Search

Introduction: Anxiety disorders are one of the most common mental illnesses, and a consistent increase was observed after the COVID-19 pandemic. Mindfulness refers to a process that leads to a mental state characterized by nonjudgmental awareness of the present experience. Mindfulness can be considered both a skill and a practice. The stronger is the ability to adopt a mindful state, the less suffering one will experience. While Mindfulness-based Psychotherapies have shown efficacy in their treatment, they have not yet been thoroughly studied in Italian public mental health services. In Detached Mindfulness, negative thoughts are acknowledged and avoided by turning them into actions using a standardized, time-limited, metacognitive intervention. Objectives: The purpose of this study is to examine the efficacy and cost-effectiveness of Detachment Mindfulness for twelve patients with Generalized Anxiety Disorder (GAD) not being treated pharmacologically. Methods: We enrolled 12 patients diagnosed with GAD according to DSM-V in an 8-session program of Detached Mindfulness Psychotherapy (once a week). The Generalized Anxiety Disorder - 7 Scale (GAD-7) and the Kellner Symptom Questionnaire (SQ) were used to assess anxiety symptoms at baseline (T0), after 4 sessions (T1), and at the end of treatment (T2). The Client Satisfaction Questionnaire (CSQ-8) was used to assess treatment satisfaction. Results: The GAD-7 score showed consistent reductions in generalized anxiety symptoms after Detached Mindfulness treatment (mean decrease of -42% at the end of the program). As measured by SQ, patients also reported improvement in physical well-being, relaxation, and somatic symptoms significantly respect to baseline. As for treatment satisfaction, ten out of twelve patients rated their treatment as satisfactory. As reported by patients, mindfulness can become a powerful and effective means to relate to one's own internal experiences such as anxiety or fear, learning to recognize them, staying with them and avoiding their consequences. Conclusions: These results showed that detached mindfulness was an effective and cost-effective intervention for GAD, given the short amount of time it requires and the ease with which it can be implemented. For its extensive use in the public mental health system to be further supported, studies on larger populations are needed. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Persistent depressive episodes and subsyndromic depressive symptoms frequently characterize mood alterations in bipolar disorder (BD) and negatively influence quality of life and suicide risk. BD patients with predominant depressive episodes generally show significantly higher treatment resistance rates. Although not specifically approved in Italy for bipolar depression, recently published observational data suggest that the cariprazine add-on may be a potential effective short-term treatment for resistant bipolar depression. Nevertheless data on long-term cariprazine treatment are lacking. Objectives: This study evaluated the efficacy and safety of long-term cariprazine augmentation in patients suffering from treatment-resistant bipolar depression. Methods: 30 resistant bipolar depressed patients, whose resistance was defined according to The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder, were treated with cariprazine 1,5 -3 mg flexible dose for 4 weeks, added to previous mood stabilizing and/or antidepressant treatment. Psychopathology at time 0 and at 4, 8, 12, 16, 20, 24 weeks of treatment was evaluated using the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS) and the Bipolar Depression Rating Scale (BDRS); safety and tolerability was measured by the UKU Side Effect Rating Scale. The drop-out rate was assessed throughout the study duration. Results: Cariprazine add-on was effective in the study sample but only during the first 4 weeks of treatment. Improvement in depression scores started from the first week, reaching about 40% mean HDRS score reduction at T4; a moderate ulterior decrease (-15%) was reached at T24 but was accompanied by a significant drop-out rate; anxiety symptoms improved (mean HARS score reduction 37% at T4) mainly during the first 4 weeks. The treatment was generally well tolerated. From week 4 to 24 we observed a near 70% drop-out rate (18 total drop-outs) with maximum drop-outs between weeks 4-8 (n=7) and 18-24 (n=7). Discontinuation causes were inefficacy (5/18); clinical worsening (10/18); side effects (3/18); hypomanic shift (2/18). Conclusions: Despite the relatively small population examined and the observational design, our results suggest that cariprazine may represent an effective and safe short-term enhancement strategy in resistant bipolar depression. Long-term treatment, in this sample, did not lead to significant improvements and was burdened by a high drop-out rate, mainly due to inefficacy/clinical worsening. Further studies on larger samples are needed to confirm these preliminary findings, both in short-term and in longer observations. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

This response to a reader's comment on our paper "The Global Assessment of OCD" addresses the critique regarding the stated prevalence of OCD as the fourth most common mental disorder. We acknowledge an oversight in our initial reference, discuss the variable prevalence rates from various studies, and highlight the significant disability caused by OCD. We have requested a correction to the original citation to reflect more recent findings, aiming to ensure accuracy in the discourse on OCD's public health impact., (Copyright © 2024. Published by Elsevier Inc.)

Obsessive-compulsive disorder (OCD) is a common and debilitating psychiatric disorder with an approximate incidence of 2.5% in the general population. Serotonin reuptake inhibitors (SRIs) are considered the first line of pharmacological treatment but up to 50% of patients fail to achieve clinical remission or response. Atypical antipsychotics are one of the most common augmentation strategies in OCD treatment resistant patients. Brexpiprazole, a novel atypical antipsychotic with dopamine partial agonism action, has never been studied in addition to SRIs treatment in OCD resistant patients. This study retrospectively investigated the safety and efficacy of a 12 week brexpiprazole augmentation trial in 34 OCD resistant patients. SRI treatment resistance was defined as failing to improve the YBOCS total score by more than 25% from the beginning of the SRI trial. Brexpiprazole augmentation response was defined as at least a 25% improvement in the YBOCS total score. At the end of the study, 17 patients (50.0%) met the response criteria of ≥25% improvement in YBOCS total score vs. baseline. No safety issues were raised throughout the observation period. A total of 19 patients (55.9%) reported adverse experiences, generally mild and not requiring medical intervention. This is the first study to examine the safety and efficacy of brexpiprazole augmentation in resistant OCD patients. Our findings show that brexpiprazole may be a promising and well-tolerated augmentation strategy for SRI-resistant OCD patients. However, further research in larger populations is needed to confirm these results and investigate the long-term safety and tolerability of brexpiprazole in OCD patients.

Obesity and weight gain represent a challenging issue in people suffering from schizophrenia and other severe mental illnesses (SMI). Most of clinical guidelines for the management of overweight and obesity in people with SMI share a stepwise approach starting with more conservative interventions, with diet, physical activity, lifestyle coaching and behavioral modifications. The aim of this study was to evaluate the effectiveness of a group weight management program in a real-world outpatient Italian setting. Data from 100 patients diagnosed with schizophrenia or bipolar disorder, undergone to a group metabolic management program, were analyzed through a 12 months follow-up. The main body weight (kgs) decreased from 98.01±18.30 at baseline to 93.29±17.36 (p>0.001) at 6 months to 90.35±17.90 at 12 months. Parallel statistically significant decreases were found for BMI, waist circumference, glycaemia and systolic blood pressure. After patients' segmentation into normal-weight, overweight and obese at baseline, the significant of the decrease emerged only between baseline and the 6-month endpoint, thus suggesting that the program was successful in the short-term. Notwithstanding the limitations of the study, the 12-month intervention evaluated demonstrated feasibility and a high retention rate. This allowed a relevant weight reduction during the first six months, followed by durable maintenance until the end of the study. Current NICE recommendation guidance indicates that people with SMI, particularly those on antipsychotic treatment, should be provided with integrated nutrition and exercise programmes by their healthcare professional. Future research should focus on the effectiveness and cost-effectiveness of this kind of interventions and their reliability in the different real-world healthcare settings.

Rationale & Objective: Estimates of the incidence of hyperkalemia in patients with chronic kidney disease (CKD) vary widely. Our objective was to estimate hyperkalemia incidence in patients with CKD from routine clinical care, including by level of kidney damage or function and among important patient subgroups., Study Design: Retrospective cohort study., Setting & Participants: 1,771,900 patients with stage 1-4 CKD identified from the US Optum De-Identified electronic health records database., Exposures or Predictors: Impaired kidney damage or function level at baseline based on urinary albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR), respectively, and selected patient subgroups., Outcomes: Hyperkalemia: 2 elevated serum potassium values (≥5.5 mmol/L) from the inpatient setting (2-24 hours apart) or outpatient setting (maximum 7 days apart), or 1 elevated serum potassium value plus pharmacotherapy initiation or hyperkalemia diagnosis (maximum 3 days apart)., Analytical Approach: Incidence rates of hyperkalemia were calculated. Estimates were stratified by UACR and eGFR level at baseline and patient subgroups., Results: Over a mean follow-up of 3.9 years, the incidence of hyperkalemia was 3.37 events/100 person-years (95% confidence intervals, 3.36-3.38). Higher incidence rates were observed with increased UACR and lower eGFR. Highest rates were observed with UACR ≥3,500 (up to 19.1/100 person-years) irrespective of decreased eGFR level. High rates also occurred in patients with type 2 diabetes mellitus (T2DM, 5.43/100 person-years), heart failure (8.7/100 person-years), and those prescribed steroidal mineralocorticoid receptor antagonists (sMRAs, 7.7/100 person-years)., Limitations: Potential misclassification of variables from possible medical coding errors; potential data incompleteness issues if patients received care at institutions not included in Optum., Conclusions: Hyperkalemia is a frequent occurrence in CKD, particularly in patients with T2DM, heart failure, or prescribed sMRAs, indicating the need for regular serum potassium and UACR monitoring in this patient population to help mitigate risk., (© 2024 The Authors.)

Background: Treatment-resistant bipolar depression is one of the leading problems in psychiatry with serious consequences on patients functioning, quality of life and resource utilization. Despite this, there is a lack of consensus on diagnostic criteria and treatment algorithms., Objective: The objective of the present study is to assess the acute effectiveness and tolerability of cariprazine in the management of treatment resistant bipolar depression., Methods: This is a four weeks retrospective multicentric observational study on patients with treatment resistant bipolar depression receiving cariprazine in augmentation to the current treatment. Cariprazine dosage changed during the follow-up period according to clinical judgment. Since data followed a non-normal distribution, non-parametric tests were used to pursue the analysis. The effectiveness of cariprazine was assessed through the mean change in Hamilton Depression rating scale (HAM-D) scores from baseline to endpoint. For missing values, a "Last Observation Carried Forward" approach was applied., Results: Fifty-one patients were enrolled. Four patients (7.8%) discontinued cariprazine mainly due to adverse events. Mean cariprazine dose was 1.7 mg/day. The mean HAM-D score decreased significantly from baseline (T0) to week 4 (T4) at each evaluation point. Fourty-five one percent of the patients benefited of cariprazine add-on strategy: 23.5% achieved a clinical response and 21.6% were remitters. Among the completers, 70.6% experienced at least one adverse event. All side effects were mild to moderate., Conclusion: Cariprazine seems to be an effective and well tolerated option in the management of patients with treatment resistant bipolar depression., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Among individuals receiving an adequate pharmacological treatment for Major Depressive Disorder (MDD), only 30% reach a full symptom recovery; the remaining 70% will experience either a pharmacological response without remission or no response at all thus configuring treatment resistant depression (TRD). After an inadequate response to an antidepressant, possible next step options include optimizing the dose of the current antidepressant, switching to a different antidepressant, combining antidepressants, or augmenting with a non-antidepressant medication. Augmentation strategies with the most evidence-based support include atypical antipsychotics (AAs). Few data are available in literature about switching to another antipsychotic when a first augmentation trial has failed. We present a case-series of patients with unipolar treatment resistant depression who were treated with a combination of antidepressant and low dose of cariprazine after failing to respond to a first augmentation with another AA. We report data about ten patients affected by unipolar depression, visited at the outpatients unit of Mental Health Department of ASL CN2 of Bra and NA1 of Napoli (Italy). All patients failed to respond to conventional antidepressant therapy. A low dose of AA (aripiprazole, risperidone or brexpiprazole) was added for one month to the ongoing antidepressant treatment without clinical improvement. A second augmentation trial was then made with cariprazine. Seven out of ten patients were responders at the end of period, of them 1 patient reached responder status by week 2. HAM-D mean scores decreased from 23.9 ± 3.9 (baseline) to 14.8 ± 5.3 (4 weeks). Cariprazine was well tolerated, no severe side effect was observed during the trial. Our sample of treatment resistant unipolar patients showed good response to augmentation with cariprazine. Failure to a first AA-augmentation trial does not preclude response to a second one. This preliminary result requires confirmation through more rigorous studies conducted over greater samples., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Pessina, Martini, Raffone and Martiadis.)

Aim: Finerenone is safe and efficacious for treating patients with chronic kidney disease (CKD) and Type 2 diabetes (T2D). Evidence on the use of finerenone in clinical practice is lacking. Objective: To describe demographic and clinical characteristics of early adopters of finerenone in the United States, according to sodium-glucose cotransporter 2 inhibitor (SGLT2i) use and urine albumin-creatinine ratio (UACR) levels. Methods: Multi-database, observational, cross-sectional study, using data from two US databases (Optum Claims and Optum EHR). Three cohorts were included: finerenone initiators with prior CKD-T2D, finerenone initiators with prior CKD-T2D and concomitant SGLT2i use, finerenone initiators with prior CKD-T2D stratified according to UACR. Results: In total, 1015 patients were included, 353 from Optum Claims and 662 from Optum EHR. Mean age was 72.0 and 68.4 years in Optum claims and EHR, respectively. Median eGFR was 44 and 44 ml/min/1.73 m 2 ; and median UACR was 132 (28-698)/365 (74-1185.4) mg/g, in Optum Claims and EHR, respectively. 70.5/70.4% were taking renin-angiotensin system inhibitors, 42.5/53.3% SGLT2i. Overall, 9.0/6.3% of patients had baseline UACR <30 mg/g, 15.0/20.2% had UACR 30-300 mg/g, and 14.4/27.6% had UACR >300 mg/g. Conclusion: Current management of patients with CKD-T2D reflects use of finerenone independently from background therapies and clinical characteristics, suggesting implementation of therapeutic strategies based on different modes of action.

Metacognition refers to the cognitive ability to control, monitor and modulate cognitive processes thus guiding and orienting behavior: a continuum of mental activities that ranges from more discrete ones, such as the awareness of the accuracy of others' judgment, to more integrated activities, such as the knowledge of cognitive processes. Metacognition impairment in schizophrenia, which is considered a core feature of the illness, has become a growing research field focusing on a wide range of processes including reasoning, autobiographical memory, memory biases, cognitive beliefs and clinical insight. There is a well-established relationship between metacognition and schizophrenia symptoms severity, as well as between impaired metacognitive functioning and specific symptomatic sub-domains, such as positive symptoms, negative symptoms, or disorganization. The development of specific cognitive-derived psychotherapies for metacognitive deficits in schizophrenia has been ongoing in the last years. Although sharing a metacognitive feature, these treatments focus on different aspects: false or unhelpful beliefs for metacognitive therapy; cognitive biases for metacognitive training; schematic dysfunctional beliefs for cognitive behavioral therapy (CBT) for psychoses; metacognitive knowledge and sense of identity for MERIT; interpersonal ideas or events triggering delusional thinking for MIT-P. This article reviews the instruments designed to assess metacognitive domains and functions in individuals with schizophrenia, providing mental health professionals with an overview of the heterogeneous current scenario ranging from self-administered scales to semi-structured interviews, which are supported by a variety of theoretical frameworks. Future directions may address the need for more specific and refined tools, also able to follow-up psychotherapeutic-induced improvements., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Martiadis, Pessina, Raffone, Iniziato, Martini and Scognamiglio.)

Obsessive Compulsive Disorder (OCD) is a common mental disorder that often causes great sufferance, with substantial impairment in social functioning and quality of life and affects family and significant relationships. Notwithstanding its severity, OCD is often not adequately diagnosed, or it is diagnosed with delay, leading often to a long latency between onset of the OCD symptoms and the start of adequate treatments. Several factors contribute to the complexity of OCD's clinical picture: early age of onset, chronic course, heterogeneity of symptoms, high rate of comorbidity with other psychiatric disorders, slow or partial response to therapy. Therefore, it is of primary importance for clinicians involved in diagnosing OCD, to assess all aspects of the disorder. This narrative review focuses on the global assessment of OCD, highlighting crucial areas to explore, pointing out the clinical features which are relevant for the treatment of the disorder, and giving an overview of the psychometric tools that can be useful during the screening procedure., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and objectives : Aripiprazole is a first-line agent in the treatment of bipolar disorder (BD) and available data demonstrates its efficacy on clinical symptoms in serotonin reuptake inhibitors-resistant obsessive-compulsive disorder (OCD) patients. Therefore, aripiprazole augmentation to mood stabilizers could represent a promising treatment in BD patients with comorbid OCD. The study examined the efficacy and safety of aripiprazole added to lithium or valproate for the treatment of obsessive-compulsive (OC) symptoms in euthymic BD patients with comorbid OCD. Materials and methods : This is a 12-week prospective observational study. The efficacy of aripiprazole on OC symptoms was assessed through the mean change of Yale-Brown Obsessive-Compulsive (YBOCS) total score. Tolerability was assessed with the Utvalg for Kliniske Undersogelser (UKU) side effect scale and by reporting adverse events. Results : A total of 70 patients were included in the analyses. The withdrawal rate was 21.4%, mainly due to adverse events. Mean ± SD final aripiprazole dose was 15.2 ± 5.3 in the completer sample ( N = 55). The Y-BOCS mean score decreased from 24.0 ± 4.1 at baseline to 17.1 ± 4.3 at 12 weeks. Treatment response rate (Y-BOCS reduction ≥ 35%) was 41.8%, while partial response rate (Y-BOCS reduction greater than 25% but less than 35% from baseline) accounted for the other 18.2% of patients. Overall, 91.4% of completers had at least 1 adverse effect (tremor, tension/inner unrest, reduced duration of sleep, akathisia). No significant differences emerged comparing aripiprazole efficacy and tolerability between patients treated with lithium or valproate. Conclusion : Our findings show that aripiprazole addition to lithium or valproate can reduce OC symptoms in real-world BD euthymic patients.

This study evaluated the impact of comorbid OCD on suicide attempt risk and suicide methods in 990 patients with main diagnosis of BD. Two hundred and one patients (20.3%) had lifetime comorbid OCD. No significant differences were found comparing rates of lifetime suicide attempts between patients with or without comorbid OCD (30.3% vs 24.6%). In the subgroup of patients with concomitant OCD more subjects performed suicide attempts with violent methods (48.3% vs 28.7%). Therefore, our results suggest a correlation between comorbid OCD and violent suicide attempts. This finding is worthy of interest and deserves to be explored by further studies., Competing Interests: Declaration of Competing Interest The paper is not under review elsewhere. All authors declare that there are not any actual or potential conflict of interest including any financial, personal or other relationship with other people., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The impact of diagnosis-related group (DRG)-based funding has been analyzed along a wide range of dimensions. Its effects on hospital specialization, however, have been investigated only sparsely. This paper examines such effects in the context of the Italian National Health Service, where decentralization has produced a significant degree of variation in funding arrangements. To this end, a 9-year panel data set covering 762 Italian public and private hospitals was analyzed using a finite mixture model approach. Hospital specialization was measured by the internal Herfindahl-Hirschman Index. Three variables were introduced as proxies for the choices made by Italian Regions with respect to the development and use of their DRG systems. The best finite mixture model identified three groups of hospitals, two of which sizeable. Of these, one included nearly all public hospitals, while the other was composed almost exclusively of small and medium-sized investor-owned hospitals. Averagely, private and smaller hospitals showed a stronger tendency to specialize over time. The positive impact of DRG funding on the hospitals' propensity to specialize found only limited empirical support. Moreover, it emerged as comparatively much smaller for public hospitals vis à vis private ones., (© 2018 John Wiley & Sons, Ltd.)

Italian and American hospitals, in two different periods, have been urged by external circumstances to extensively redesign their quality improvement strategies. This paper, through the use of a survey administered to chief quality officers in both countries, aims to identify commonalities and differences between the two systems and to understand which approaches are effective in improving quality of care. In both countries chief quality officers report quality improvement has become a strategic priority, clinical governance approaches, and tools-such as disease-specific quality improvement projects and clinical pathways-are commonly used, and there is widespread awareness that clinical decision making must be supported by protocols and guidelines. Furthermore, the study clearly outlines the critical importance of adopting a system-wide approach to quality improvement. To this extent Italy seems lagging behind compared to US in fact: (i) responsibilities for different dimensions of quality are spread across different organizational units; (ii) quality improvement strategies do not typically involve administrative staff; and (iii) quality performance measures are not disseminated widely within the organization but are reported primarily to top management. On the other hand, in Italy chief quality officers perceive that the typical hospital organizational structure, which is based on clinical directories, allows better coordination between clinical specialties than in the United States. In both countries, the results of the study show that it is not the single methodology/model that makes the difference but how the different quality improvement strategies and tools interact to each other and how they are coherently embedded with the overall organizational strategy.

Oral and long-acting injectable second-generation antipsychotics are known to be associated with a high risk of metabolic adverse effects. Together with other drug treatments, poor lifestyle choices, and genetic liability, they contribute to development of metabolic syndrome (MetS), which occurs in nearly one third of patients with schizophrenia.The primary objective of this multicenter prospective observational study was to explore the prevalence of MetS in a sample of 60 real-world patients treated with paliperidone palmitate (PP) over a period of 12 months. The secondary objectives were to assess other tolerability aspects and the efficacy of PP on schizophrenic symptoms.The proportion of patients with MetS at baseline (33%) did not significantly change neither at 6 (39.0%) nor at 12 months (29.5%) of PP treatment. The same applies to each individual component of MetS. We found a slight but statistically significant increase in body mass index (26.3 ± 6.0 vs 27.1 ± 4.6, P = 0.031) and of waist circumference (98.2 ± 17.9 vs 100.3 ± 15.9, P = 0.021) from baseline to end point. Weight gain was detected in approximately 15% of patients.At least 1 mild or moderate adverse event was found in 71.3%, 88.0%, and 52.1% of patients, respectively, at baseline, 6 months, and 12 months. A significant improvement in schizophrenic symptoms emerged by means of Positive and Negative Syndrome Scale total and subscale scores.Together with previous literature findings, our results seem to indicate that PP could be a valid therapeutic option for patients with a severe disorder and with a high metabolic risk profile.