Cognitive control of emotions by reappraisal strategies is a psychotherapeutic technique reducing emotional load and anxiety in stressful situations. A previous study in healthy subjects resulted in a top-down regulatory effect by reappraisal during the anticipation of negative and unknown cued emotional stimuli as expressed by increased medial prefrontal cortical activation and accordingly reduced amygdalar activity. We were now interested in neurobiological changes in patients with major depressive disorder (MDD) compared to healthy controls during the application of cognitive control.

20 patients suffering from a depressive episode in the course of MDD and 20 healthy subjects underwent functional magnetic resonance imaging. All subjects were instructed and trained to apply a ‘reality check’ as cognitive control strategy during the cued anticipation of known negative and possibly negative, thus unknown (50% positive/negative) emotional stimuli.

Applying cognitive control during the anticipation of negative and unknown cued stimuli, depressed patients had lower brain activity compared to healthy controls in thalamic and occipital regions as well as in the right extended amygdala, in the anterior cingulate cortex and the right anterior insula. Brain activity was increased in depressed patients in the right precentral gyrus and the left superior temporal gyrus/posterior insular region (close to Wernicke region).

We found several areas with reduced and also increased activations in MDD compared to healthy controls. We found no obvious deficits in this preliminary analysis in regions as the amygdala and the MPFC, corresponding to the hypothesized deficits in cognitive control mechanisms in MDD.

Extraversion and neuroticism are differentially correlated with affective disorders: Neuroticism is strongly correlated with depression and anxiety disorders, whereas extraversion is rather negatively correlated with anxiety disorders. Theories have implicated a common biological basis of neuroticism and affective disorders.

This study examined neural correlates of neuroticism and extraversion as well as of affective measures with functional magnetic resonance imaging using a task addressing pessimistic emotion processing during the cued anticipation of emotional stimuli in 14 healthy subjects. The measures of personality and affectivity were used as primary covariates for the correlation with brain activity during the anticipation of emotional versus neutral stimuli to identify brain regions in which individual brain activity was strongly correlated with psychometric measures.

Neuroticism, depression and anxiety were correlated with brain activity in parieto-temporo-occipital regions, functionally involved in visual-perceptual processing and attentional modulation, and also in caudate regions. Extraversion was correlated with brain activity particularly in prefrontal regions.

Our results point to possible common neural correlates of neuroticism and the affective measures, whereas extraversion seems to have a differential neurobiological basis. Particularly, the correlation with caudate regions, involved in implicit patterns of reaction, points to possible “automatized” biases in neuroticism and depression.

Numerous researches show significant presence of cardiovascular disorders, especially hypertension in depressed patients that show up several years after first depressive episode.

Mortality caused by cardiovascular disorders in depressed patients is 50% higher than in general population. Comorbid depression and cardiovascular disorders is making worse health condition, increasing suffering, making hard treatment, and outcome is not good.

The goal is to confirm presence of hypertension in depressed patients as the most common comorbid cardiovascular diseases.

A retrospective study has been conducted using data from medical history of 274 depressed patients hospitalized and treated at the Psychiatric Clinic, Clinical Center Banjaluka. These parameters were assessed: sex, age, number of hospitalizations, marital and employer status, comorbid disease, BMI, presence of hypertension, lipid status and glicemia's level. Data were presented using tables and graphs.

Results obtained in our study were:

Hypertension in comorbidity with depression was found in 106 patients (38,5%), 75 of them were males and 31 of them were females. The majority were at age 40-60 years. Obesity was found in 21% of them. High lipid's level was found in 20% of them. 11% of patients had high level of glicemia. More than half of the patients had lower socio-economic status.

Depression is often accompanied by cardiovascular disorders. It is very important to recognize this comorbidity in order to treat it successfully and to make better treatment's outcome.

Mixed state, since Kraepelin's pioneering contribution, refers to an affective condition in which various admixtures of depressive and manic symptoms occur simultaneously.

To evaluate the efficacy and safety of quetiapine plus ADs, both SSRIs and SNRIs in the treatment of acute mixed episodes of Bipolar I Disorder patients.

We pooled data from two ours independent studies for a total of 44 inpatients, 21 male and 23 female, diagnosed with type I mixed Bipolar Disorder (DSM-IV-TR). After receiving open-label quetiapine for 2 weeks, patients were subsequently randomised to receive either treatment with quetiapine + ADs or quetiapine alone for 18 weeks. Pooling the data, 22 received quetiapine alone (10 XRquetiapine) and the other were treated with an association of quetiapine plus an antidepressant. We evaluated these patients every week during the first month and every two weeks after that, using YMRS, HAMD-21.

The efficacy over depressive symptoms was similar in both groups. Compared with the baseline YMRS, at week 6 the percentage of improved YMRS responder was better in the group receiving quetiapine plus antidepressants than quetiapine alone. Three YMRS item scores improved significantly at week 6 in the group quetiapine plus AD(irritability, disruptive-aggressive behaviour and insomnia).

We suggest that adding an AD in order to treat every main features of mixed episode further improved the outcome, probably due to a specific action on a particular subtype of mixed state. In particular, the dysphoric subtype along with irritability and insomnia manic factors, seem to be better responsive to AD supplementation.

To compare the effectiveness of a psychoeducational group program and conventional treatment versus individual conventional care in patients with a mild/moderate depression disorder in urban primary healthcare centers (PHCC).

:

randomized controlled trial of two groups.

patients aged 20 years attended in 13 PHCC, identified by general practitioners and nurses with diagnosis of mid/moderate depression disorder (BDI scale) between December 2008 and April 2009.

The intervention group received a psycoeducational group program (12 weeks, two nurses). The program provided health education about the illness, pharmacological treatment, diet, physical exercise, problem solving, and cognitive-behavioral therapy.

The control group received conventional care.

The evolution of patients is monitoring up to 1 year after the inclusion by an individual interview (baseline and 3, 6, 9 months).

The battery of assessment included: Sociodemographic, BDI and EuroQol-5D questionnaires.

241 patients (126 intervention Group (IG); 115 control Group (CG)), 217 women (53% IG and 47%CG) with a mean age of 54, 11 (SD=12,656). 92% Spanish. 45% married. Academic level: 76, 5 % study and 13,5% non-study.

The mean BDI in the baseline GI 21, 66 (SD=6,87) and CG 19.62(SD=6.85), follow up 3 months, GI 13,91(SD=8.22) and CG 17,07(SD=7,930). The mean of EuroQoL in the baseline IG 48, 29 (SD= 17,77) and CG 53,0 (SD= 19,06), follow up 3m, GI 56,57(SD=22,12) and CG 45,28(SD=23,74).

The two groups are comparable for all variables analyzed. There is an improvement in the IG versus CG on depressive symptoms and quality of life.

This case is a presentation of three siblings diagnosed as affective disorder with polycythaemia vera during the episodes. Polycythaemia dissappearing with the remission of affective disorder is focus of attention of these cases.

First sister is 28 years old, single, treated for manic and subclinic depressive episodes for almost ten years. Polycythaemia vera has been developed with beginning of every manic episode and disappeared with the remission of episode. The patient made venopunction of 500cc weekly during the manic episode. Second brother is 26 years old, single, polycythaemia and psychotic depression were developed rapidly after a stressful life event. Venopunction was made for four times during one month medication. Polycythaemia and depression remitted at the same time. Third brother is 24 years old, single, polycythaemia and nonpsychotic depression were developed after his brother's depression. Venopunction was made for three times during three weeks of treatment. Again polycythaemia and depression remitted at the same time.

The siblings had no internal disease. Only first sister was on lithium treatment, 600mg/day for chronic affective disorder but her first polycythaemia attack was prior to lithium treatment. We found only one report upon the relationship between affective disorder and polycythaemia vera in which mania, delirium and polycythaemia rubra vera were documented. #Freeman MP, Wiegand C, Gelenberg AJLithium. İn Textbook of Psychopharmacology. Third Edition. Schatzberg AF, Nemenoff CB (editors) American Psychiatric Publishing, Washington DC. 2004, 547-565.

The present study was aimed at evaluating psychological well being (PWB) among subjects with affective disorders and healthy controls.

83 subjects with affective disorders were compared to 83 healthy controls. Measures of PWB, psychological symptom status, basic social skills underlying social and emotional competence, and health-related quality of life (QoL) were obtained from standardised, self-administered rating scales. Statistical analyses focused on between-groups differences and on correlations among the major variables under study.

Cases showed significantly higher levels of psychological symptoms, and lower PWB, social competence, and QoL than healthy controls. Between-groups differences in emotional competence did not attain statistical significance. When correlations were evaluated, cases showed negative correlations between PWB and psychological symptoms, and positive correlations between PWB and QoL. Only some PWB constructs correlated with the social competence, while no correlation was found between PWB and emotional control.

In healthy controls, similar correlations between PWB and social competence as well as between PWB and QoL were found. On the other hand, no correlation was found between PWB and emotional competence, between psychological symptoms and the two PWB constructs named “purpose in life” and “personal growth”.

Subjects with affective disorders seemed to link their PWB to psychological symptoms, QoL, and social skills with the exception of emotional control. Healthy subjects seemed, on the other hand, to link their PWB to QoL and social competence, only in part to psychological symptoms, and not at all to the emotional competence.

Alert for the efficiency of the clozapina, in high doses, in refractory mania to pharmacological treatment.

Review of literature relevant after the description of a clinical case example.

Description of a clinical case: Woman 30 years, ethnicity african, with bipolar disease type 1, with 12 years of evolution, and 11 treatments with around 1 year duration. Specifics took place with medication, such as intolerance to mood stabilizers, including lithium and valproate. Last inpatient care, with 5 months, it was for outbreak manic characterized by huge dysphoria and easy irritability with aggressiveness. There were administered antipsychotics, in high doses, and attempted electroconvulsive therapy, without success. Clinical remission has been achieved by the gradual increase of clozapina, in accordance with the patient tolerance, until 1400 mg daily without occurrence of agranulocytosis. The only intercurrence was a epileptic seizure, controlled with phenytoin.

Refractory mania is treated with clozapina in high doses, which must be administered according to the patient tolerance and clinical improvement. The risk of agranulocytosis (1-3%) is low, and is the only formal indication to suspend the treatment. The extensive metabolizers do not respond to conventional doses of psychotropic substances, they need larger doses and are more frequent in african people.

Lack of patient compliance in a general psychiatric ambulatory causes delays in diagnosing as well as in patient treatment efficacy.

a 30 year old patient underwent a psychiatric treatment which lasted two yaers. He was treated with a combination of psychopharmacs and psychotheraphy.

The patient contacted a psychiatrist for the first time exhibiting the following symptoms: loss of will and interests, weight gain, lowered general mood, avoidance of social contacts. A depressive episode was diagnosed and and antidepressive was introduced to his therapy (fluvoxamine). He did not comply to the therapy assigned nor he attended his scheduled examination.

His medicamentous therapy was intensified (fluoxamine, alprazolam, promazine). After six months, the patient returned in company with his family, and his non-compliance with the therapy was revealed.

After a sucessfful therapy an improvement in his mental state was noticed. During the last year, he was regular at his examinations and medication, with psychotherapy once a week.

Patient compliance is a prerequisite for diagnosing and a successful treatment. Combined treatment methods (psychopharmacotherapy, psychotherapy) with an adherend patient guarantee a good remission.

A partial solved issues in the treatment of Bipolar Disorder (BD) is depressive episode if is rapid cycling. Often, antidepressant monotherapy increases the risk of switching into mania/hypomania. Using quetiapine XR in these cases may help to avoid these disease burdens.

To estimate the clinical efficacy and acceptability, in rapid cycling depressive episode of quetiapine XR.

34 yrs. woman, Bipolar Disorder-Depressive Episode, rapid cycling (DSM-IV), scores YMRS=10 and HAMD-17=32 at baseline.

Depression (HAMD-17), mania (YMRS), CGI-S, CGI-I, side effects and relapse (follow-up: 12 month). The patient has a history of 12 yrs. of BD with 5 depressive and 6 manic episodes. Last year depressive episodes were 3 manic and 1 depressive episodes.

After 4 weeks, of treatment with quetiapine XR 300mg/day in the evening, the depressive scores improved 75%, sleep became normal, no co-medication was needed. The patient continued to receive quetiapine XR and assessments were performed monthly. The follow-up priod demonstrated no relapses (depressive or manic).

1. In this case of Bipolar Disorder-rapid cycling, the treatment of depressive episode quetiapine XR-300mg/day was effective and well tolerated; no switch in manic or hippomanic was noticed.

Chronic diabetics at some point gives up their vigilance in the sugar control. Many of them end up with intractable diabetic feet with limb losses incurring health budget, enormous morbidity and mortality.

300 patients who presented with diabetic feet been interviewed and noticed that ‘few weeks or months prior to their start of symptoms a major change in the treatment mechanism happens which lead to catastrophic complications of Diabetes’. They do not qualify according to DSM IV classification to be called MDE. But can be called Dysthymia. Surgical, Medical, Vascular and Psychiatric units in an Australian Hospital have been involved in these interviews (a simple questionnaire). Personal audit in two countries (Fiji Islands & Bangladesh) where Diabetes is pretty alarming in number have been included in the data.

Diabetic patients over time develop Dysthymia when they feel hopeless about control of their illness. Often they are overwhelmed by thoughts of long-term complications like retinopathy, neuropathy that they give up hope that they could combat its complications. Diabetic educators should be involved during their early stage of their illness before complications set in and should be trained to pick up dysthymic signs and symptoms for prompt referral for early psychological and psychiatric intervention.

:

• • Diabetic feet are preventable.

• • Early psychiatric assessment is helpful.

• • Preventive steps are cost effective.

• • Should Psychiatry Department have a role in the multidisciplinary management team of Diabetes?

To collect the opinions of a sample of Spanish psychiatrists and their patients about the acceptability, preference and adherence to treatment of mirtazapine orally disintegrating tablets in relation to mirtazapine conventional tablets.

It was carried out an on-line survey recruiting a total of 422 psychiatrists who responded to a questionnaire of 14 closed questions. Fieldwork for this project was conducted out between January and March 2009.

The 422 psychiatrists who responded to the present survey had an average age of 45. 54% of them were men and 46% were women. The scope of activity of the participants (multiple choice possible) was: 27.5% hospital, 68% mental health center, 27% private practice and 6% other kind of activity. The 42.5% of visited patients suffered major depression and concomitant chronic organic disease.

When prescribing an antidepressant, psychiatrists of the sample did not usually take account the patient preferences: 26% did not and 33% asked the patient “in less than 50% of the time.”

The doctors emphasized that mirtazapine orally disintegrating tablets was more convenience for the patient (94%), support for better compliance (91%), had a pleasant taste (87%) and had patient preference (86%) among the main issues that took into account when they opting for that drug formulation.

The change from mirtazapine conventional tablets to mirtazapine orally disintegrating tablets did not caused any problem for 70% of doctors.

Differences in galenic presentations of the same drug should lead significant perceived differences in clinical practice, by doctors and their patients

To estimate the prevalence of depressive symptoms in patients affected by subclinical hypothyroidism by means of Hamilton Rating Scale for Depression (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS); to assess which depressive symptoms are prevalent in our population, with references to the factorialization of HAM-D by Cleary and Guy (1977); to verify whether levothyroxine replacement therapy alone can induce total remission of depressive symptoms.

The study enrolled 63 patients affected by subclinical hypothyroidism undergoing follow-up at the endocrinology service of San Paolo Hospital in Milan. All patients underwent an evaluation by means of HAM-D and MADRS scales and serum TSH, free T4, free T3, TPO-Ab and Tg-Ab levels were measured.

We estimated a prevalence of depressive symptoms in our population of 63.5%. Concerning the qualitative assessment of psychiatric disturbances in the population we considered, our results showed that the most frequent symptoms were part of four factors, according to the Cleary and Guy factorialization of HAM-D: these factors are representative of anxiety and somatisation (factor I), cognitive impairment disturbances (factor III), psychomotor retardation (factor V) and sleep disorders (factor VI). Levothyroxine replacement therapy alone wasn’t effective in inducing total remission of depressive symptoms.

This study suggests the importance of a psychiatric evaluation in patients affected by subclinical hypothyroidism.

Behavioural addictions (BAs) can be understood as disorders characterized by repetitive occurrence of impulsive and uncontrolled behaviours. Very few studies have investigated their association with mood disorders. The present study was undertaken to determine the prevalence of the main behavioural addictions in a sample of bipolar outpatients in euthymic phase or stabilised by medications and to investigate the role of impulsivity and temperamental and character dimensions.

One-hundred-fifty-eight Bipolar Disorder (BD) (DSM-IV) outpatients were assessed with tests designed to screen the main behavioural addictions: pathological gambling (SOGS), compulsive shopping (CBS), sexual (SAST), internet (IAD), work (WART) and physical exercise (EAI) addictions. TCI-R and BIS-11 were administered to investigate impulsivity and personality dimensions mainly associated with BAs. The clinical sample has been compared with 200 matched healthy control subjects.

In bipolar patients, 33% presented at least one BA respect to the 13% of controls. Significantly higher scores at the scales for pathological gambling (p< .001), compulsive buying (p< .05), sexual (p< .001) and work addictions (p< .05) have been found. Self-Directness (p=.007) and Cooperativeness (p=.014) scores were significantly lower while impulsivity level was significantly higher (p=.007) in bipolar patients with BA than those without BA.

To our knowledge, this is the first study investigating the prevalence of behavioural addictions in BD showing a significant association of these disorders. BAs are more frequent in bipolar patients than in healthy controls and are related to higher impulsivity levels and character immaturity.

We have randomly divide patients into control group(N=45) without antidepressants, and experimental groups in accordance with applied antidepressants: clomipramine(N=48), fluoxetine (N=49), sertraline (N=51), escitalopram (N=49), mirtazepine (N=45), and tianeptine (N=52). We have used HAMD for estimation of depression, QOL scale for quality of life, and UPDRS subscales I(behaviour and mood) and II(daily activities) for PD symptoms at pretrial, and after 3 months scores in all groups. Data were processed with SPSS for Windows.

There is no statistical significance in pretrial scores between groups. After 3 months there is: significant increase in control and significant discrease(p=0.000) of HAMD scores in all experimental groups, in favour of antidepressant with higher mediana(escitalopram 9; sertralin 8; tianeptin 6;clompramin 3; mirtazapin 3;fluoxetine 1; control -2); significant increase of QOL scores in favour of antidepressant with higher mediana(escitalopram 1.24; sertraline 1.12; tianeptine 0.65; clomipramine 0.40; mirtazapine 0.27; fluoxetine 0.27), and significant difference in UPDRS II pretrial and after 3 months subscores(p=0.016), in favour of escitalopram.

All tested antidepressant are efficient in reducing HAMD score, but only escitalopram,sertraline,and tianeptine improved HAMD, QOL, UPDRS I, and II scores without side effects.

Determine levels of folic acid and vitamin B12 in a sample of depressed patients in the first visit to mental health center.

Demonstrate a high prevalence of folate and vitamin B12 deficiency in this group of patients and the relation with the depression and treatment resistant.

The sample was all the patients with a diagnosis of unipolar depression, who were derivated by general practitioner (GP) between January and June 2009 to Vallecas Villa Mental Health Center in Madrid. The sample was 82 patients, they were between 20 and 86 years old. In 62 cases the GP derivated the patients because resistant to treatment, and in 20 cases were naive-treatment. In the first visit folate serum and vitamin B12 were measured.

69 patients present low levels of folate (84,14%), and 4 low levels of vitamin B12 (4,87%). The mean of folate was 2,2 ng/ml in low-serum folate sample and the mean of vitamin B12 was 93 pg/ml in low vitamin B2 sample. 90,80% (56) of the resistant-treatment group presents low folate serum, in the naive sample was 65% (13).

In our sample depression is associated to a very high prevalence of folate deficiency. The highest prevalence appeared in the resistant-treatment group, so it could be a factor that influence in the persistent depressive symptoms, and poor antidepressant response.

Treatment of BDII may place the physician in difficulty because of the treatment resistence.

2 male patients 48 and 52 years old diagnosed with BDII (according to DSM IV) lastest episode, major depressive episode, with a poor or partial response to long-term treatment with antidepressant, mood stabilizer and sometimes antipsychotic drugs during the presence of psychotic symptoms.

During last year their treatment was: Paroxetine 40mg/ 2x day and Lamotrigine 150mg/day. Because of the lack of response the treatment was changed as follows:

Remove of lamotrigine; decrease of paroxetine to 20 mg; adding Aripiprazole 15 mg.

BPRS, HAMD and CGI-severity were used to evaluate their symptoms and gravity.

After 2 weeks of treatment significant improvement was noticed. This includes depressive and psychotic symptoms, sleep, anxiety and cognitive symptoms. Increase of professional performance.

After using this combination, they started psychosocial rehabilitation program. Since September 2007 their situation is stabile and there have not been noticed recurrences.

Favorable clinical results were noticed to both patients, with no noticeable adverse side effects. Aripiprazole combined with Paroxetine has improved depressive and psychotic symptoms of these patients with bipolar depression.

Our findings suggest that Aripiprazole - Paroxetine is a safe and tolerable combination; however, control trials are needed to validate our findings.

Bipolar disorder begins during adolescence but often escapes diagnosis at this time because episodes are misinterpreted with other psychiatric disorders. Lithium, carbamazepine, valproate, and other drugs are used for the treatment of acute episodes and maintain treatment of bipolar disorders.

To compare the efficacy of Valproate vs. Lithium in the long-term treatment of patients with subtypes of bipolar disorders.

120 patients with more than two episodes of BD (according to DSM-IV) in a longitudinal, comparative and randomized clinical trial, for 2 years (104 weeks) divided in two equal parallel-groups with open label pre-randomized phase. Primary outcome measure was time to relapse/recurrence of any mood episodes. Survival analyses (Kaplan-Mayer and Cox Proportional Hazard) were used for statistical analysis.

Cumulative survival for valproate's group was S(104)=0.3570, (35.70% and lithium's group S(104)=0.3136, (31,36%). Valporate is superior to lithium for the treatment of non classic BD I (Log Rank 0.0309, p=0.0100). Valproate prolongs median survival time with 11±9 and mean survival time to 7±4 weeks more than lithium. Treatment with lithium has 20.4% higher relative risk for relapse/recurrence than treatment with valproate Vp (β = 0.186, p = 0.434). Valproate is superior for the treatment of BD with psychiatric comorbidity (Log Rank =0.0007. p=0.0026).

We found that valproate is significantly more effective than lithium in prophylactic treatment of bipolar I disorders in non-classic subtype and in bipolar disorder with psychiatric comorbidity.

Recurrent depression could be considered as a stumbling block for the individuals during their active period of life. Beside the global functionality, recurrent depression could affect negatively academic skills of depressed subjects that will result in considerable higher indirect costs of the disorder. Our main objective was to reveal the clinical and non clinical factors correlated with academic impairment in subjects with recurrent depression.

We performed a longitudinal retrospective study on 248 patients admitted in our Clinic for Recurrent depressive disorder during 2001 - 2005. Two control samples were done, one with Bipolar affective disorder (N=44) and other with Persistent delusional disorder (N=59).

From 90 depressed subjects who were employed at the onset of psychiatric disorder, 56 (62.2%) became retired and another 6 (6.6%) became unemployed. Despite the treatability of recurrent depression the negative outcome on academic skills was similar to that occurring in both control groups that traditionally are considered as being more disabling. The clinical factors that concurred to the worsening of academic status were the more advancing age at the onset and actual moment of recurrent depression (p=0.006 and p=0.012 respectively), along with longer total duration of recurrent depression (p< 0.001), the absolute total number of depressive episodes and psychiatric hospitalizations (p=0.001).

Recurrent depression has a significant negative outcome on academic skills. The disabling character of recurrent depression could be caused by its high chronicity along with high recurrent pattern of clinical evolution.