Current Psychiatry Reviews - Volume 3, Issue 4, 2007

The aim of this systematic review is to report the pre- and postmorbid trajectories leading to suicide in schizophrenia, with special focus on novel research published in 2003-2006. Individuals with schizophrenia who commit suicide seem to follow a developmental trajectory that differs partly from that of other schizophrenia patients. According to the studies analysed, there seem to be five main pathways for schizophrenia patients leading to suicide. One obvious pathway is comorbid depression that leads to suicide. Second, there is a group of patients with a difficult, chronic course of illness and many relapses and exacerbations. They lose their hope progressively over time. The third group comprises patients (mostly young males) with impulsiveness, dysphoric affect and substance abuse. Fourth, there is a relatively small but theoretically interesting and clinically important group of mainly young patients with high premorbid functioning and above average intellectual capacity. The high suicide rate among this group may be a consequence of their own and their relatives' high expectations that are in line with their good premorbid functioning. The fifth group, failure in treatment, comprises patients lacking social support whose treatment has failed. We also propose a life span model showing these five different pathways to suicide in schizophrenia. These suicidal trajectories could be useful in clinical work when evaluating patients' possible suicide risk and treating them. They might also provoke some further research ideas and hypotheses.

Many patients suffering from schizophrenia feel dispossessed from some of their actions or thoughts. This dispossession could result from impaired self-monitoring (SM), defined as the ability to monitor self-willed intentions and actions. SM has been widely studied during the past decades with very different paradigms; central error correction, feedback distortion, sense of effort, and motor imagery. The present article first reviews the methods used and results obtained in investigation of SM. Second, we address what we consider to be the critical questions that must be answered in order to fully understand the role of SM deficit in schizophrenia: 1) Is SM deficit only impaired in patients with specific symptoms? 2) Is SM deficit associated with other cognitive processes that are also impaired in patients with schizophrenia? 3) Can SM impairment be characterized as a trait or a state marker? Finally, we discuss the consequences of SM investigation on diagnostic evaluation and therapeutic orientations and we propose future research that we think is essential in order to clarify the role of SM in schizophrenia.

Until recently it was thought that no more than 50% of clinical coronary heart disease was explicable in terms of classical cardiac risk factors such as dyslipidemia, cigarette smoking, high blood pressure and diabetes. Recent large scale epidemiological studies have increased our understanding of the mechanisms generating cardiac risk and have provided evidence indicating that psychosocial factors, including stress at work and at home, financial stress, recent major life events and the presence of depressive illness are involved here, “triggering” clinical cardiovascular events, and possibly also contributing to hypertension and atherosclerosis development. The underlying mechanisms in play are most likely multi factorial in origin, involving the autonomic nervous system, platelet activation, thrombogenesis and endothelial dysfunction. Given that strategies for preventive therapy remain largely unformulated, future research should focus on generating a better understanding of the neurobiology of psychogenic heart disease as a basis for rational and effective therapy.

The term “Atypical Depression” refers to a subtype of mood disorder that has been most clearly associated with reversed neurovegetative features and interpersonal deficits such as rejection sensitivity and social avoidance. The most robust clinical correlates of atypical depression include a high preponderance of female cases, an early age of onset, and high rates of chronicity and co-morbidity. Particularly strong links to early adversity and chronic stress have also been described. Regarding treatment outcomes, atypical depression has historically been associated with both MAOI responsiveness and tricyclic resistance, with recent data further suggesting that it is the early onset atypical subgroup that accounts for these findings. There have been few large scale studies of newer anti-depressants such as SSRIs and buproprion in atypical depression, although practical issues have encouraged the use of these agents as first-line treatments. Going forward, high priorities for research include optimizing the definition of atypical depression for DSM-V, more clinical studies with newer anti-depressant classes, and a greater focus on developmentally-based research that considers intergenerational transmission of risk, gene-environment interaction and adverse early environments.

Few studies have examined Obsessive-Compulsive Disorder (OCD) during the perinatal period. Existing data suggest there to be increased rates of OCD during this vulnerable period, with both new onsets and exacerbation of preexisting symptoms. The course of perinatal OCD appears to be varied, although trends suggest that symptoms in women with pre-existing OCD are likely to remain consistent throughout pregnancy and become exacerbated after delivery. Symptoms of OCD specifically associated with the perinatal period consist of: fears of contamination or germs regarding the fetus or infant, fears of intentional or accidental harm to the fetus or neonate, and fear of losing the baby. Associated compulsions are excessive washing and cleaning, avoidant behavior, and checking behaviors. Although many theories exist attempting to account for the etiology of OCD to this point it remains unclear. Both pharmacological treatments and psychological treatments have shown promise for treating perinatal OCD. Further research in this area is necessary for clinicians to better understand how to diagnose and treat OCD in pregnancy and the postpartum period.

Tourette syndrome (TS) is defined as a chronic motor and vocal tic disorder. Because dopamine blocking drugs reduce tics it has been suggested that the dopaminergic system is pathophysiologically involved. However, comorbidities such as obsessive-compulsive behavior (OCB), depression, and anxiety are often associated suggesting that imbalances among other neurotransmitter systems may also exist. An increasing body of evidence points to an involvement of the serotonergic system. Serotonin reuptake inhibitors are effective in the treatment of comorbid OCB, depression, and anxiety. Levels of serotonin (5-hydroxytryptamine; 5-HT), the primary metabolite 5-hydroxyindoleacetic acid (5-HIAA), and tryptophan, respectively, have been found to be reduced not only in blood and CSF but also in different brain regions. In addition, neuroimaging studies demonstrated a significant reduction in serotonin transporter binding ratios in TS compared to controls. In addition, alterations in 5-HT2A receptor binding and tryptophan metabolism have been demonstrated. Recent genetic studies suggested a pathogenetic role of polymorphic variation(s) of the novel 5-HT synthesizing enzyme tryptophan hydroxylase 2 (TPH2) in TS. In summary, several findings from clinical, laboratory, neuroimaging and genetic studies strongly support the etiological relevance of the serotonergic system in TS.

Inhalant abuse of toluene is frequently accompanied by visual and auditory hallucinations that cease at varying intervals following withdrawal. One study of institutionalized abusers describes persistent hallucinations despite abstinence, with evolution into a “schizophreniform” psychosis. It is suggested that occupational exposure to toluene can have a similar outcome. Taken in concert with the credible neurological literature, our considerable experience with more than 30 cases of toluene abuse, 15 of toluene solvent mixture neurotoxicity, and of many with considerable workplace exposure indicates the combination of persistent psychosis and toluene inhalation does rarely occur. However, it is the chance coincidence of two relatively common conditions, toluene encephalopathy and underlying schizophrenia.

Sleep disturbances occur more often in the elderly than in patients in any other age category. Traditional treatment regimens for insomnia in older patients have emphasized benzodiazepines. The useful anxiolytic and hypnotic properties of these agents have made them the most widely prescribed class of drugs in the world. Concern has been expressed however about the significant side effect profile associated with these agents. There is now considerable evidence that all benzodiazepines show significant dose-dependent impaired daytime performance on a variety of memory, cognitive and psychomotor tests. In addition, the risk of falls, hip fractures, and traffic accidents is significantly increased in patients who are treated with benzodiazepines. There is little evidence that benzodiazepine hypnotics are still effective after chronic use. On the other hand, several impairments persist when using these hypnotics over long time. Recently, the nonbenzodiazepine drugs zolpidem and zaleplon have been introduced and are claimed to be relatively safe (i.e. less daytime sedation) when compared to benzodiazepines. Zopiclone, a non-benzodiazepine hypnotic, shows no advantages over benzodiazepines with respect to daytime performance. Several factors may interact with the effects of hypnotics on daytime functioning, including normal cognitive decline during aging, the effects of insomnia itself on daytime functioning, the presence or absence of co-morbid disorders, and pharmacokinetic changes accompanying aging. The impact of hypnotics on daytime performance further depends on various drug-related factors including the administered dose, half-life, time between intake and performance, duration of treatment, gender, and individual differences. In contrast, zolpidem and zaleplon do not significantly impair daytime performance when administered at bedtime at the recommended dose. Although further studies of drug effects in elderly insomniacs are necessary, the available evidence suggests that these short acting and relatively safer non-benzodiazepine hypnotics are a preferred alternative therapy for treating insomnia in the elderly.