Current Psychiatry Reviews

ISSN: 1573-4 005

Current Psychiatry Reviews
Volume 2, Number 2, May 2006

Contents


Changing the Course of Alzheimer’s Disease: Emerging Disease Modifying Therapies Pp. 179-188
Daniel D. Christensen
[Abstract]


Closing the Gap Between Cognitive Performance and Real-World Functional Outcome in Schizophrenia: The Importance of Metacognition Pp. 189-198
Danny Koren and Philip D. Harvey
[Abstract]


A Review of Developments in Brain Stimulation and the Treatment of Psychiatric Disorders Pp. 199-205
Paul B. Fitzgerald
[Abstract]


Motivational Interviewing in Psychotic Disorders Pp. 207-213
Emile Barkhof, Lieuwe de Haan, Carin J. Meijer, Annemarie J. Fouwels, Ireneus P.M. Keet, Kai P. Hulstijn, Gerard M. Schippers and Don H. Linszen
[Abstract]


Omega-3 Fatty Acids: Role in the Prevention and Treatment of Psychiatric Disorders Pp. 215-234
Emmanuel Tsalamanios, Amalia E. Yanni and Christina Koutsari
[Abstract]


Psychotic (Delusional) Major Depression in the Elderly: A Review Pp. 235-244
Rossetos Gournellis and Lefteris Lykouras
[Abstract]


Depression in Coronary Heart Disease Patients: Etiological and Screening Issues Pp. 245-254
Colin R. Martin and David R. Thompson
[Abstract]


Understanding Gender Differences in Schizophrenia: A Review of the Literature Pp. 255-265
Rachel Taylor and Robyn Langdon
[Abstract]


Nucleus Accumbens Dopamine and the Forebrain Circuitry Involved in Behavioral Activation and Effort-Related Decision Making: Implications for Understanding Anergia and Psychomotor Slowing in Depression Pp. 267-280
John D. Salamone, Mercè Correa, Susana M. Mingote, Suzanne M. Weber and Andrew M. Farrar
[Abstract]


Kleptomania: Differential Diagnosis and Treatment Modalities Pp. 281-283
Pinhas N. Dannon, Anat Aizer and
Katherine Lowengrub
[Abstract]




Abstracts

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Changing the Course of Alzheimer’s Disease: Emerging Disease Modifying Therapies
Daniel D. Christensen

Drugs that prevent the onset, delay the progression, or eliminate the symptoms of Alzheimer’s disease are urgently needed. Current neurotransmitter-based treatments are widely used and provide modest symptom relief. The amyloid hypothesis in which the pathological processing of amyloid precursor protein (APP) produces the toxic 42-amino acid peptide (i.e., Aβ42) and initiates a cascade of amyloid accumulation, neurodegeneration, plaque formation, and dementia, is the predominant mechanistic theory of Alzheimer’s disease. Drug development programs focus on Aβ42, the enzymes involved in its generation (i.e., γ-secretase, β-secretase), APP, Aβ aggregation, and plaque formation as targets for therapeutic intervention. Disease modifying drugs being studied include anti-amyloid immunotherapy (active and passive immunization), γ-secretase inhibitors (LY450139), β-secretase inhibitors, selective Aβσ42 lowering agents (Flurizan™), inhibitors of amyloid aggregation (Alzhemed™), and others. Preclinical studies and clinical trials suggest that drugs with anti-amyloid properties produce cognitive benefit. However, tolerability and adverse events are important factors to consider when developing treatments for the elderly. Disease modifying drugs that specifically target the amyloid cascade and do not interact with other biological pathways are expected to possess a lower rate of unintended adverse events. Discovery of safe and effective disease modifying therapies will usher in a new age of Alzheimer’s disease treatment.


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Closing the Gap Between Cognitive Performance and Real-World Functional Outcome in Schizophrenia: The Importance of Metacognition
Danny Koren and Philip D. Harvey

Functional outcome in schizophrenia has received increased attention in recent years, as the knowledge that cognitive functioning is a major determinant of outcome has become widely accepted. While impaired cognitive functioning is the most consistent predictor of functional deficits in schizophrenia, the overlap is far from complete and cognition accounts for at most 50% of the variance in functional outcome. In this paper, we review the research on factors other than cognition that relate to functional skills deficits in schizophrenia and focus on several potential moderators between cognition and functional outcome. These factors include various affective and societal variables, as well as metacognition. Metacognitive processes include the ability to appraise the accuracy of one’s knowledge and competence and to use these appraisals to adjust real-world behaviors accordingly. Metacognition is related to, but separate from social cognition as well as from formal, base-level cognitive test performance. An example of metacognitive process is the ability to monitor the limits of personal knowledge base, and seek assistance in situations where requisite information or skills are lacking. Being able to perform these monitoring and control operations can allow for suitable functional performance despite cognitive limitations. Conversely, failing to perform these operations can account for poor functional outcome despite intact cognitive abilities. We argue that metacognition is an important moderator between cognition and real-world function and that this factor, in contrast to societal variables, may be modifiable in individual patients with schizophrenia.


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A Review of Developments in Brain Stimulation and the Treatment of Psychiatric Disorders
Paul B. Fitzgerald

Objective: To examine developments in the application and use of a number of developing brain stimulation techniques for psychiatric disorders including treatment resistant major depression.

Method: A review of studies outlining the development of the research base pertaining to the use of Transcranial Magnetic Stimulation (TMS), Magnetic Seizure Therapy (MST), Vagal Nerve Stimulation (VNS) and Deep Brain Stimulation (DBS).

Results: A substantial but somewhat patchy research base is supporting a gradual shift of TMS from primarily a research tool to a technique available in clinical practice. MST has the potential to provide marked benefits over other forms of seizure induction, but requires rigorous efficacy evaluation. VNS and DBS are new and more invasive potential treatment methods in psychiatry. They both require rigorous evaluation of efficacy, and the safety of DBS remains uncertain.

Conclusion: There is considerable potential for recent developments in non-pharmacological biological treatments in psychiatry to substantially enhance our options, especially for patients with treatment resistant disorders.


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Motivational Interviewing in Psychotic Disorders
Emile Barkhof, Lieuwe de Haan, Carin J. Meijer, Annemarie J. Fouwels, Ireneus P.M. Keet, Kai P. Hulstijn, Gerard M. Schippers and Don H. Linszen

Patients with schizophrenia and related disorders often present problematic behaviour, such as non-adherence to medication or substance abuse, which have a negative influence on the course of the disease. Changes in such maladaptive behaviour are often difficult to accomplish in this group of patients because of specific disease related symptoms such as active psychotic symptoms, negative symptoms and cognitive disturbances. Over the last ten years, treatment strategies incorporating forms of Motivational Interviewing have been tried to influence these problems in a positive direction.

Motivational Interviewing is an intervention which has proved to be successful in altering behaviour in the field of substance abuse disorders and also shows promising results in other health care areas.

With the emphasis on a non-judgemental and empathetic attitude, patients are engaged in strategically directed conversations about their problems in which ambivalences on behaviour change are explored and patients are helped to move through different stages of change.

This article provides a narrative review of the research data on the application of Motivational Interviewing in patients with schizophrenia and related disorders.


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Omega-3 Fatty Acids: Role in the Prevention and Treatment of Psychiatric Disorders
Emmanuel Tsalamanios, Amalia E. Yanni and Christina Koutsari

The purpose of this article is to review the current literature regarding the role of omega-3 (ω-3) fatty acids (mainly eicosapentaenoic acid and docosahexaenoic acid) in the etiology and treatment of psychiatric disorders. Omega-3 fatty acids are essential for normal structure and function of neuronal membranes. They also influence cell signaling and are precursors to the eicosanoids, which play important regulatory roles in a wide range of physiological functions. There has been considerable interest in the potential use of ω-3 fatty acids for the treatment of psychiatric disorders including depression, bipolar disorder, schizophrenia, borderline disorder, obsessive compulsive disorder and childhood developmental and psychiatric disorders. This article provides a critical review of the recent findings and discusses future directions and questions that remain unanswered.


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Psychotic (Delusional) Major Depression in the Elderly: A Review
Rossetos Gournellis and Lefteris Lykouras

The prevalence in the community of psychotic (delusional) major depression (PMD) in the elderly was found to be 1%. In inpatient settings the frequency of the disorder varies between 24% and 53%. There is also evidence that its frequency increases in old age. In the elderly, PMD compared to non-PMD was found to be a more severe and melancholic form of depression with more psychomotor disturbances (agitation or retardation) and feelings of guilt, more anxiety and hypochondriacal complains and less insight. Delusional beliefs of paranoid and hypochondriacal content have been found to be prominent. Additionally, elderly psychotic depressives (PDs) are possibly at greater risk of suicide attempt. Also, elderly PDs have been observed to have more cognitive processing difficulties. As regards neurobiological findings, they have been found to have lower dopamine-beta-hydroxylase activity, smaller volume of prefrontal cortex, more brain stem and left-side frontotemporal atrophy, enlargement of the third ventricle and pontine reticular formation hypertensities. The prognosis for the disorder seems worse, with higher relapse rates and mortality although not all studies are in agreement. In the acute phase, the response to ECT is favourable (88%), however the response rates to combination of an antipsychotic and an antidepressant (25-50%) seem to be inferior to those observed in younger adults (70-80%). Close follow-up and continuation therapy with an antidepressant is needed to avoid relapses.


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Depression in Coronary Heart Disease Patients: Etiological and Screening Issues
Colin R. Martin and David R. Thompson

Coronary heart disease (CHD) is associated with significant psychiatric comorbidity, in particular, depression. Recent evidence suggests that depression following a coronary event or diagnosis is a significant risk factor for both mortality and morbidity. Further, there is compelling evidence that depression is a significant predictor in the development of CHD. Surprisingly, given the relationship of depression to patient outcome, screening for depressive disorder in this patient group is generally not routine and clinically significant psychiatric disorder often remains undetected. This mini review summarises the contemporary evidence of the mechanisms underpinning the CHD-depression relationship and explores the main issues that need to be considered by clinicians in providing effective screening for this clinical group. Examples of best screening practice will be highlighted and the efficacy of interventions targeting depression in this group discussed.


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Understanding Gender Differences in Schizophrenia: A Review of the Literature
Rachel Taylor and Robyn Langdon

Schizophrenia is the most severe of the psychotic disorders and has a neurobiological and genetic basis, with environment being a moderating factor but not the primary cause. Numerous studies have demonstrated gender differences in the phenomenology of schizophrenia. This review evaluates three theoretical frameworks that have been developed to explain how gender differences develop in schizophrenia: (1) the neurodevelopmental approach; (2) the structural, neuropathological approach; and (3) the estrogen protection hypothesis. It is concluded that findings are most coherently accounted for by the estrogen protection hypothesis; gender differences in schizophrenia most likely emerge due to the multiple effects of estrogens and their complex interactions with neurotransmitter receptors and in-utero brain development. Women predisposed to schizophrenia appear to be particularly protected from the early-onset form of the illness due to high levels of circulating estrogen, and consequent dopamine suppression. Nonetheless, taken together, the three theoretical frameworks can integrate a wide variety of findings of gender differences in schizophrenia, with compelling evidence existing for all approaches.


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Nucleus Accumbens Dopamine and the Forebrain Circuitry Involved in Behavioral Activation and Effort-Related Decision Making: Implications for Understanding Anergia and Psychomotor Slowing in Depression
John D. Salamone, Mercè Correa, Susana M. Mingote, Suzanne M. Weber and Andrew M. Farrar

The notion that motivated behaviors having an energetic or activational component is an old one, and there are numerous examples of this idea from the literatures of psychology and ethology. Behavioral researchers have demonstrated that vigor or persistence of work output in stimulus-seeking behavior is a fundamental aspect of motivation. In addition, psychiatrists and clinical psychologists have come to emphasize the importance of energy-related dysfunctions, such as psychomotor slowing and apathy, in various clinical syndromes. Because of the potential scientific importance and clinical relevance of behavioral activation processes, it is critical to determine the brain mechanisms that are involved. Considerable evidence indicates that DA in nucleus accumbens is involved in activational aspects of motivation. Accumbens DA depletions decrease spontaneous, stimulant-induced, and food-induced motor activity. In addition, the effects of accumbens DA depletions on food-seeking behavior depend greatly upon the response requirements of the task. Research involving concurrent choice tasks has shown that rats with accumbens DA depletions reallocate their instrumental behavior away from food-reinforced tasks that have high response requirements, and instead select a less-effortful type of food-seeking behavior. Rats with accumbens DA depletions are particularly sensitive to lever pressing schedules with high ratio requirements (i.e., a large number of lever presses must be emitted for reinforcement to occur). Together with studies of frontal cortex function in animals, and clinical studies on neurochemical and other functional changes in the human brain, this line of research could have implications for understanding the brain circuitry involved in energy-related psychiatric disorders such as psychomotor slowing in depression, anergia, fatigue and apathy.


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Kleptomania: Differential Diagnosis and Treatment Modalities
Pinhas N. Dannon, Anat Aizer and
Katherine Lowengrub

Kleptomania is classified in the psychiatric nomenclature as an impulse control disorder. Patients with kleptomania, however, often suffer from repetitive intrusive thoughts about stealing, an inability to avoid the compulsion to steal as well as a relief of tension following the theft. These associated symptoms suggest that kleptomania may be a form of obsessive compulsive spectrum disorder. On the other hand, some authors describe kleptomania as a non-pharmacological addiction because of the inability to control maladaptive behavior. A broad range of pharmacotherapeutic agents has been found to be beneficial in the treatment of kleptomania including serotonin reuptake inhibitors (SSRIs), mood stabilizers, and opioid receptor antagonist medications. Adjuvant cognitive behavioral therapy (CBT) is recommended.