Introduction
Current clinical guidelines recommend the use of clozapine for the treatment of refractory schizophrenia, present in up to a third of patients with this disease. Despite the evidence, ...the data point to low prescription, underdosing, and delayed initiation.
Objectives
The objective of the study is to elucidate which factors may interfere in clozpine prescription.
Methods
This is a cross-sectional observational study, carried out using a survey designed specifically for it.
It was answered online by seventy psychiatrists affiliated with the Catalan Society of Psychiatry.
Results
More than half admitted having prescribed two or more antipsychotics without having previously ruled out pseudorefractoriness through depot treatment. 70% recognized the need for monitoring as the main prescription barrier, while the main reason for withdrawal was its adverse effects. The most alarming was considered agranulocytosis, with drooling, drowsiness and weight gain being the most reported.
Statistically significant differences (p=0.031) were found in relation to the years of experience and the device where clozapine was preferred to be started: <10 years in hospital, 10-20 years in partial hospitalization and >20 years outpatient office.
Statistically significant differences were observed in the preference of the device for its initiation depending on the usual work device: hospitalization (p<0.000) and partial hospitalization (p=0.046) preferred to schedule it from their respective devices, without any preference in consultations.
The level of experience and the most reported side effect were statistically significant: for the newest psychiatrists it was weight gain (p=0.031), without presenting differences in the rest of the groups.
Conclusions
Clozapine is the psychoactive drug of choice in refractory schizophrenia, so efforts should be devoted to reducing prescription barriers, offering training on its management and innovating forms of monitoring to promote its use.
Disclosure of Interest
None Declared
There is a lack of studies investigating the dose-response effect of childhood trauma, recent events and cannabis use on recent psychosis. This study aims to determine the relationship between the ...level of exposure to stress factors and cannabis use with psychosis and to determine the combination effect among these factors in predicting a psychotic disorder.
146 recent onset psychotic (ROP) patients and 61 healthy controls were included. Childhood trauma was evaluated using the childhood trauma questionnaire (CTQ) and recent events using the Holmes-Rahe social readjustment scale. The pattern of cannabis use was assessed by a detailed interview. A hierarchical multiple regression was run in order to determine both the cumulative and independent contribution of each factor in predicting a psychotic disorder.
The highest levels of exposure to childhood trauma and cannabis were associated with psychosis while neither low nor high recent event exposure was associated. The combined effect of risk factors yielded a significant association with psychosis (×2 = 86.76, p < .001) explaining the 49% of its variation. ROP were more likely to be exposed to one, two or three environmental factors than HC. Exposed to two or all factors were 7.5-fold and 26.7-fold more likely to have a diagnosis of psychosis, respectively.
Our study provides evidence for a cumulative and a dose-response effect of environmental factors on recent psychosis. Considering that cannabis use and stress are highly prevalent in the population with psychosis, investigations of their relationships are needed to implement targeted prevention and treatment strategies.
Abstract
Background
People with psychosis are at higher risk of cardiovascular events, partly explained by a higher predisposition to gain weight. This has been observed in studies on individuals ...with a first-episode psychosis (FEP) at short and long term (mainly up to 1 year) and transversally at longer term in people with chronic schizophrenia. However, there is scarcity of data regarding longer-term (above 3-year follow-up) weight progression in FEP from longitudinal studies. The aim of this study is to evaluate the longer-term (10 years) progression of weight changes and related metabolic disturbances in people with FEP.
Methods
Two hundred and nine people with FEP and 57 healthy participants (controls) were evaluated at study entry and prospectively at 10-year follow-up. Anthropometric, clinical, and sociodemographic data were collected.
Results
People with FEP presented a significant and rapid increase in mean body weight during the first year of treatment, followed by less pronounced but sustained weight gain over the study period (Δ15.2 kg; SD 12.3 kg). This early increment in weight predicted longer-term changes, which were significantly greater than in healthy controls (Δ2.9 kg; SD 7.3 kg). Weight gain correlated with alterations in lipid and glycemic variables, leading to clinical repercussion such as increments in the rates of obesity and metabolic disturbances. Sex differences were observed, with women presenting higher increments in body mass index than men.
Conclusions
This study confirms that the first year after initiating antipsychotic treatment is the critical one for weight gain in psychosis. Besides, it provides evidence that weight gain keep progressing even in the longer term (10 years), causing relevant metabolic disturbances.
Introduction
The influence of sexual hormones on mental disorders have been extensively reported. In fact, recent studies suggest that sex hormones may play a relevant role in the pathophysiology of ...psychosis, may be a precipitant when exogenously administered or even be used as a treatment agent of psychotic disorders.
Objectives
To describe the case of a patient with a recent diagnosis of delusional disorder (DD) with an onset in the perimenopausal period.
Methods
Case report and narrative review focused on the impact of sexual hormones on depressive symptoms and alcohol use comorbidity during perimenopause in DD women by using PubMed database.
Results
Case report: A 48-year-old woman diagnosed with DD. The clinical assessment of climacteric symptoms, as well as the gonadotropins (elevated levels of follicle-stimulating hormone -FSH- and luteinizing hormone -LH-) and estrogen levels monitoring (variations on 17-β-estradiol -E2-) enabled to link the endocrine changes with the onset and course of the psychiatric disorder. During the development of the disease, the patient also presented comorbid depressive symptoms and alcohol use disorder. Review: Estrogen depletion seems to increase the risk of psychosis, while scientific literature is not conclusive in establishing a definitive relationship between depressive symptoms and hormonal imbalance in DD. Alcohol use disorder is a common comorbidity in both perimenopausal women and patients with DD.
Conclusions
Multiaxial management of the case helped clinicians to achieve clinical stabilization. Sex differences as well as hormonal pattern disturbances should receive special attention due to the seminal implications in pharmacotherapy and clinical outcomes.
Disclosure
No significant relationships.
Introduction
Borderline personality disorder (BPD) has been characterized by mood instability, impulsive behavior and eventual dissociative and psychotic symptoms. Around 70% of patients present ...repeated self-injury behavior which is associated with high risk of completed suicide.
Objectives
To investigate the effect of group psychotherapy on the annual incidence of self-harm behavior and suicide attempts in BPD.
Methods
We carried out a retrospective longitudinal study by selecting BPD patients who received group psychotherapy during 2016. Systems Training for Emotional Predictability and Problem Solving (STEPPS) or Mentalization-Based Treatment (MBT) psychotherapies were applied. Patients without any self-harm/suicidal attempt before the intervention, those with comorbid diagnosis and those who did not engage at least half of total sessions were excluded for final analyses. Number of self-harm events, suicide attempts and other clinical events were recorded and compared one-year before and one-year post-intervention. SPSS software version 21.0 (IBM) was used for statistical analyses. Nonparametric tests and Survival tests were performed.
Results
Eight women out of 35 fulfilled our inclusion criteria. After group psychotherapy, a significant reduction in the number of self-harm events and suicidal attempts was found (mean 1.9+/-1.4 vs 0.5+/-1.1; p=0.042). Survival tests revealed significant differences in the occurrence of suicidal attempts. We did not find significant differences in the other clinical events.
Conclusions
Our results show a clear effectiveness of group psychotherapy in reducing self-harm events and/or suicidal attempts in BPD patients. If these findings are confirmed in future studies including larger samples, group psychotherapy could be indicated for diminishing suicide risks in BPD.
Disclosure
No significant relationships.
Introduction
Prevalence rates of panic attacks have been reported to be around 24-63% in psychotic patients. Common underlying biological substrates for panic and paranoia have been proposed, ...suggesting that delusional disorder (DD) may be preceded by the development of anxiety disorders.
Objectives
The main objective of this study was to investigate anxiety comorbidity in DD. As a second objective, we set ourselves to know prescription rates for the use of antidepressants and benzodiazepines in anxiety disorders in the context of DD.
Methods
A systematic literature search was performed using PubMed (1980- September 2020) according to the PRISMA guidelines. The following search terms were used: (delusional disorder) AND (anxiety OR anxiety disorder OR anxi*). Research studies and case reports were included if they met the following criteria: DD diagnosis (DSM, ICD), publication in peer-review journal and investigations containing information on anxiety comorbidity in DD.
Results
Four studies fulfilled our criteria, including 155 patients: 65 (42%) women, mean age 42.7 years (SD:14.96). Thirty-three of the 155 patients (21.29%) presented at least one comorbid anxiety disorder: 14 specific phobias, 9 panic attacks, 5 social phobias and 2 agoraphobias. Treatment was not reported for many patients (n= 28). Four patients received fluoxetine and 1 patient benzodiazepines. All of them showed partial improvement of symptoms.
Conclusions
Less than a third of DD patients showed an anxiety disorder. The effectiveness of antidepressant and benzodiazepine treatment has been poorly described. Future studies may be focused on the investigation of preceding comorbid anxiety disorders in patients with DD.
Introduction
Treatment response in schizophrenia can be influenced by cultural and ethno-biological factors. However, in delusional disorder (DD), these potential influences have been poorly ...investigated.
Objectives
This review aims to synthesize what is known about the influence that cultural and biological factors may have on treatment response in DD.
Methods
A systematic review was performed on PubMed from inception to 2020 in keeping with PRISMA directives. Search terms: (cultural OR ethnic* OR ethno*) AND (treatment OR therap* OR antipsychotic response) AND (delusional disorder). We included all studies whose objective was to explore ethno-psychopharmacological aspects of treatment response in DD.
Results
A total of 182 papers were retrieved. Four studies tested ethno-biological factors and 10 reported cultural aspects of treatment response in DD. 1. Cultural hypothesis: 3 studies reported cultural differences in diagnostic practices; in 2 studies, culturally-determined long durations of untreated psychosis (DUP) and comorbidity with mood disorders was associated with response to both antipsychotics (AP) and antidepressants (AD); 3 studies reported that response and AP dose were similar among cultures and that culturally-sensitive psychotherapy improved adherence; 2 studies showed that, where women had poor access to health care, mortality rates were high. 2. Ethno-biological hypothesis: 1 study reviewed moderators and mediators of ethno-specific treatment response; 1 study presented a culture-bound syndrome (Taijin kyofusho) for which AD were found effective; 2 studies in diverse populations found that DD and schizophrenia were both significantly linked to HLA genes.
Conclusions
The sociodemographic profile of DD is consistent across various cultures and, when treated appropriately, responds, but in an ethno-culturally-specific manner.
Disclosure
No significant relationships.
Introduction
A delusion of parasitosis is defined as the fixed, false belief of infestation by invisible organisms or fibrous material of unknown origin. The differential diagnosis is true infection, ...substance use disorder, dementia or other neuropsychiatric disease.
Objectives
Our goal was to characterize delusions of parasitosis, classically named Ekbom syndrome, among individuals attending our emergency department (ED).
Methods
Over a four-year period (2017-2020), we carried out a retrospective case-register study of patients with DSM-5 Ekbom syndrome attending an ED that provides mental health services to an area of nearly 450.000 inhabitants in Sabadell (Barcelona, Spain).
Results
There were 13 eligible patients: 7 were diagnosed for the first time and 6 had multiple episodes. Female-to-male ratio was 1.6:1; average age was 56.9. The most common diagnosis was delusional disorder (n=5;8.5%), followed by schizophrenia (n=3;23.1%) and organic disorders (n=2;15.4%). Origin: Africa (n=5;38.5%), South-America (n=4;30.8%) and Spain (n=4;30.8%). Fifty percent showed poor treatment compliance. Antipsychotics used: risperidone (n=8;61.54%), olanzapine (n=4;30.8%). Five patients received antidepressants. Most patients had previously been seen by other medical specialties (internal medicine, dermatology and hematology). ‘’Match box sign’’: 7 patients (53.8%). Cerebral atrophy was present on brain scan in 4 patients. After discharge: acute psychiatric unit (n=7), outpatient appointments (n=4), day hospital (n=1) and 1 to a psychogeriatric unit.
Conclusions
Delusions of parasitosis are rare in our emergency department. The typical patient is a postmenopausal woman, a visitor or immigrant to Spain. Effective treatment requires a focus on cultural, gender, and age aspects, with close cooperation between psychiatry and other relevant specialties.
Introduction
Over the last decades, antipsychotic plasma levels have been used to evaluate therapeutic response, adherence and safety of antipsychotics in schizophrenia. Their clinical utility in ...delusional disorder (DD) has been poorly studied.
Objectives
To investigate the relationship between plasma concentrations of risperidone (R), 9-OH-risperidone (9-OH-R) and olanzapine (OLZ), and clinical outcomes in DD.
Methods
Case-series of inpatients and outpatients with DD receiving treatment with risperidone (n=19) or olanzapine (n=2). Determination of R, 9-OH-R (active metabolite) and OLZ levels were obtained by high-performance liquid chromatography with electrochemical detection. Clinical variables such as treatment response or adverse events were recorded for all patients. These variables were correlated with two plasmatic ratios in patients treated with R: R:9-OH-R concentration ratio and total concentration-to-dose (C: D) ratio, indicating CYP2D6 activity and R elimination respectively.
Results
Twenty-one patients were included: inpatients (n=10) and outpatients (n=11). Dose range: R, 1-6 mg/day; OLZ, 5-10 mg/day. Three outpatients (R, n=2; OLZ, n=1) presented antipsychotic levels under the detection limit (non-adherence). All R patients showed CYP2D6 activity (R: 9-OH-R ratio <1). Eight patients presented C: D > 14, indicating a reduction of R elimination, which was associated with poor clinical response (n=3), adverse events (n=3) and no clinical relevance (n=2). OLZ (n=2), no association between levels and clinical outcomes.
Conclusions
The determination of antipsychotic plasma levels may be of clinical utility in the assessment of treatment resistance, antipsychotic-adverse events or non-adherence in inpatients or outpatients with DD. Therapeutic drug monitoring should be further studied in future works.
Disclosure
AGR has received honoraria, registration for congresses and/or travel costs from Janssen, Lundbeck-Otsuka and Angelini.
Introduction
Several neuroimaging studies on psychosis spectrum have been published in the last decades, most of them based on schizophrenia. In the context of neuroanatomical dysfunctions, clinical ...and prognosis implications have been reported. Nevertheless, only a few studies have been focused on delusional disorder (DD).
Objectives
To present the case of a patient diagnosed with DD who suffered from two cerebrovascular events after the onset of the psychiatric disease. Our aim is to elucidate potential implications of those lesions on the course of DD. We also reviewed the literature to assess evidence for specific changes in DD on brain structures and functions.
Methods
Case report and non-systematic narrative review in PubMed (2000-2020).
Results
Case report: A 66-year-old female with DD presenting, during the course of the disease, general atrophy and consecutive ischemic lesions on parietal, occipital and cerebellar areas. Clinical stabilization was achieved 12-16 months after risperidone 1.5mg/day treatment. Review: 19 studies were included: Structural brain data (n=15), Functional data (n=13). Most of the structural neuroimaging studies reported white and gray matter abnormalities, particularly in temporal, parietal and frontal lobes, and in limbic structures. Functional neuroimaging studies pointed to temporal and parietal lobes, as well as basal ganglia and limbic related structures.
Conclusions
Temporal, parietal, frontal, basal ganglia and limbic-related structures, as well as dysfunctions in other specific brain regions, may be implicated in the core symptoms of DD. These findings might be further investigated as potential neuroimaging markers of prognosis, such as partial or delayed response to antipsychotic treatment, as presented in our case.
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