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College of Psychiatrists of Ireland Winter Conference 2017

‘Psychosis, Somatisation and Society’

Kidney transplant outcomes no worse in schizophrenia and bipolar patients

There is no difference in kidney transplant outcomes between people with schizophrenia and bipolar disorder and those without such diagnoses, according to a retrospective study presented at the recent College of Psychiatrists of Ireland Winter Meeting 2017.

The study entitled ‘Outcomes of renal transplantation in patients with schizophrenia and bipolar affective disorder, a national retrospective cohort study’ was conducted by Dr Mary Butler, SpR in Cork University Hospital.

Transplant teams around the world are increasingly looking at psychiatric status, along with other factors, when deciding who should get a kidney transplant, said Dr Butler. In the US, some health regions deny people with schizophrenia access to transplants, even if they are stable, she reported.

Dr Butler said, however, there was little evidence to indicate whether patients with schizophrenia or bipolar disorder did worse following kidney transplantation so she decided to conduct a study into this.

Her study covered a 28-year period when some 3,000 kidney transplants were conducted in Beaumont Hospital, Dublin, including six people with schizophrenia and 15 with bipolar disorder. Twelve of those with bipolar disorder required a kidney transplant because of lithium-induced interstitial nephritis.

“There were no differences in patient survival across bipolar, schizophrenia and the main group in terms of graft function, acute rejection and the length of time in hospital for the procedure,” reported Dr Butler.

“Those with bipolar and schizophrenia did very well, but the limitations to the study were the small numbers and it was retrospective.”

Given that these small numbers were gathered over a long time, it would be necessary to do a multi-centre study to achieve higher numbers in any potential future study, she concluded.

 ‘No reason to delay clozapine in first episode schizophrenia’ – study

The ability to predict who will develop treatment resistance at first presentation of schizophrenia can improve clinical outcomes and reduce the average delay of clozapine use, which is four to five years on average, the recent College of Psychiatrists of Ireland Winter Meeting 2017 heard.

Dr John Lally, St Vincent’s University Hospital, Dublin, presented findings from his research into predictors of treatment resistance in first episode schizophrenia spectrum psychoses.

Dr Lally said that clozapine is the ‘gold standard’ treatment for schizophrenia, with two-third of patients showing an adequate response, but there remains a hesitancy in clinical practice to switch patients to clozapine. The side effects profile, with high doses of antipsychotic drugs leading to functional decline over time, means it is viewed as a treatment of last resort.

Dr Lally told delegates at the meeting that he wanted to investigate risk factors over the first five years of treatment and his cohort was recruited from the South London Mosely Trust. He traced 246 patients five years after their first presentation and collected a wealth of clinical, social and drug history data on patients over the timeframe.

Dr Lally sought to determine whether there were any significant predictors of treatment resistance in this group at an early stage of their illness.

He found that the only significant predictor for resistance for that first contact for psychosis before the age of 20 years was living away from family or friends at the time they started clozapine.

Some 23 per cent of patients were treatment-resistant from the onset of their illness. Dr Lally said that this means that for the more than 70 per cent of patients who are not resistant there is no reason to delay them starting on clozapine.

Less free tryptophan found in pre-term breast milk

The essential amino acid typtophan is essential in mothers’ diet as it is a precursor for serotonin and melatonin, but freely available tryptophan is lacking in pre-term breast milk, according to a study presented by Dr Louise O’Rourke, Cork University Hospital at the College of Psychiatrists of Ireland Winter Meeting 2017.

Tryptophan in a form that is easily metabolised is essential to produce serotonin and melatonin, which are important for stabilising the sleep-wake cycle in the infant and for the normal development of its brain. 

However, tryptophan gets broken down during pregnancy due to indoleamine 2,3-dioxygenase (IDO) activation, which helps achieve foetal immune-tolerance and maintains the pregnancy.

Dr O’Rourke investigated the metabolic profile of tryptophan in term and pre-term breast milk and the implications for health.

The study was carried out in 2013 in Cork University Hospital and recruited 24 mothers. Milk was collected from the 24 mothers on day seven post-birth and delivered for analysis to the Alimentary Probiotic Centre at University College Cork.

That analysis found that there was significantly less free tryptophan found in pre-term breast milk. This was a surprise because free tryptophan is an immediate source of tryptophan for the organs and it can cross the blood-brain barrier too. It is more difficult to access if it requires processing via digestion.

Another interesting finding was that mothers of pre-term babies did not show higher levels of the stress hormone cortisol, as might have been expected.

Dr O’Rourke said there was a need for tryptophan in its free form to be high in pre-term milk and the finding that it is not may have implications for mothers who are exclusively breastfeeding a pre-term infant.

The next step, said Dr O’Rourke, is to conduct a study where blood samples are taken from the mother and the infant. This would be to test the hypothesis that a mother with less tryptophan will have depression and this will be passed on to the infant.

If that is found to be the case, then mothers of pre-term infants may be given tryptophan.

ECT study supports the inflammatory model for depression

New Irish research on patients who have undergone electroconvulsive therapy (ECT) has confirmed the link between inflammation and conditions such as depression.

In a presentation at the College of Psychiatrists of Ireland Winter Meeting 2017, Ms Niamh Corcoran, a medical student in the Trinity College Institute for Neuroscience, working with Prof Declan McLoughlin, explained how she set out to identify inflammatory markers in people with depression and the therapeutic response they had to ECT.

When the body feels under threat with injury imminent, as occurs in mental illness, it is natural to trigger the immune system to respond, said Ms Corcoran.

The dysregulation of the immune system is known to play a crucial role in depression, as there are several pathways involved, which can lead to diabetes, as well as depression. It is also known that ECT brings about long-term down regulation of immune activation.

The study set out to assess the differences in inflammatory markers in patients pre- and post-ECT, and to identify change in mood scores based on those inflammatory markers.

Ms Corcoran collected plasma as part of the EFFECT-Dep Trial, a large Irish trial comparing the effectiveness of high-dose unilateral ECT and standard bitemporal ECT in severe depression. There were 57 controls and 94 patients, aged 55 years on average, with 65 per cent of them female. These demographics, said Ms Corcoran, were in line with larger patient populations on other ECT trials.

The research found a significant increase in all four inflammatory markers of depression pre-ECT versus healthy controls. The baseline CRP was far higher in remission patients and far lower in those that relapsed.

“Our study found that depression is associated with increased inflammation,” said Ms Corcoran. “This study supports the inflammatory model of depression, but we don’t know if it is inflammation that causes depression or depression causing inflammation.”

The elucidation of the pathways involved in depression can point the way to drug development, she noted.

“We have also demonstrated that CRP blood tests before ECT is useful and can avoid unnecessary ECT treatments,” Ms Corcoran added.

The stria medullaris is implicated in depression by diffusion imaging

A study using diffusion imaging has found differences between depressed people and controls in the area of the brain called the stria medullaris, the College of Psychiatrists of Ireland 2017 Winter Meeting  heard.

The stria medullaris is a relatively unknown area of the brain which has input from the pleasure centres and those centres involved with pain, comfort, reward, as well as decision making, social processing and error detection.

Diffusion imaging allows researchers to look at neurons, to see connections, isolate tracts and look at them in greater detail.

Dr Shane Rooney, Registrar at Tallaght Hospital, Dublin, conducted an investigation using advanced diffusion imaging of the stria medullaris in people with depression.

There were 60 people involved in the study, 30 of which had the first episode of depression as well as 30 others. All participants had diffusion scans done and the results of the depressed participants were compared to the controls.

Dr Rooney reported that differences were found and reflected in the fact that the fractional anisotropy scalar value was decreased in depression patients versus controls, while radial diffusivity increased in patients with depression.

“This is the first study that may put the stria medullaris as a target for deep brain stimulation in the treatment of resistant depression,” said Dr Rooney.

The findings also appeared to show damage to the stria medullaris in people with depression, he added.

Alcoholics are not powerless over their addiction – philosopher

The alcoholic or drug addict patient is not powerless over their addiction, but makes the rational decision to give up when the price to be paid is too high, as they see it, the College of Psychiatrists of Ireland Winter Meeting 2017 heard.

This theory was put forward by Dr Piers Benn, a UK philosopher and medical ethicist, in a challenging talk that questioned the way the ‘addiction industry’ operates.

Dr Benn began his talk by looking at the nature of addiction and whether it is right that the medical profession, and society generally, now regard it as a disease.

However, he said the concept of alcoholism being a disease has been under attack since the 1980s and he questioned why it should be considered a disease.

The definition of disease goes back to Aristotle, Dr Benn noted, and the idea is that a disease describes when something does not do what it is designed for. The alcoholic or addict does not have something wrong in that sense, but they may be unable to make a rational decision on their drinking.

The alcoholic might well have insight, said Dr Benn, and simply decide that drinking themselves to death is not a strong enough reason to give up their addiction.

Dr Benn asked whether the irresistible urge to drink or take drugs was the same as someone not being able to push a lorry up a hill on their own. He said that it was not at all clear whether these two things were the same, as people did give up drink, but no one could push a lorry up a hill on their own.

The advance of neuroscience has contributed to the idea of alcoholism as a disease, said Dr Benn, with metaphors to describe what is going on, like the prefrontal cortex has lost its connections with the other parts of the brain.

This feeds into the idea that the addict is powerless, he said, but the reality is that people do control their alcoholism despite notions of powerlessness.

He asked whether alcoholism should not be treated as a disease like Alzheimer’s where people genuinely have no control, but perhaps as a mental illness.

If alcoholism is a disease like Alzheimer’s then why are there 12 steps to recovery, which can work? There are not 12 steps for Alzheimer’s he said.

Dr Benn questioned the basis of AA and its idea that the alcoholic’s life has become unmanageable and requirement that people admit powerlessness over drink.

The admission of powerlessness is at the very heart of AA, said Dr Benn.

He said there were many cases of alcoholics trying to give up and then going back drinking very quickly. But this was not because they are powerless, he said.

Dr Benn put forward the idea that the alcoholic is perhaps genuine when they agree to stop drinking, but then simply change their mind later in the pub.

This would explain why alcoholics regularly ‘fall off the wagon’. The addict changed their mind under the pressure of desire, said Dr Benn.

There are those, such as the rational recovery movement (www.rational.org), who regard AA as keeping people trapped in their behaviour. The rational movement puts a greater stress on developing the willpower to say no to drink.

“The addict intensely wants the pleasure or the relief and knows it would be better not to do it, but pleasure or desire for relief are reactions for actions that are competing with prudence, morality or whatever,” said Dr Benn.

It must also be considered, said Dr Benn, that aspects of the ‘treatment industry’ encourages a dependent mindset as money changes hands – ‘we have the solution, it might take years, but you must keep coming to us’.

“I suspect that alcoholism is not a disease and not a mental illness, but about desires and you have choices about those desires,” said Dr Benn.

“Humans are self-ruled, autonomous, they can act on desires, against competing desires,” he concluded.

Childhood bullying increases lifetime risk of mental illness

Being bullied in childhood can leave people at risk from mental illness into their 50s and 60s, according to Prof Louise Arseneault, King’s College London.

The title of Prof Arseneault’s talk at the recent College of Psychiatrists of Ireland Winter Meeting 2017  was ‘The pervasive and persistent impact of childhood bullying victimisation’.

Her research into bullying began about 15 years ago when she looked at 1,000 families with twins living in the UK. The researchers saw them first at the age of five years, then again at age seven, 12 and 18.

 “This cohort shows that those being bullied between five and 12 frequently were three times more likely to report self-harm or suicide ideation at age 12,” said Prof Arseneault.

“When the kids were aged 12 they were asked about psychotic experiences such as hearing things others couldn’t hear, or seeing things others couldn’t see, and the children that were bullied between [the age of] five and 12 were more likely to report these psychotic symptoms,” she reported.

Prof Arseneault and her team identified 114 pairs of twins where – at age seven – one twin was bullied and one was not. “The bullied twins have much higher symptoms of anxiety and depression than co-twins.”

There was also data available on the children’s emotional state at age five prior to bullying, so the idea that the problem was there already could be ruled out, she explained.

Further evidence that bullying puts people at risk of mental illness came last month, Prof Arseneault said, with the results of the Twins Early Development Study (TEDS).

TEDS investigated 6,000 twins and it found that twins that have been bullied have a higher rate of ADHD than those who were not.

Other bullying data has shown, said Prof Arseneault, that people in their early 20s who were bullied are more affected by suicidal thoughts, while data examining 18,000 people that were born in a single week in the UK in 1958 showed that being bullied in childhood was linked to psychological distress in adulthood.

“At age 50, people who were bullied in childhood still have higher levels of psychological distress, less education, were more likely to be living without a partner and have less perceived support from friends when they are sick,” said Prof Arseneault. They were also more likely to be using mental health services.

Bullying must be stopped, she said, but anti-bullying efforts up to now have focused on stopping bullies, rather than just helping victims, she maintained.

In terms of public policy, bullying interventions are welcome, but they will not eliminate bullying and can only reduce the behaviour by about 25 per cent, the professor acknowledged.

This means that there will always be victims of bullying, she added, and in this context a useful public policy would be to build resilience in the victims. It is possible to identify children that are at risk from bullying and policy can be drafted accordingly.

Some of the main risk factors are being male, overcrowding in school, being younger, the school climate, abuse or neglect at home, a negative parent, and a lack of supervision and involvement by parents.

The children who are at risk can be better protected by teaching them how to make a friend, how to be a friend and to capitalise on the warmth of a parent, she said.

This is the best way to protect children at risk from bullying, Prof Arseneault concluded.

Language and avoiding myths crucial with somatisation disorders

Psychiatrists must use the language of ‘coping’ rather than ‘cure’ and avoid believing some common myths, such as that patients are ‘putting it on’, to achieve the best outcomes for patients with somatisation disorders.

That is according to Dr Siobhan McHale, Beaumont Hospital, Dublin, who gave a talk at the recent Psychiatrists of Ireland Winter Meeting entitled ‘Somatic symptom disorder – explaining the (medically) unexplained’.

The definition of somatoform disorders is when a patient has repeated presentations for physical symptoms, together with persistent requests for medical investigation, even though patients have been reassured that the symptoms have no physical basis, she explained.

This type of patient presentation is very common, she said, with one-third of symptoms presented in hospital medical clinics unexplained by disease.

Somatisation can also be viewed as a person experiencing psychological distress as physical symptoms, said Dr McHale. However, it can be difficult for doctors and patients in these cases, because patients might think that doctors are not listening, and doctors might think that ptients are malingering.

There are several myths regarding patients with somatisation which need to be addressed, said Dr McHale, including that patients are looking for lots of tests, that they are ‘putting it on’, that it is not as serious as one of the more recognised mental disorders, and that these cases are not a psychiatrist’s job, thus someone else should be sorting the situation out. Yet, somatisation, depression and anxiety commonly co-exist, share the same risk factors, respond to similar treatments and may be different expressions of the same problem.

There are biological, psychological and social factors in the aetiology, said Dr McHale. The assessment and diagnosis should start with the patient’s symptoms, then look for co-morbid organic disease, appropriately investigate new symptoms and avoid iatrogenesis.

Crucially, the language that the psychiatrist uses when communicating with patients is very important. The way to explain it to the patient, said Dr McHale, is that all significant illness affects both mind and body, external events trigger internal change and shift the focus from curing to coping.

There is a crossover of mental and physical symptoms, she pointed out. The ‘fight or flight’ reflex, which is triggered in many people with somatisation, can trigger muscle cramp, while hyperventilation can cause biochemical changes and chronic hyperarousal can lead to endocrine changes.

It should also be remembered, said Dr McHale, that while many people with somatisation can develop insight and work with biopsychosocial management, a minority cannot.

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