This issue of the Spanish Journal of Psychiatry and Mental Health brings together a series of excellent papers reporting recent advances in the management of various psychiatric conditions, including obsessive-compulsive disorder (OCD), schizophrenia, bipolar disorder, and depression with physical pain, amongst others.
Two studies focus on the prediction of treatment response in individuals with OCD from a specialist clinic in Barcelona. In the first1 examined the question of whether sex is a predictor of long-term response to deep brain stimulation (DBS) for severe, treatment resistant OCD. Analysing data from 25 patients, the study found no significant sex differences in the initial response to DBS (1 year after start of stimulation). However, significant differences emerged in the long-term response to DBS. At follow-up, 77% of men were considered responders compared to only 33% of women, highlighting the potential influence of sex on the efficacy of DBS over extended periods. Interestingly, women also had higher rates of adverse events, including manic episodes. While the study included a modest sample size of only 25 participants, the results are intriguing and, if replicated by other groups, they could warrant considering the patient's sex in optimizing DBS stimulation parameters.
In a second study2 used machine learning techniques to predict pharmacological response in OCD. The study included 135 OCD-diagnosed patients and used a combination of sociodemographic, clinical, and neurocognitive data to develop predictive models. The most reliable algorithm included variables such as the severity of obsessive-compulsive symptoms at baseline, depressive symptoms, and cognitive functions assessed with the Digits subtest from the Wechsler Adult Intelligence Scale-IV and Raven's Progressive Matrices. The algorithm achieved a remarkably high correlation (0.847) between predicted and true values of the Yale-Brown Obsessive Compulsive Scale score after 12 weeks of treatment. This strong predictive reliability suggests that machine learning could be a valuable tool in personalizing pharmacological treatment for OCD patients, potentially reducing the current trial-and-error approach. As ever, these results should be replicated by other research groups and the models tested in additional treatment modalities, such as cognitive-behaviour therapy (CBT).
Miquel-Giner et al3 describe the protocol for a multicentre randomized controlled trial (RCT) investigating the efficacy of Mindfulness-Based Cognitive Therapy (MBCT) for OCD symptoms in patients who did not respond to first-line treatments. The trial will include 60 adults with OCD who will be randomized to either an MBCT program or treatment as usual (TAU). Although the authors do not define TAU, this is inferred to involve evidence-based treatment for the disorder. The primary outcome is the change in OCD severity using clinician and self-reported measures. Additionally, a comprehensive neurocognitive and neuroimaging protocol using structural and functional magnetic resonance imaging (fMRI) will be employed to identify socio-demographic, clinical, and neurobiological characteristics that mediate or moderate treatment response. It will be fascinating to follow the results of this trial and see if MBCT can show superiority to an already powerful treatment for OCD.
A study conducted in Singapore investigated the prevalence of obsessive-compulsive symptoms (OCS) and OCD in clozapine-treated schizophrenia patients4. The study included 159 patients with schizophrenia or schizoaffective disorder who were on a stable dose of clozapine. The prevalence of OCS and OCD was found to be 21.4% and 12.6%, respectively. Factors associated with OCS included younger age and younger age of onset of psychosis. Younger age and younger age of onset of psychosis were significantly associated with OCS and/or OCD. By contrast, clozapine dose, plasma clozapine levels, duration of clozapine use, and severity of psychotic illness were not associated with OCS or OCD in this sample. As the study was cross-sectional in nature, the authors could not verify if OCS or OCD were present prior to the initiation of treatment. Nevertheless, these findings replicate previous studies from other countries and suggest that clinicians should routinely screen for OCS and OCD in patients treated with clozapine, especially those with a younger age of onset of psychosis.
In a case series from the Hospital Clínic in Barcelona5 evaluated the 1-year effects of DBS in four treatment-resistant patients with schizophrenia spectrum disorders or bipolar disorder. The study found that DBS of the nucleus accumbens (3 patients) and subgenual anterior cingulate cortex (1 patient) produced significant clinical improvement, with decreases in the Clinical Global Impression and Hamilton Depression Rating Scale scores. Two patients showed notable and durable therapeutic responses, one patient had clinically relevant relief, and one patient did not respond. Maintenance electroconvulsive therapy sessions could be discontinued in the three patients who responded to DBS, although the follow-up was too short to have a real sense of long-term prognosis. There were no side effects or relevant changes in cognitive functioning. These promising results add to the limited literature on last-resource DBS options for this patient group and open the door for more systematic studies. Carefully considering ethical aspects, as well as participant and DBS target selection will be critical.
Pérez-Solá et al6 describe a consensus document providing practical recommendations for the diagnosis and management of patients with major depressive disorder who present with pain as a prominent physical symptom. The aim was to reduce the variability of clinical practice while the evidence base continues to expand. The methods included expert meetings, literature reviews and Delphi surveys. The consensus highlighted the importance of screening for depression in patients with chronic pain, especially if it interferes with functionality. It emphasized the need for a personalized approach to diagnosis and treatment, considering the mutual influence of pain and depression. Recommendations included the use of serotonin-norepinephrine reuptake inhibitors for managing pain associated with depression, CBT, and educational programs to improve self-management skills.
In a preregistered, prospective repeated assessment study7 investigated the relationship between coping behaviours and subsequent changes in anxiety and depressive symptoms during the aftermath of the COVID-19 pandemic. The study included 942 adults who completed bi-weekly online assessments over one year, measuring the frequency of ten potential coping behaviours and anxiety (measured with the GAD-7) and depressive symptoms (measured with the PHQ-9). Perhaps unsurprisingly, they found that avoiding excessive exposure to distressing news and maintaining a healthy/balanced diet were the coping behaviours most strongly associated with short and long-term reductions in anxiety and depressive symptoms. Spending time outdoors and physical exercise were also associated with symptom reductions. Engaging in relaxing activities and drinking water to hydrate were associated with short-term symptom reductions, while socializing was associated with long-term symptom reductions. Although the COVID-19 pandemic now feels like a distant memory, the recommendations in this paper will remain valuable for both authorities and the general public in preparing for future crises of a similar nature.
Other interesting papers in this issue include a study evaluating the reliability and validity of proxy reports on impulsivity and aggression, which are often included in psychological autopsy methods8, a fascinating case study of a Koro-like syndrome (shrinking penis syndrome) in a patient with Huntington's disease9, a research letter using ecological momentary assessment methods linking self-reported low sleep satisfaction to death and life wishes10, and a summary of the numerous achievements of CIBERSAM, a network of Spain's most productive psychiatry research groups11.
