 'the others' in patients with unipolar depression patients with depressed mood and also other psychiatric indications at within Bedford East Community Mental Health Team , using discharge rates from the out-patient clinic as the outcome measure. SUBJECTS AND METHODS: We included all patients on an antidepressant monotherapy in Bedford East Community Mental Health Team in our analysis (206 patients in total) (Figure 1). We examined the clinical notes for each patient to assess whether they were diagnosed with unipolar depression or another psychiatric condition, and whether they had been discharged from the out-patient clinic after being prescribed the antidepressant. This allowed us to calculate discharge rates for each antidepressant monotherapy. RESULTS: For patients with unipolar depression, discharge rates were higher when they were prescribed one of 'the four' and highest when prescribed escitalopram. For patients with other indications, discharge rates were higher for 'the others' and highest for fluoxetine . DISCUSSION: A greater percentage of patients with unipolar depression were discharged from clinic compared with patients treated with antidepressant monotherapy for depressed mood and also other psychiatric indications. CONCLUSION: These results suggest that co-morbid undiagnosed other mental illness may be a cause of 'resistant depression'.

An audit to compare discharge rates and suicidality between antidepressant monotherapies prescribed for unipolar depression.

INTRODUCTION: It has been demonstrated that there are differences in efficacy and acceptability of commonly prescribed antidepressants (Cipriani et al. 2009). This meta-analysis showed that escitalopram, sertraline, venlafaxine and mirtazapine were the most effective antidepressant monotherapies in the acute treatment of unipolar depression in adults. We aimed to analyse prescribing patterns of antidepressant monotherapies in Bedford Hospital. We intended to compare the efficacy of antidepressant monotherapies in patients with unipolar depression at Bedford East CMHT, using discharge rates and rates of reduced suicidality (including suicidal ideation and Behaviour) after treatment by the CMHT as the outcome measure. We also decided to compare the efficacy of 'the four' versus 'the others' in patients with unipolar depression in Bedford East CMHT, using discharge rates and rates of reduced suicidality (including suicidal ideation and Behaviour) after treatment by the CMHT as the outcome measures. SUBJECTS AND METHODS: We identified and included all patients with unipolar depression prescribed an antidepressant monotherapy in Bedford East CMHT. We identified patients who were discharged after treatment, as well as patients who were suicidal before treatment, and after treatment. Hence we could work out discharge rates and reduction in suicide rates for each antidepressant monotherapy. These were then compared, using graphs. RESULTS: The most frequently prescribed antidepressant monotherapy was citalopram. Prescription of 'the four' was associated with a greater percentage of patients discharged from the clinic than 'the others'. Sertraline was the antidepressant most likely to reduce suicidality in our sample. DISCUSSION: This audit in a small group of patients suggests that prescription of 'the four' leads to a higher discharge rate than 'the others'. Regarding suicidality, this audit in a small group of patients suggests that sertraline is the most effective antidepressant monotherapy in reducing suicidality in patients with unipolar depression. CONCLUSION: The study has several limitations, however it does appear that the antidepressants identified by Cipriani are effective compared with other monotherapies. We recommend that all CMHTs should carry out audits of their prescribing practice.

Exploring the impact of ketamine on the experience of illusory body ownership.

BACKGROUND: Our sense of body ownership is profound and familiar, yet it may be misleading. In the rubber-hand illusion, synchronous tactile and visual stimulation lead to the experience that a rubber hand is actually one's own. This illusion is stronger in schizophrenia. Given the evidence that ketamine, a noncompetitive N-methyl-D-aspartate antagonist reproduces symptoms of schizophrenia, we sought to determine whether the rubber-hand illusion is augmented by ketamine. METHODS: We studied 15 healthy volunteers in a within-subjects placebo-controlled study. All volunteers carried out two versions of the rubber-hand task, each under both placebo and ketamine infusions. In one task, they saw a rubber hand being stroked in synchrony with tactile stimulation of their real, hidden hand. In the other, stroking of the real and rubber hands was asynchronous. We recorded subjective changes in sense of ownership, as well as participants' ability to localize their hidden hand. RESULTS: Ketamine was associated with significant increases in subjective measures of the illusion and in hand mislocalization. Although asynchronous visuotactile stimulation attenuates the strength of the illusion during both placebo and ketamine, there remained a significant illusory effect during asynchronous visuotactile stimulation under ketamine compared with placebo. The strength of the illusion during asynchronous visuotactile stimulation correlated with other subjective effects of the drug. CONCLUSIONS: Ketamine mimics the perturbed sense of body ownership seen in schizophrenia, suggesting that it produces a comparable alteration in integration of information across sensory domains and in the subjective and behavioral consequences of such integration.