The catechol-O-methyltransferase (COMT) enzyme inactivates catecholamines, and the COMT Val(108/158)Met polymorphism (rs4680) influences the enzyme activity. Recent clinical studies found a significant effect of rs4680 on antidepressant response to fluoxetine and paroxetine, but several other studies were negative. No study considered drug plasma levels as possible nuisance covariate.

We studied the effect of rs4680 on response to fluvoxamine antidepressant monotherapy.

Forty-one consecutively admitted inpatients affected by a major depressive episode in course of major depressive disorder were administered fluvoxamine for 6 weeks. Changes in severity of depression were assessed with weekly Hamilton Depression ratings and analyzed with repeated measures ANOVA in the context of General Linear Model, with rs4680 and fluvoxamine plasma levels as factors.

rs4680 significantly interacted with time in affecting antidepressant response to fluvoxamine, with outcome being inversely proportional to the enzyme activity: better effects in Met-carriers, worse effects in Val/Val homozygotes. The effect became significant at the fourth week of treatment, and influence final response rates. Fluvoxamine plasma levels had marginal effects on outcome.

This is the first study that reports a positive effect of rs4680 on response to fluvoxamine, and the third independent report of its influence on response to selective 5-HT reuptake inhibitors (SSRIs). Our findings support the hypothesis that factors affecting catecholaminergic neurotransmission might contribute to shape the individual response to antidepressants irrespective of their primary molecular target.

To know prevalence of depression in Spanish nursing home(NH) by analysing the clinical profile of residents from RESYDEM study (Identification of patients with cognitive deterioration and dementia in NH).

A multicentral, transversal, observational study was carried out in April 2005. 71 geriatrician from 54 NH representing the Spanish state participated. Depression was analysed in patient´s history and determined by NPI of Cummings, NH version.

1037 residents were randomized, 1020 were used by clinical data analysis. 941 were used to determine depression prevalence. Median age 83,4yo, 66.6% were women, 70.9% with basic educational level, 57.4% widows, 25.7% single, 41.5% had some degree of functional deterioration, 22.1% had delirium. In 26.4% were documented Stroke(17,9% TIA). 61.7% had dementia.

Depression appears in 31.4% of elderly institutionalized with the only diagnosis of depression or independent of others. There were no significant differences in age groups. However, was most frequent in women. 95.7% of patients with diagnosis of dementia had at least one drug for depression. Most used anti-depressants were trazadone (23%), citalopram (20.9%), sertraline (15.8%), fluoxetine (10.1%). No tricyclical anti-depressant reached 1% of consumption.

Depression affects practically one in three institutionalized elderly in Spain

Institutionalized elderly with depression are largely treated with ISRS. It is believed that the use of trazadone is linked with the effects on sleep and anxiety.

The high prevalence of depression, its overlapping with other processes and the comorbility of residents requires a careful search and approach in NH which implies a challenge for professionals in order to treat it.

Serotonin and dopamine neurotransmitters have been extensively studied in association with temperamental and character traits.

In the present study we considered the association between 1A, 2A and 2C serotonin receptor and COMT SNPs and personality traits, as measured by the Temperament and Character Inventory (TCI), in a sample of suicide patients and controls. The SNPs considered were for 1A receptor rs1423691, rs878567 and rs6295, for 2A receptor rs643627, rs594242, rs6311 and rs6313, for 2C receptor rs547536, rs2192372, rs6318, rs2428707, rs4272555 and rs1801412, and for COMT rs737865, rs4680 and rs165599.

The sample was composed of three groups: two German samples, consisting of a healthy control group of 289 subjects (42.6% males, mean age: 45.2±14.9) and a psychiatric patient group of 111 suicide attempters (38.7% males, mean age: 39.2±13.6), and an Italian sub-sample, composed of 70 mood disorder patients (44.3% males, mean age: 42.9±14.4).

Controlling for sex, age and educational level, single markers and haplotypes were not or only marginally associated with personality dimensions.

Our study does not support 1A, 2A, 2C and COMT role on personality traits.

Determine the presence of neuropsychiatric symptoms (NPS), using the NPI-NH(Neuropsychiatric Inventory Nursing Home(NH) Version),in order to provide a multidimensional profile in behavioural symptoms in residents and to calculate its prevalence in Spanish NH.

From randomized population of RESYDEM study (Identification of patients with cognitive deterioration and dementia in NH) a multi-central, cross-sectional and observational study was carried out. 71 geriatrician from 54 NH representative the Spanish state participated.NPS was determinated by NPI Cummings NH version. This version includes upsets in sleep and feeding patterns.

992 residents were examined (Median age 83.4yo, 66.6% women, 91.8% received at least one type of treatment, 61.7% with dementia). 523 (52.7%) presented at least one type of NPS. In order of greatest frequency, the following were noted: alterations in sleep patterns (41.7%), depression/disphoria (31.4%), anxiety (31.2%), agitation/aggressiveness (29.6%), apathy/indifference (25.8%), delirious ideas (23.7%), irritability (22.4%), feeding/appetite upsets (18.5%), anomalous motor behaviour (15.3%), hallucinations (13.8%), desinhibition (11.1%), euphoria (4.4%).

35.9% of residents received benzodiapines, 26.7% antidepressants. Atypical neuroleptics were used in 15.8%, in contrast with 7.4% of the use of classic ones.

NPS ´s reached a high prevalence in NH and it is usual that more than one co-exists in the patients.

Alterations in sleep patterns, depression, anxiety, agitation/aggressiveness affect approximately one in three residents.

It is useful and recommendable to evaluate the 12 behavioural areas from the NH version of the NPI scale. This instrument was chosen as a sifting measure to establish neuropyschiatric symptomology in residences.

Bipolar disorder (BD) is a severe, disabling and life-threatening illness. Disturbances in emotion and affective processing are core features of the disorder with affective instability being paralleled by mood-congruent biases in information processing that influence evaluative processes and social judgment. Several lines of evidence, coming from neuropsychological and imaging studies, suggest that disrupted neural connectivity could play a role in the mechanistic explanation of these cognitive and emotional symptoms. The aim of the present study is to investigate the effective connectivity in a sample of bipolar patients.

Dynamic causal modeling (DCM) technique was used to study 52 inpatients affected by bipolar disorders consecutively admitted to San Raffaele hospital in Milano and forty healthy subjects. A face-matching task was used as activation paradigm.

Patients with BD showed a significantly reduced endogenous connectivity in the DLPFC to Amy connection. There was no significant group effect upon the endogenous connection from Amy to ACC, from ACC to Amy and from DLPFC to ACC.

Both DLPFC and ACC are part of a network implicated in emotion regulation and share strong reciprocal connections with the amygdale. The pattern of abnormal or reduced connectivity between DLPFC and amygdala may reflect abnormal modulation of mood and emotion typical of bipolar patients.

Major depression affects 1.5%-19% general population. High use of healthcare services and increase in morbidity and mortality are common consequences. Despite of appropriate pharmacological treatment, 30-40% of patients don't achieve significant improvement. TRD refers to no remission after two adequate trials of antidepressants: these patients qualify for ECT.

Our Mood Disorder Unit treats about 600 patients/year, 4% undergo ECT for TRD.

Ongoing, retrospective, observational study on 73 TRD patients treated with ECT 2/week, considering acute and late responsiveness 1 and 12 months later.

Sample of 52 (71.22%) patients with Recurrent Major Depression and 21 (28.78%) with Bipolar Disorder, collecting epidemiological and clinical data. Clinical course assessment through weekly Hamilton Rating Scale for Depression (HRSD); follow-up evaluation after 12 months, with telephone interviews.

73 inpatients, 26(35.62%) males, 47(64.38%) females with 4.31±3.43 previous episodes; mean age 59.42±11.60 years. Average duration of reference episode 52.71±39.42 weeks with HRSD initial score 30.16±4.76. Each patient was treated with 6.92±2.90 ECT applications. 64(87.67%) patients responded to treatment (50% reduction of HRSD initial score), 33(45.21%) achieved remission (HRSD≤8); 18(24.66%) patients maintained 12-months remission.

Our experience strengthens pivotal role of ECT in TRD. Each patient had long-lasting, severe episode under 1 year-long unsuccessful pharmacological therapy. ECT managed to quickly ameliorate their clinical course. We didn't record any adverse event. ECT showed similar relapse rates compared to conventional pharmacological treatment. This procedure requires further studies about long-term outcome.

Few questionnaires on the psychopathological onset and latency to treatment in psychiatric patients are currently available.

In this perspective we developed a brief questionnaire: the Psychopathological Onset Latency and Treatment Questionnaire (POLQ).

The questionnaire was administered to 265 patients with any psychiatric diagnosis. Statistical analyses were performed using SPSS.

The sample showed the following demographic variables in terms of age (48 ± 15 years), occupation (17% unemployed) and familiarity (54%). Clinical variables included: age at onset (30.66 ± 15 years), age at first diagnosis (36 ± 19 years) and age at first drug treatment (35 ± 14 years). the most common symptoms at onset were related to the anxiety spectrum (41.2%), mood spectrum (24.5%) or both (25.3%). Stressful life-events in relation to onset occurred in 63% of patients (12.1% familiar issues, 11.3% work problems, bereavement or end of a relationship in 16.6%). Most frequent first diagnoses were major depressive episode (26.8%), manic/hypomanic/mixed episode (13.6%) and anxiety disorders (11.7%). Average latency to the first visit was 34 months. in the 76.2% of the sample, the first contact was with a psychiatrist, a psychologist in 15.8%; 78.1% were treated with drugs as a first treatment, 11.7% with psychotherapy, 7.2% with both. the average duration of first treatment was 23 months (4 weeks - 360 months) and reasons for discontinuation were: lack of efficacy (23.8%) or complete remission (21.9%).

POLQ resulted to be a useful and reliable instrument in the collection of information on the psychopatological onset and latency to treatment.

Despite appropriate treatment, 30–40% of depressed patients, both unipolar and bipolar, do not achieve improvement, with high morbidity and mortality. For bipolar patients another risk is the switch into mania due to antidepressant treatment. The concern about the switch, suggests to administer antidepressants at lower doses, in combination with mood stabilizers and second generation anti-psychotics.

We performed an observational study on a sample of 23 bipolar patients treated with ECT for severe TRD in last 3 years, in order to evaluate the risk of switch.

Twenty-three bipolar inpatients, undergoing bitemporal ECT twice/week, with MECTA spectrum device. Main demographic and clinical data collected. Hamilton rating scale for depression (HAM-D). Clinical response defined as 50% reduction of HAM-D score at the endpoint from baseline; remission as HAM-D score at the endpoint < 8. Young Mania rating scale (YMRS) weekly in order to assess switch into mania.

Thirteen (56.5%) females, 10 (43.5%) males, mean age 60.1 ± 10.3 years. Mean age at onset 35.5 ± 13.6 years. Mean number of episodes: 7.1 ± 3.6. Mean duration of current episode: 33.4 ± 24.9 weeks. Mean HAM-D basal score: 30.0 ± 5. Each patient underwent a cycle of ECT (mean No. 6.7 ± 3.3). Pharmacological treatment was administered upon clinical need. Response rate 87%, remission rate 43.5%. Three out of 23 (13.04%) patients had transient hypomanic switch, spontaneous recovery within 7 days after the last ECT.

Our experience confirms that ECT is a powerful antidepressant, especially in patients with severe long-lasting depression, refractory to treatment. ECT is also a safe procedure: no adverse effects were reported. The manic switch rate is comparable with antidepressant drugs.

The authors have not supplied their declaration of competing interest.

Patients affected by severe manic episode, often with delusional symptoms, are commonly treated with a combination of mood stabilizers, antipsychotics and other sedatives. The choice of a specific drug, dose and term is still debated.

A naturalistic study on a sample of 84 inpatients affected by acute severe mania treated with a combination therapy.

To compare efficacy and tolerability of haloperidol/risperidone/quetiapine in association with lithium and/or valproate.

Eighty-four bipolar inpatients affected by a manic episode according to DSM-5 criteria. Drugs administered according to our best practice. Clinical course weekly monitored with Young Mania Rating Scale (YMRS) for 4weeks. Extrapiramidal side effects (EPSE) monitored with Saint Hans Rating Scale (SHRS).

Twenty-five men (29.76%) and 59 women (70.24%); mean age 43.37 ± 13.58 years. Mean YMRS score T0 40.27 ± 9.04. Forty-one patients (48.81%) treated with haloperidol (3.4 mg/die); 16 (19.05%) with risperidone (4.3 mg/die); 27 (32.14%) with quetiapine (438 mg/die). The 3 groups showed no difference regarding clinical characteristics and YMRS basal scores. Chi2 analysis confirmed an higher response rate (50% of reduction of YMRS final score compared to T0) with haloperidol (χ2 = 14.88; P = 0.00). The repeated-measures model analysis showed a significant decrease (P < 0.05) in YMRS scores in haloperidol vs. risperidone vs. quetiapine patients for all time points from second week. No statistical difference for EPSE was found.

We suggest that haloperidol could be advisable in the treatment of severe mania, with rapid efficacy, even with low doses. Occurrence of EPSE was not considerable during the acute treatment. Studies with a larger sample size, randomization, fixed doses, double blind design are needed.

The authors have not supplied their declaration of competing interest.

Independently of the drug choice, antimaniac treatment has to be continued at least until full remission. Most guidelines recommend continuation therapy for 6–12 months but controlled studies are lacking.

A six months follow-up study on a sample of 57 inpatients affected by mania at Mood Disorder Unit.

To evaluate a timeframe for the discontinuation of the antipsychotic therapy.

Fifty-seven bipolar inpatients affected by a manic episode according to DSM-5 criteria. Patients treated according to our pharmacological protocol with a mood stabilizer (lithium or valproate) and an antipsychotic (haloperidol or risperidone). Course of illness assessed with Young Mania Rating Scale (YMRS) scored at week 0, 1, 2, 4, 8, 24. Remission defined as YMRS < 12.

Twenty men (35.09%) and 37 women (64.91%); mean age 43.18 ± 12.71 years. Mean YMRS basal score 38.55 ± 8.08. At 4th week, remission rate was 54.39% (31 patients); at 8th week was 80.70% (46 patients). At 8th week, 39/57 patients (68.42%) discontinued the antipsychotic. Relapse rate after 6 months was 26.32% (12 depressed, 3 manic). Multiple regression, t-test and Chi2 analysis were performed: older patients (P = 0.01) and with higher number of episodes (P = 0.04) tend to relapse earlier. Neither severity of the episode (P = 0.3), nor delusional symptoms (P = 0.6) nor discontinuation of the antipsychotic (P = 0.3) correlate with relapse time.

Our experience suggests that an early discontinuation of antipsychotics, usually 4–8 weeks after remission, does not worsen the short-term course of illness. This approach could minimize the risk of side effects. Evidence is lacking about the duration of this therapy, long-term studies are still necessary.

The authors have not supplied their declaration of competing interest.

Suicides that occur during psychiatric hospitalization are tragic events causing immense distress to relatives, peers, and physicians. Suicide risk is particularly high in patients with mood disorders.

To identify a clinical risk profile which can be predictive of suicide in patients undergoing a major depressive episode, hospitalized and within three months after discharge.

We are going to include consecutively admitted depressed patients in San Raffaele Turro hospital (Milan), with a diagnosis of major depressive disorder or bipolar disorder, for a longitudinal prospective study. Demographical and clinical characteristics will be assessed. Barratt impulsiveness scale, aggression questionnaire, Hamilton psychiatric rating scale for depression, scale for suicide ideation, Columbia suicide severity rating scale will be administered to evaluate, respectively, traits of impulsiveness and aggression, severity of psychopathology and suicidal ideation. A follow-up program has been established to evaluate suicidal ideation one month and three months after discharge.

Considering suicide rates in other psychiatric wards, we retrospectively analyzed in our mood disorder unit the inpatient suicide rate of the last 3 years. In this period, we admitted 1794 patients. The suicide rate has been cumulatively of 0.17% (4 patients): 0.16% in 2014, 0.16% in 2015, and 0.19% in 2016. In the same period, outpatient suicide rate has been of 0.39%; 57.14% of outpatient suicides happened within three months after discharge.

Hospitalization and discharge are critical circumstances for psychiatric patients. Evaluation of risk factors will contribute to explain our ward suicide rate and hopefully to reduce it in the future.

The authors have not supplied their declaration of competing interest.

Several studies suggest that in severe bipolars there is a long-term benefit in continuing antipsychotic therapy plus a mood stabilizer also after remission from a manic episode. Nevertheless, the long-term use of antipsychotics is associated with significant side effects which can interfere with patient global functioning. In this sense, antipsychotics should not be continued unless the benefits outweight the risks.

The present study describes the course of illness between bipolar patients remitted from a manic episode, in continuation treatment with or without antipsychotic therapy during a 12-months follow-up period.

Cinquante-six bipolars (22 male and 44 female) remitted (Young < 12) from a severe manic episode were observed during a 12-months follow-up. According to clinical judge, as continuation treatment, 21/56 (37.5%) took antipsychotic plus mood stabilizer (AP + MS); 35/56 (62.5%) took mood stabilizers monotherapy (MS). During follow-up period YMRS and HAM-D were administered at 6th and 12th month to verify remission.

At the end of follow-up up, 33/56 patients (58.9%) maintained remission, 23/56 (41.1%) relapsed (56.5% depressive, 31.4% manic). The greater number of relapses occurred within 6th month: 16/56 (28.8%). In AP + MS group 12/21 patients relapsed (57.14%); in MS group 11/35 patients relapsed (31.4%). No statistical difference between the two continuation treatment strategies was observed (Chi-square = 3.586; P = 0.06).

Our data confirm the efficacy of mood stabilizers monotherapy in long-term treatment of our severe (psychotic features, revolving-doors) bipolar patients. In fact, once the remission was obtained, the clinical choice of discontinuing antipsychotic therapy did not worsen the course of illness without a higher risk of relapse.

The authors have not supplied their declaration of competing interest.

The origin of malnutrition in older age is multifactorial and risk factors may vary according to health and living situation. The present study aimed to identify setting-specific risk profiles of malnutrition in older adults and to investigate the association of the number of individual risk factors with malnutrition.

Data of four cross-sectional studies were harmonized and uniformly analysed. Malnutrition was defined as BMI < 20 kg/m2 and/or weight loss of >3 kg in the previous 3–6 months. Associations between factors of six domains (demographics, health, mental function, physical function, dietary intake-related problems, dietary behaviour), the number of individual risk factors and malnutrition were analysed using logistic regression.

Community (CD), geriatric day hospital (GDH), home care (HC), nursing home (NH).

CD older adults (n 1073), GDH patients (n 180), HC receivers (n 335) and NH residents (n 197), all ≥65 years.

Malnutrition prevalence was lower in CD (11 %) than in the other settings (16–19 %). In the CD sample, poor appetite, difficulties with eating, respiratory and gastrointestinal diseases were associated with malnutrition; in GDH patients, poor appetite and respiratory diseases; in HC receivers, younger age, poor appetite and nausea; and in NH residents, older age and mobility limitations. In all settings the likelihood of malnutrition increased with the number of potential individual risk factors.

The study indicates a varying relevance of certain risk factors of malnutrition in different settings. However, the relationship of the number of individual risk factors with malnutrition in all settings implies comprehensive approaches to identify persons at risk of malnutrition early.

Resource utilisation for infants with single ventricle CHD remains high without well-studied ways to decrease economic burden. Same-day discharge following cardiac catheterisation has been shown to be safe and effective in children with CHD, but those with single ventricle physiology are commonly excluded. The purpose of this study was to investigate the economic implications of planned same-day discharge following cardiac catheterisation versus universal overnight hospital admission in infants with single ventricle CHD.

A probabilistic decision-tree analysis with sensitivity analyses was performed. All included patients were categorised into four possible outcomes; discharge, readmission following discharge (within 48 hours), observation and prolonged hospitalisation. Baseline probabilities of each node of the tree were then combined with the cost data to evaluate the comparative dominance of one decision (immediately discharge) versus the other decision (routinely admit). Patients discharged on the same day as the procedure accrued the lowest attributed hospital cost ($5469), while patients readmitted to the hospital had the highest attributed cost ($11,851). Currently, no other studies have assessed the cost of hospitalisation following cardiac catheterisation in this population. Thus, we allowed for a wide range of cost variation, but same-day discharge dominated the decision outcome with a lower economic burden.

Same-day discharge following routine cardiac catheterisation in patients with single ventricle physiology is less costly compared to universal overnight admission. This demonstrates an important cost-limiting step in a complex population of patients who have high resource utilisation.

We aimed to investigate the incidence and causes of readmission of infants with single-ventricle and shunt-dependent biventricular CHD following routine, outpatient cardiac catheterisation.

Cardiac catheterisation is commonly performed in patients with single-ventricle and shunt-dependent biventricular CHD for haemodynamic assessment and surgical planning. Best practices for post-procedural care in this population are unknown, and substantial variation exists between centres. Outpatient catheterisation reduces parental anxiety and decreases cost. Our institutional strategy is to discharge patients following a 4- to 6-hour post-procedure observation period.

Retrospective cohort study using the Society of Thoracic Surgeons Database identified patients <1 year of age with pre-stage II single-ventricle CHD or shunt-dependent biventricular CHD who underwent cardiac catheterisation between 2007 and 2015. Readmission was defined as admission to the hospital within 48 hours after discharge after catheterisation.

A total of 92 patients were included in the analysis. Among them, 62 patients (67%) were discharged after a 4- to 6-hour observation period with only 3% readmission, 18 patients (20%) stayed for a 23-hour observation period, and 12 patients (13%) were admitted for >23 hours. There were no differences in baseline characteristics between discharged and admitted patients. Patients who underwent intervention were more likely to be admitted. Patients with hypoplastic left heart syndrome did not have major adverse events or readmissions. No intra- or peri-procedural deaths occurred.

Outpatient cardiac catheterisation may be a safe option for infants with single-ventricle and shunt-dependent biventricular CHD, with low readmission rates and minimal morbidity.