Which clinical factors and biochemical parameters are associated with late-life major depression?

INTRODUCTION: Late-life major depression (MD) is a frequent and high-cost psychiatric disorder. Our purpose was to detect clinical and biological factors possibly associated with this condition to better prevent and treat it. METHODS: We recruited 343 patients, consecutively admitted for a Major Depressive Episode to the inpatient clinic of Policlinico of Milan and ASST Monza, Italy. A large set of clinical and biochemical variables was collected from clinical charts. Univariate analyses were performed both dividing the sample into two groups (age < or ≥65) and considering age as a continuous quantitative variable. Regression analyses were then performed considering as independent variables only those statistically significant at univariate analyses. RESULTS: Patients aged ≥ 65 resulted in having longer duration of illness, shorter duration of last antidepressant therapy, higher number of antidepressants assumed in the past, higher frequency of treatment-resistant depression, higher frequency of overweight/obesity and diabetes. As for biochemical parameters, patients ≥ 65 showed lower total plasmatic proteins and albumin, higher uric acid and creatinine. CONCLUSIONS: These preliminary results suggest less effectiveness of antidepressants, more susceptibility to metabolic disorders and poor nutritional status in patients with late-life depression; such aspects may consequently be taken into consideration for a proper therapeutic approach. KEY POINTSDepression in late life seems to be associated with poorer response to antidepressants;Clinicians should prefer compounds with minimal pharmacokinetic interactions and less risk of side effects including metabolic ones;The poor nutritional status and the higher risk of metabolic disorders in older patients points out the importance of proper diet and healthy lifestyle in this group of subjects;Further studies are needed to confirm the results of this research.

Which Clinical and Demographic Factors are Related to Incarceration in Male Patients With Antisocial Personality Disorder?

Antisocial Personality Disorder (APD) is a condition largely represented in detention centers where can reach a prevalence of 60% in male prisoners. The objective of this study is to identify the clinical and demographic factors that differentiate subjects with APD and hosted in penitentiary with respect to those are treated in outpatient psychiatric clinics. We recruited 65 male patients affected by APD, whose 26 were followed up in community mental health services and 39 were serving their sentence in a detention center located in Monza. Socio-demographic and clinical data were obtained through a review of the clinical charts, and interviews with patients or their relatives (if available). We performed descriptive analyses on the total sample, then we compared the two groups identified by the type of setting (outpatient clinic vs. penitentiary) by independent sample t tests (quantitative variables) or χ2 tests (qualitative ones). For qualitative variables odds ratios (ORs) were also calculated. Outpatients with APD (with respect to those hosted in the detention center) resulted: to be older (p = .02), to be less likely married (p = .01), to have more pre-onset psychiatric comorbidity (p = .05), to have more pre-onset substance poly-misuse (p = .01), to have more previous psychiatric hospitalizations (p < .01), and to be less likely to have received lifetime psychotherapy (p < .01). Globally, the results of this study show how the presence of psychiatric comorbidity or substance abuse (with the probable access to psychiatric services) before the onset of APD prevents imprisonment. This aspect is even more surprising when we consider that the two groups of patients show no differences in the frequency of crimes. Future research will have to confirm if early mental health care can really limit the access to penitentiary of subjects affected by APD.

Which factors are associated with duration of untreated illness in borderline personality disorder?

AIM: Borderline personality disorder (BPD) is a prevalent condition associated with high rates of hospitalizations. The purpose of this manuscript was to detect the factors associated with duration of untreated illness (DUI) in BPD. METHODS: Through chart review, we identified 152 patients followed up by community psychiatry services in Milan and Monza, Italy. The association between DUI and socioeconomic and clinical variables was examined using Pearson correlation and analyses of variances. The statistically significant variables from univariate analyses were then inserted in regression models. RESULTS: A longer DUI was associated with several variables (substance misuse after the onset of BPD, older age, earlier age at onset, longer duration of illness), but these results were not maintained in the regression analyses. CONCLUSIONS: In conclusion, DUI does not seem to be significantly associated with specific clinical aspects of BPD, or significantly modify the course and outcome of the disorder. Studies with larger samples have to confirm these preliminary findings.

Clinical Markers of Panic and Generalized Anxiety Disorder: Overlapping Symptoms, Different Course and Outcome.

Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) share underlying neurobiological mechanisms and several clinical features which, with medical comorbidities, may increase misdiagnosis and delay proper treatment. The aim of the study was to evaluate the association between clinical/socio-demographic markers and GAD/PD diagnosis. Outpatients (N = 290) with PD or GAD were identified in mental health services in Monza and Milan (Italy). Descriptive analyses and a binary logistic regression model were performed. Post-onset psychiatric (p = 0.05) and medical (p = 0.02) multiple co-morbidities were associated with GAD; treatment with selective serotonin reuptake inhibitors (SSRIs) was associated with PD, while GAD diagnosis was associated with treatment with atypical antipsychotics or GABAergic drugs (p = 0.03), as well as psychodynamic psychotherapy (p < 0.01). Discontinuation of the last pharmacological treatment was associated with GAD diagnosis rather than the PD one (p = 0.02). GAD patients may have a worse prognosis than PD patients because of more frequent multiple co-morbidities, relapses and poorer treatment compliance. The different treatment approaches were consistent with the available literature, while the association between GAD and psychodynamic psychotherapy is an original finding of our study. Further studies on larger samples are necessary to better characterize clinical factors associated with GAD or PD.

Gender differences in clinical and biochemical parameters of patients consecutively hospitalized for unipolar depression.

Major Depressive Disorder (MDD) is a medical illness twice as common in women than in men lifetime. Purpose of this study is to identify gender differences in clinical and biochemical parameters in subjects affected by MDD to implement individualized treatment strategies. We recruited 234 patients (112 males and 122 females) consecutively hospitalized for MDD in Milan (Italy). Data were obtained through a screening of the clinical charts and blood analyses. Univariate analyses, binary logistic regressions and a final logistic regression model were performed. The final logistic regression model showed that female patients (compared to males) had lower plasmatic levels of hemoglobin (p = 0.020) and uric acid (p = 0.002), higher levels of cholesterol (p < 0.001), had been treated with a lower number of antidepressants (p = 0.011), presented lower red blood cells (p < 0.001) and showed more frequently comorbidity with hypothyroidism (p = 0.036). Univariate analyses identified also that women had an earlier age at onset (p = 0.043), were less likely to have comorbidity with diabetes (p = 0.002) and were less frequently treated with a psychiatric polytherapy (p < 0.001). Finally, female patients had achieved more frequently remission in the last depressive episode (p = 0.001) and were more likely to have family history for psychiatric disorders (p < 0.001) than males. Female patients globally have a better response to treatments, but they seem to be more vulnerable to specific metabolic abnormalities as showed by more frequent hypercholesterolemia and lower plasma levels of uric acid. These results have to be confirmed by further studies.

Which Clinical and Biochemical Parameters Are Associated with Lifetime Suicide Attempts in Bipolar Disorder?

INTRODUCTION: Bipolar Disorder (BD) is a disabling condition with suicidal behavior as one of the most common adverse outcomes. The purpose of the present research is to investigate the relationship between lifetime suicide attempts and the clinical factors/biochemical parameters in a large sample of bipolar patients. METHODS: A total of 561 patients, consecutively hospitalized for BD in Milan and Monza (Italy), were recruited. Data about the demographic and clinical variables, as well as the values of blood analyses, were collected. The groups identified according to the presence/absence of lifetime suicide attempts were compared using univariate analyses. Then, three preliminary binary logistic regressions and a final logistic regression model were performed to identify the clinical and biochemical parameters associated with lifetime suicide attempts in BD. RESULTS: Lifetime suicide attempts in BD were predicted by a longer duration of untreated illness (DUI) (p = 0.005), absence of lifetime psychotic symptoms (p = 0.025), presence of poly-substance use disorders (p = 0.033), comorbidity with obesity (p = 0.022), a last mood episode of manic polarity (p = 0.044), and lower bilirubin serum levels (p = 0.002); higher total cholesterol serum levels showed a trend toward statistical significance (p = 0.058). CONCLUSIONS: BD patients with lifetime suicide attempts present unfavorable clinical features. Some specific biochemical characteristics of bipolar patients may represent potential markers of suicidal behavior and need to be better investigated to identify new targets of treatment in the framework of personalized medicine. These preliminary findings have to be confirmed by further studies in different clinical settings.

Clinical and Biological Factors Are Associated with Treatment-Resistant Depression.

BACKGROUND: Treatment-resistant depression (TRD) is a debilitating condition associated with unmet clinical needs. Few studies have explored clinical characteristics and serum biomarkers associated with TRD. AIMS: We investigated whether there were differences in clinical and biochemical variables between patients affected by TRD than those without. METHODS: We recruited 343 patients (165 males and 178 females) consecutively hospitalized for MDD to the inpatient clinics affiliated to the Fondazione IRCCS Policlinico, Milan, Italy (n = 234), and ASST Monza, Italy (n = 109). Data were obtained through a screening of the clinical charts and blood analyses conducted during the hospitalization. RESULTS: TRD versus non-TRD patients resulted to be older (p = 0.001), to have a longer duration of illness (p < 0.001), to be more currently treated with a psychiatric poly-therapy (p < 0.001), to have currently more severe depressive symptoms as showed by the Hamilton Depression Rating Scale (HAM-D) scores (p = 0.016), to have lower bilirubin plasma levels (p < 0.001). In addition, more lifetime suicide attempts (p = 0.035), more antidepressant treatments before the current episode (p < 0.001), and a lower neutrophil to lymphocyte ratio at borderline statistically significant level (p = 0.060) were all associated with the TRD group. CONCLUSION: We identified candidate biomarkers associated with TRD such as bilirubin plasma levels and NLR, to be confirmed by further studies. Moreover, TRD seems to be associated with unfavorable clinical factors such as a predisposition to suicidal behaviors. Future research should replicate these results to provide robust data in support of the identification of new targets of treatment and implementation of prevention strategies for TRD.

Misdiagnosis, duration of untreated illness (DUI) and outcome in bipolar patients with psychotic symptoms: A naturalistic study.

BACKGROUND: A number of data show the negative role of duration of untreated illness (DUI) on outcome in mood disorders, but no investigation has been carried out about the impact of this variable in bipolar disorder (BD) with psychotic symptoms. Clinical experience shows that many bipolar patients with psychotic symptoms receive other diagnoses and often are chronically treated with first generation antipsychotics, with the effect to reduce duration of untreated psychosis/untreated episode with psychotic symptoms (DUP), but not DUI. Purpose of the study was to define the rate of misdiagnosis and the impact of DUP/DUI on outcome of bipolar patients with psychotic symptoms. METHOD: Clinical information (DUP, DUI, first received diagnosis) about bipolar outpatients with psychotic symptoms (N=240) were extrapolated through a retrospective review of the clinical charts, Lombardy database and, if necessary, through clinical interviews with patients and their relatives. Outcome measures included psychiatric and substance abuse comorbidity, occupational status, Global Assessment of Functioning (GAF), number of hospitalizations and of suicidal attempts, number of depressive/manic recurrences. Patients were divided in two groups according to the DUP (1 year) and DUI (8 years) median, and the groups were compared through analyses of variance (ANOVAs) for continuous variables or χ(2) tests for dichotomous ones. Multivariate analysis of variance (MANOVA) with duration of illness as covariate was then performed to eliminate the effect of this variable. Finally, binary logistic regressions were performed considering age at onset, DUI, DUP as independent variables and outcome variables as dependent ones (presence of hospitalizations/suicidal attempts, GAF scores<50, occupational status). RESULTS: Most of patients (61.5%) received a first diagnosis different from BD with the most frequent DSM-diagnosis being delusional disorder (17.9%). Patients with longer DUP were not different in outcome measures with respect to patients with shorter DUP. Patients with a DUI >8 years presented higher number of hospitalizations (F=6.04, p=0.015), higher number of manic recurrences (F=5.25, p=0.023), higher number of depressive recurrences (F=7.13, p=0.008) and lower GAF scores (F=17.74, p<0.001). Statistical significance persisted for number of hospitalizations (p<0.001) and GAF scores (p=0.003) after MANOVA. Finally binary logistic regression showed that a longer DUI was predictive of GAF scores<50 (F=17.74, p<0.001). DISCUSSION: More than half of bipolar patients with psychotic symptoms receive a different diagnosis at first contact with psychiatric services. DUI (but not DUP) is a predictor of outcome in bipolar patients with psychotic symptoms. This indicates that an early diagnosis and proper treatment with a mood stabilizer (or an atypical antipsychotic with mood stabilizing effects) may improve long-term outcome of these patients. In the light of the naturalistic design of the present paper, these results have to be considered as preliminary and have to be confirmed by prospective controlled studies.