Suicide attempts and self-harm during a dramatic national economic transition: a population-based study in Iceland.

Background: Macroeconomic downturns have been associated with increased suicide rates. This study examined potential changes in suicide attempts and self-harm in Iceland during a period of major economic transition (2003-12). Methods: Data were retrieved from the National University Hospital in Reykjavik (population size: 204.725), containing all ICD-10 diagnoses connected to potential suicidal behaviour. Poisson regression models were used to compare attendance rates before and after the 2008 economic collapse. Results: During the study period, a total of 4537 attendances of 2816 individuals were recorded due to suicide attempts or self-harm. We noted a significant change in total attendance rates among men, characterized by an annual increase in attendance rate pre-collapse of 1.83 per 100.000 inhabitants and a decrease of 3.06 per 100.000 inhabitants post-collapse ( P = 0.0067). Such pattern was not observed among women. When restricting to first attendances only, we found a reduced incidence post-crisis among both men (RR: 0.85; 0.76-0.96) and women (RR: 0.86; 0.79-0.92). We further found 1% increase in unemployment rate and balance of trade to be associated with reduced attendance rates among men (RR: 0.84; 0.76-0.93 and RR: 0.81; 0.75-0.88, respectively) but not among women. Conclusion: These data suggest no overall increase in attendance rates due to suicide attempts or self-harm following the 2008 Icelandic economic collapse. In fact, a high-point in self-harm and suicide attempts was observed among men at the height of the economic boom and a decrease in new attendances among both men and women after the economic collapse.

Superior temporal lobe dysfunction and frontotemporal dysconnectivity in subjects at risk of psychosis and in first-episode psychosis.

BACKGROUND: Superior temporal lobe dysfunction is a robust finding in functional neuroimaging studies of schizophrenia and is thought to be related to a disruption of fronto-temporal functional connectivity. However, the stage of the disorder at which these functional alterations occur is unclear. We addressed this issue by using functional MRI (fMRI) to study subjects in the prodromal and first episode phases of schizophrenia. METHODS: Subjects with an at risk mental state (ARMS) for psychosis, a first psychotic episode (FEP), and controls were studied using fMRI while performing a working memory task. Activation in the superior temporal gyrus (STG) was assessed using statistical parametric mapping, and its relationship to frontal activation was examined using dynamic causal modeling. RESULTS: The STG was differentially engaged across the three groups. There was deactivation of this region during the task in controls, whereas subjects with FEP showed activation and the response in subjects with ARMS was intermediately relative to the two other groups. There were corresponding differences in the effective connectivity between the STG and the middle frontal gyrus across the three groups, with a negative coupling between these areas in controls, a positive coupling in the FEP group, and an intermediate value in the ARMS group. CONCLUSIONS: A failure to deactivate the superior temporal lobe during tasks that engage prefrontal cortex is evident at the onset of schizophrenia and may reflect a disruption of fronto-temporal connectivity. Qualitatively similar alterations are evident in people with prodromal symptoms of the disorder.

Neural correlates of executive function and working memory in the 'at-risk mental state'.

BACKGROUND: People with prodromal symptoms have a very high risk of developing psychosis. AIMS: To use functional magnetic resonance imaging to examine the neurocognitive basis of this vulnerability. METHOD: Cross-sectional comparison of regional activation in individuals with an'at-risk mental state' (at-risk group: n=17), patients with first-episode schizophreniform psychosis (psychosis group: n=10) and healthy volunteers (controls: n=15) during an overt verbal fluency task and an N-back working memory task. RESULTS: A similar pattern of between-group differences in activation was evident across both tasks. Activation in the at-risk group was intermediate relative to that in controls and the psychosis group in the inferior frontal and anterior cingulate cortex during the verbal fluency task and in the inferior frontal, dorsolateral prefrontal and parietal cortex during the N-back task. CONCLUSIONS: The at-risk mental state is associated with abnormalities of regional brain function that are qualitatively similar to, but less severe than, those in patients who have recently presented with psychosis.

Pattern of activation during delayed matching to sample task predicts functional outcome in people at ultra high risk for psychosis.

BACKGROUND: Clinical outcomes in people identified as at ultra-high risk (UHR) for psychosis are remarkably heterogeneous, and are difficult to predict on the basis of the presenting clinical features. Individuals at UHR are at risk of poor functional outcome regardless of development of psychotic disorder. The aim of the present study was to assess whether there is a relationship between functional neuroimaging measures at presentation and functional outcome as measured by the GAF three years after scanning. METHODS: Functional magnetic resonance imaging (fMRI) data were collected during an object working memory task in 34 ultra-high risk (UHR) subjects and 20 healthy controls. On the basis of their GAF scores at follow up, the UHR participants were divided into subgroups with good and poor functional outcomes, respectively. RESULTS: At baseline, the UHR group differed from controls in showing altered frontal and cuneus/posterior cingulate activation. Significant group x task interactions were found in the left cuneus and posterior cingulate gyrus, reflecting differential responses to the task conditions. Within the UHR sample, the subgroup with a poor functional outcome exhibited altered activation in frontal, temporal and striatal regions, and reduced deactivation within default-mode network regions, relative to those with a good outcome. Within the whole UHR sample, in these regions the local task response was correlated with the GAF score at follow up. CONCLUSIONS: The findings suggest a potential role of functional neuroimaging in the prediction of outcomes in people at high clinical risk of psychosis.

Cognitive remediation therapy in schizophrenia: cost-effectiveness analysis.

PURPOSE: There is a lack of evidence on the cost-effectiveness of cognitive remediation therapy (CRT). METHODS: Randomised controlled trial comparing usual care plus CRT with usual care alone. Participants had a diagnosis of schizophrenia and cognitive and social functioning difficulties. Health/social care and societal costs were estimated at 14 weeks (time 2) and 40 weeks (time 3) after randomisation. The outcome, proportion of participants improving their working memory since baseline, was combined with costs to explore cost-effectiveness. RESULTS: 85 participants were recruited. There were no differences in total health/social care or societal costs between the two groups at either time 2 or time 3. An additional 21% of participants in the CRT group improved their working memory at both follow-ups. When placing these cost and outcomes in hypothetical scenarios concerning how much policy-makers would pay for another 1% of participants improving their working memory, there was more than an 80% chance that CRT would be cost-effective compared to usual care; at time 3, the likelihood of cost-effectiveness peaked at 30% even for investments up to pound 5000. CONCLUSIONS: CRT can improve memory among people with schizophrenia and cognitive deficits at no additional cost. Although cost-effective in the short term, CRT may have limited potential to save costs in the medium term because it could increase take up of services. This could confer important longer term benefits for the patient group examined here, in terms of improved social functioning and less reliance on services. This can only be ascertained through longer follow-up.

Does age matter? Effects of cognitive rehabilitation across the age span.

BACKGROUND: Cognitive remediation (CR) therapy in its various disguises can be helpful for people with schizophrenia but it is not clear if patient characteristics are likely to interfere with its effectiveness. METHODOLOGY: This paper describes the assessment of one putative moderating variable, age, on the outcome of CRT in a rigorous randomised control trial with memory, cognitive flexibility and planning as primary outcomes and social behaviour, symptoms and self-esteem as secondary outcomes. Calendar age was divided into younger (< 40; N55) and older (40 or more years; N30). There were no differences between the groups at baseline in their cognitive, social or demographic data except on predicted variables. RESULTS: Younger people benefited more from cognitive remediation in two of the three cognitive domains tested. In the memory domain both groups benefited. Only negative symptoms showed a moderating effect of age on CRT, where again the younger group showed improvements in the context of CRT but the older group did not. When older people did show a cognitive advantage in memory following therapy this cognitive improvement benefited social behaviour. CONCLUSION: CRT needs some modification to increase the benefits to older participants. However, any cognitive improvements do still seem to have a beneficial effect.

Medial temporal lobe activity at recognition increases with the duration of mnemonic delay during an object working memory task.

Object working memory (WM) engages a disseminated neural network, although the extent to which the length of time that data is held in WM influences regional activity within this network is unclear. We used functional magnetic resonance imaging to study a delayed matching to sample task in 14 healthy subjects, manipulating the duration of mnemonic delay. Across all lengths of delay, successful recognition was associated with the bilateral engagement of the inferior and middle frontal gyri and insula, the medial and inferior temporal, dorsal anterior cingulate and the posterior parietal cortices. As the length of time that data was held in WM increased, activation at recognition increased in the medial temporal, medial occipito-temporal, anterior cingulate and posterior parietal cortices. These results confirm the components of an object WM network required for successful recognition, and suggest that parts of this network, including the medial temporal cortex, are sensitive to the duration of mnemonic delay.

Mesenteric panniculitis presenting with autoimmune haemolytic anaemia.

Mesenteric panniculitis is a rare idiopathic inflammatory disorder that can lead to sclerosis. We describe a patient with mesenteric panniculitis presenting with abdominal symptoms and autoimmune haemolytic anaemia. The symptoms remitted after splenectomy and gradual steroid taper. This may suggest an autoimmune component in the aetiology of mesenteric panniculitis.