Alam A, Chengappa KNR. Obstructive sleep apnoea and schizophrenia: a primer for psychiatrists

Objective: The main objective of this review is to improve psychiatric clinician awareness of obstructive sleep apnoea (OSA) and its potential consequences in patients with schizophrenia. This article will also discuss the diagnosis and treatment options for OSA while considering the significant role psychiatrists can play in facilitating the diagnosis and treatment of OSA.

Data sources: Ovid, Medline and PsychInfo databases were searched for articles between 1960 and 2010. Search terms used were Sleep apnoea or apnoea and schizophrenia or psychosis. The number of articles retrieved was 38. Articles were carefully reviewed for any data pertinent to OSA in patients with schizophrenia.

Conclusions: OSA is a common disorder that is frequently unrecognised. As a chronic breathing condition, OSA is associated with adverse health outcomes and high mortality. OSA may co-occur with schizophrenia or evolve over time, especially with weight gain. The diagnosis should be considered whenever a patient presents with risk factors or clinical manifestations that are highly suggestive of OSA. Those who report snoring, daytime sleepiness and are obese or have a large neck circumference should be considered for an OSA diagnosis. Appropriate diagnosis and treatment of OSA can reduce daytime sleepiness, improve cardiovascular and other medical conditions, as well as reduce mortality. Psychiatrists can play very important role in suspecting OSA in their patients and making the initial referral. Furthermore, behavioural management, especially promoting weight loss and smoking cessation, are effective components of OSA treatment that psychiatrists are positioned to facilitate with their patients.

Calati R, Pedrini L, Alighieri S, Alvarez MI, Desideri L, Durante D, Favero F, Iero L, Magnani G, Pericoli V, Polmonari A, Raggini R, Raimondi E, Riboni V, Scaduto MC, Serretti A, De Girolamo G. Is cognitive behavioural therapy an effective complement to antidepressants in adolescents? A meta-analysis.

Objective: Evidence on effectiveness of combined treatments versus antidepressants alone in adolescents consists on a few studies in both major depressive and anxiety disorders. A meta-analysis of randomised 12-week follow-up studies in which antidepressant treatment was compared to combined treatment consisting of the same antidepressant with cognitive behavioural therapy has been performed.

Methods: Data were entered into the Cochrane Collaboration Review Manager software and were analysed within a random effect framework. A quality assessment has been performed through Jadad Scale.

Results: Higher global functioning at the Children's Global Assessment Scale was found in the combined treatment group (p < 0.0001) as well as higher improvement at the Clinical Global Impressions Improvement Scale (p = 0.04). No benefit of combined treatment was found on depressive symptomatology at the Children's Depression Rating Scale – Revised.

Conclusion: Combined treatment seems to be more effective than antidepressant alone on global functioning and general improvement in adolescents with major depressive and anxiety disorders.

Neuroendocrine system plays an important role in modulating our body functions and emotions. At the same time, emotions implicate a pivotal role in the regulation of brain function and neuroendocrine system. Negative affective states such as depression and stress are associated with premature mortality and increase the risk of various fatal diseases. It has been suggested that positive affective states are protective and improve our health and productiveness. Several potential mechanisms have been posited to account for these associations including improved health behaviour, direct physiological benefits, enhanced resistance and recovery from stress among individuals with high versus low positive emotional resources. This review summarises information concerning the neuronal and hormonal systems in mood, impact of negative and positive affective states on the level of cortisol, epinephrine, serotonin, dopamine and endorphins. The functional correlation of neuronal and hormonal systems in the development of diseases and their ability to enhance health-relevant biological processes are also evaluated.

Piatkov I, Jones T, Van Vuuren RJ. Suicide cases and venlafaxine.

Objective: Our aim was to establish whether the presence or absence of fully functioning cytochrome P450 2D6, 2C19 and 2C9 genetic alleles was associated with suicide in patients receiving venlafaxine treatment.

Method: Authorisation from the NSW State Coroner to perform post-mortem genetic testing was obtained for 11 samples from deceased persons who committed suicide during treatment with venlafaxine (VENADR study).

Results: All patients, but one, have at least one copy of the loss-of-function, altered or decreased cytochrome P450 enzyme activity allele. Four patients' results reveal loss-of-function genotypes, while all others were found to have diminished enzyme activity polymorphisms. Seven patients had multiple altered function polymorphisms, which included CYP2D6, CYP2C19 or CYP2C9.

Conclusion: Our preliminary limited data show that neurotoxicity development, which manifests as suicide while on venlafaxine treatment, probably correlates with a higher prevalence of gene copies of altered functioning cytochrome P450 genetic polymorphisms.

Isık Taner Y, Erdogan Bakar E, Oner O. Impaired executive functions in paediatric obsessive-compulsive disorder patients.

Objective: There are only few studies which investigated the neuropsychological performances of paediatric patients with obsessive-compulsive disorder (OCD). Previous studies show that most of adult OCD patients had an onset of their first symptoms before the age of 15. Our objective was to evaluate the neuropsychological functions in paediatric patients with OCD.

Methods: We compared the executive functions and general intelligence of child and adolescent OCD patients (n = 20) with age- and gender-matched healthy controls (n = 20). To compare mentioned skills, a neuropsychological test battery including Wechsler Intelligence Scale for Children-Revised (WISC-R), Wisconsin Card Sorting Test (WCST), Stroop Test and Verbal Fluency Test was performed.

Result: Performances of the OCD and control subjects on neuropsychological tests were statistically analysed by using multivariate analysis of covariance (MANCOVA), in which Full Scale Intelligence Quotient (FSIQ) results were taken into consideration as a covariate to observe FSIQ's effect on test scores. Our results showed that the differences in WISC-R Picture Arrangement and Coding scores remained significant when co-analysed with FSIQ scores. In a similar manner, the OCD group exhibited worse performances on STR1-duration, STR3-duration, STR3-error, STR4-duration, STR4-error, STR5-correct response, and STR5-error as compared with the control group when FSIQ scores were taken into calculation. Some variables of the WCST (perseverative responses, percent errors, abstraction-flexibility and categories completed) also yield lower test scores in the OCD group. There was no significant difference between the groups regarding Verbal Fluency Test scores.

Conclusion: Our results suggested that paediatric OCD patients had worse abstraction-flexibility, mental set-shifting, verbal comprehension and visuospatial/construction abilities.

Nielsen RE. Treatment of psychosis during pregnancy – a case report and a mini-review.

Objective: Describe clinical problems in treating a patient with psychotic symptoms during pregnancy by presenting a case report, and review the current evidence on antipsychotic drugs during pregnancy.

Methods: The review consists of a non-systematic clinical review of current data on treatment with antipsychotics during pregnancy. The case, a 27 year old female initially diagnosed with posttraumatic stress disorder (PTSD) after a rape and emotionally unstable personality disorder, illustrates some of the common challenges a clinician meets. The patient initially discontinues all treatment as she is unsure if the drugs could have a teratogenic effect and is changed to a treatment that is regarded as safe during pregnancy.

Results: The current data supports treatment with chlorpromazine although there is a risk of side effects, e.g. extrapyramidal symptoms and hypotension, but also treatment with olanzapine and risperidone. If the patient is currently treated with clozapine, this treatment should be continued, due to clozapines unique efficacy profile. Blood monitoring for six months after birth is recommended when the newborn has been exposed to clozapine treatment.

Conclusion: Current evidence on treatment with antipsychotics during pregnancy is sparse, but not treating is associated with increased risks compared to treatment.