Früherkennung des Psychoserisikos mit dem Early Recognition Inventory (ERIraos)

Die Frühintervention bei schizophrenen Psychosen kann entweder im initialen Prodrom oder in der beginnenden ersten Episode stattfinden. Dies setzt eine zuverlässige Früherkennung von Risikopersonen voraus. Wir berichten über den Aufbau des zweistufigen Früherkennungsinventars ERIraos, bestehend aus einer Checkliste als Screeninginstrument und einer umfassenden Symptomliste und weiteren modularen Komponenten. Es werden erste Ergebnisse zur Reliabilität der Checkliste und zu ihrer Übereinstimmungsvalidität mit den interventionsrelevanten Einschlusskriterien berichtet.

Medikamentöse Akutbehandlung schizophrener Ersterkrankungen

Atypische Neuroleptika werden heute für die Behandlung von Patienten mit schizophrenen Erkrankungen als Therapie der ersten Wahl empfohlen, da sie gegenüber den typischen Neuroleptika deutliche Vorteile hinsichtlich des Wirkungsspektrums und des Nebenwirkungsprofils aufweisen. Dies trifft insbesondere für ersterkrankte Patienten zu, da für diese Patientengruppe im Vergleich zu Mehrfacherkrankten ein höheres Risiko für extrapyramidal-motorische Nebenwirkungen beschrieben wurde. Ob die Vorteile der atypischen Neuroleptika aber auch nachweisbar sind, wenn typische Neuroleptika in niedrigen Dosierungen eingesetzt werden, ist bisher empirisch unzureichend geprüft. Vor diesem Hintergrund wurden im Rahmen einer multizentrischen, doppelblinden, randomisierten klinischen Studie des Kompetenznetz Schizophrenie die Effekte von Risperidon und Haloperidol im Niedrigdosisbereich (Tagesdosen von 2 mg bis maximal 8 mg für beide Medikamente) in der Akutbehandlung ersterkrankter Patienten verglichen.

Preventing progression to first-episode psychosis in early initial prodromal states

BACKGROUND

Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred.

AIMS

To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS.

METHOD

A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up.

RESULTS

A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019).

CONCLUSIONS

Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

Time course of antipsychotic treatment response in schizophrenia: results from a naturalistic study in 280 patients

OBJECTIVE

To describe the course of positive and negative symptoms during inpatient treatment and examine remission and response rates under routine clinical care conditions.

METHODS

Two hundred and eighty inpatients with schizophrenia (DSM-IV criteria) were assessed with the Positive and Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the symptom-severity component of the consensus criteria (Remission in Schizophrenia Working Group) as a rating of three or less in the relevant PANSS items at discharge, and response as a reduction of at least 20% in the PANSS total score from admission to discharge.

RESULTS

The mean duration of inpatient treatment was 54.8 days. Of the total sample, 78.5% achieved the criteria for response and 44.6% those for remission. Mean PANSS total scores decreased from 72.4 at admission to 52.5 at discharge (p<0.001). A reduction in PANSS total scores was found from visit to visit, up to week 8. The most pronounced decline was observed within the first two weeks of treatment.

CONCLUSION

Response rates were comparable to those found in efficacy studies, and remission rates were slightly higher. This may be explained by differences in the selection and the treatment of patients. Nevertheless, the findings might indicate that a complex naturalistic treatment approach is beneficial in terms of effectiveness.

Standardized remission criteria in schizophrenia: descriptive validity and comparability with previously used outcome measures

INTRODUCTION

Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear.

METHODS

The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS.

RESULTS

When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less.

DISCUSSION

The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

Structural brain alterations in subjects at high-risk of psychosis: a voxel-based morphometric study

Forty Untreated high-risk (HR) individuals for psychosis and 75 healthy control subjects (HC) matched for age, gender, handedness and educational level were investigated by structural MRI. HR subjects were recruited at the Early Detection and Intervention Centre for Mental Crises (FETZ) of the Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Germany. Measurements of gray matter volumes were performed by voxel-based morphometry using SPM5. The sample of HR subjects showed GM volume reductions in frontal, lateral temporal and medial temporal regions compared to the healthy control group. These regions are compatible with structural findings in the clinically apparent disease of schizophrenia.

Severe mental illness in depression

OBJECTIVE

The study aimed to evaluate the outcome from in-patient treatment in major depressive disorders (MDD) and its impact on the patients' 1 year outcome under the present routine care conditions.

METHOD

The reported data stem from a multicentric follow-up study on the course and outcome of patients with MDD. Patients enrolled in the study had their first or multiple psychiatric hospitalization and fulfilled the ICD-10 criteria for a depressive disorder. During in-patient treatment patients were standardized assessed in 2-weekly intervals, with yearly follow-up evaluations after discharge.

RESULTS

The analyses revealed that the elimination of depressive symptoms and a return to premorbid levels of functioning is a rarity in the in-patient treatment of MDD. Moreover, the analyses revealed that the achieved level of response during in-patient treatment clearly determines the patients state 1 year after discharge from in-patient treatment.

CONCLUSION

Considering that persisting depressive symptoms are associated with a range of unfavourable outcomes, the present data point to a serious problem in the treatment of MDD and the urgent need to further optimize antidepressive treatment strategies.

Striatal dopamine transporter availability is associated with the productive psychotic state in first episode, drug-naive schizophrenic patients

OBJECTIVE

Supposing a "hyperdopaminergic State" associated at least with acute psychotic illness phases in schizophrenia, a direct relationship between striatal dopamine metabolism and the core psychopathological symptoms rarely can be provided. Recently, a new SPECT ligand to the presynaptic dopamine transporter (DAT) was introduced. Association of DAT availability and the acute psychotic syndrome is now demonstrated in a large cohort of first episode, never treated schizophrenic patients.

METHODS

Twenty-eight inpatients suffering from a first acute exacerbation of schizophrenia and 12 healthy control subjects underwent SPECT scanning with the new radioligand [(99m)Tc]TRODAT-1. On the day of SPECT, psychopathology was assessed using specific scales including PANSS.

RESULTS

There was no significant difference in [(99m)Tc]TRODAT-1 specific binding to the striatal DAT comparing both groups. The extend of hallucinations was significantly inversely correlated with DAT availability in patients with a predominantly positive syndrome type.

DISCUSSION

Our data support evidence that differences in presynaptic dopaminergic activity in schizophrenic patients are associated with the extend of the acute psychotic syndrome. [(99m)Tc]TRODAT-1 seems to be a useful agent for in vivo assessment of a psychopathological association with dopamine metabolism.

[Modern therapy for dementia]

The most frequently diagnosed dementia diseases include Alzheimer disease (AD), vascular dementia (VD) and dementia with Lewy bodies. Cholinesterase (ChE) inhibitors and the NMDA receptor antagonist memantine are currently recommended as first line drugs for the treatment of AD. These anti-dementia drugs have not yet been approved for the treatment of VD and DLB although the results of controlled clinical studies support the effectiveness of the ChE inhibitors for both diseases. The treatment of the primary disease and the secondary prevention of cerebrovascular accidents constitute the primary objectives of VD therapy. Although single or multiple domain cognitive deficits are the clinical key symptoms of dementia, noncognitive psychopathological symptoms (so-called behavioral disorders) are particularly common and may even dominate the clinical course in the moderate to severe stages. Therefore, it is important to recognize, diagnose and specifically treat these additional symptoms. During the last decade, the classic neuroleptics and benzodiazepine have been largely replaced by modern antidepressants, atypical antipsychotics and benzodiazepine analogues.

[Diagnostics and therapy of depressive symptoms in schizophrenic patients]

The occurrence of depressive symptoms in schizophrenia is fairly common. In contrast to earlier assumptions, they usually have unfavorable consequences on the course of the disease. The response of depressive symptoms to therapy is well documented by empirical evidence and studies. In reality, however, the treatment of depressive symptoms in cases of schizophrenia occurs too rarely. This lack of medical treatment is partially explained by the clinicians' apprehension that antidepressive therapy could provoke a flare up of the psychosis. Nonetheless, this situation is often founded on the incorrect assessment of the depressive symptoms as negative symptoms that, in turn, are regarded by many clinicians as having limited treatability. In regards to this circumstance, a rethinking is desirable and, as a matter of principle, necessary.

Obsessive-compulsive Disorder (OCD) with Psychotic Symptoms and Response to Treatment with SSRI

The co-occurrence of obsessive-compulsive and psychotic symptoms in one patient often represents a diagnostic problem. Distinguishing among a schizophrenic disorder with comorbid obsessional symptoms, an OCD with comorbid psychotic symptoms, or an OCD and schizophrenia or any other psychotic disorder is of clinical importance, since the different diagnoses have different therapeutic as well as prognostic implications. In the following case report we describe a patient who suffered from a typical OCD for more than 18 years and then developed clear psychotic symptoms that completely remitted after treatment with citalopram.

Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression

BACKGROUND

Early authors described hypomanic symptoms as mixed features in depressive episode, but this syndrome has not been sufficiently explored in previous studies.

METHODS

958 consecutive depressed patients were assessed by using a standardized method in terms of 43 psychiatric symptoms at hospitalization.

RESULTS

A principal component analysis, followed by varimax rotation, extracted six interpretable factors: typical vegetative symptoms, depressive retardation/loss of feeling, hypomanic syndrome, anxiety, psychosis, and depressive mood/hopelessness. The extracted factor structure was relatively stable among several patient groups. There was no evidence that the hypomanic factor was exaggerated by antidepressant pretreatments before hospitalization. Bipolar diagnoses were associated with higher scores on depressive retardation and hypomanic symptoms, and a lower score on anxiety.

LIMITATIONS

Psychiatric syndromes and their interrelationships, found in the present study, may be strongly influenced by the rating instrument used. The sample of this study was depressed inpatients. The results should not be generalized for depressed outpatients or epidemiological depressed populations.

CONCLUSIONS

Hypomanic symptoms, as characterized by the flight of ideas, racing thought, increased drive, excessive social contact, irritability, and aggression are a salient syndrome in acutely ill depressed patients, lending support to the factor validity of mixed depression. The symptoms may not be related to pretreatments with antidepressants, or comorbidity of substance abuse, suggesting that they reflect various natural phenomenological manifestations of depressive episodes. Anxiety is unlikely to play a major role in the core phenomenological features of mixed depression. Hypomanic symptoms during a depressive episode were more represented in bipolar disorders, which may serve for further clarifications of latent bipolarity in unipolar depression, and prediction of switch into maniform states under biological depression treatments.

Thalamic volume in first-episode and chronic schizophrenic subjects: a volumetric MRI study

OBJECTIVE

The thalamus, as a composite of several functionally very different nuclei, is a major relay and filter station in the CNS and is significantly involved in information processing and gating. The aim of our study is to investigate first-episode and chronic patients and controls to shed light on the potential pathogenetic role of the thalamus in schizophrenia and to assess the relationship between thalamic volumes and psychopathology ratings.

METHODS

Forty-three male right-handed chronic and 25 male right-handed first-episode schizophrenic patients treated at the psychiatric hospital of the Ludwig-Maximilians University in Munich and 50 male control subjects were enrolled into the study. Demographic information and current symptom profile of all schizophrenic subjects were assessed using a semistructured interview, including a variety of measures relevant to the study. Volumetry of the thalamic gray and white matter was obtained with 1.5 T MRI, using the BRAINS software application.

RESULTS

No significant differences regarding thalamic volumes were detected across groups. However, negative symptoms were significantly correlated with thalamic volumes in first-episode patients, whereas duration of illness and extrapyramidal symptoms were related to thalamic volumes in chronic patients.

SUMMARY

Our findings indicate that, while the thalamus might be involved in the pathogenesis of negative symptoms, thalamic volume reduction is not a required element in the pathophysiology of the schizophrenic phenotype.

[Schizophrenics in the doctor's office. Diagnostic and therapeutic aspects]

The diagnosis and treatment of schizophrenia is usually an interdisciplinary affair, with particular stress on cooperation between family doctor and psychiatrist. The practicing physician has a major role to play in the recognition of early schizophrenia. For reasons of time and the fact that further specialist diagnostic measures are mostly required, he will, as a rule, have to restrict himself to screening examinations. Patients with a positive screening outcome will be referred to a specialized early-recognition center or a specialist clinic for further diagnostic clarification. But the family doctor also has an important role in the treatment of these patients, e.g. when physical comorbidity presents, the patient rejects treatment by a psychiatrist, or has an early form of schizophrenia or a relapse. Today, medical treatment employs atypical neuroleptics, and treatment should be initiated as early as possible.

[The classification of functional psychoses: the impact of ICD-10 diagnoses (research diagnostic criteria) for the prediction of the long-term course]

One major objective of Emil Kraepelin's system of the functional psychoses was to establish a prognostically relevant diagnostic classification. Following this idea, 197 first admitted inpatients from the years 1980 - 1982 were examined 15 years later in order to determine the impact of ICD-10 diagnoses (derived from first hospitalisation) for the long-term course. The long-term course was divided into the three course types single episode, episodic-remitting course and chronic course. The results showed that 57 % of the patients with schizophrenia, 50 % of the patients with persistent delusional disorders, 20 % of the patients with acute and transient psychotic disorders, 10 % of the patients with schizoaffective disorders and only 3 % of those with affective disorders developed a chronic course type. Using a logistic regression analysis, the predictive validity of the ICD-10 diagnoses was compared with those of a dimensional model based on psychopathological and demographic data. The results revealed that the predictive validity of the dimensional model (77 %) does not exceed the predictive validity of ICD-10 diagnoses (78 %).

Fifteen-year follow-up of ICD-10 schizoaffective disorders compared with schizophrenia and affective disorders

OBJECTIVE

The nosological status of schizoaffective disorders is still unclear. The aim of the present study was to compare ICD-10 schizoaffective disorders to schizophrenia and affective disorders with respect to the clinical picture and the long-term outcome.

METHOD

Two hundred and forty-one first-admitted inpatients from the years 1980-1982 who fulfilled the ICD-10 criteria for schizophrenia, schizoaffective or affective disorders were included. Patients were examined at the time of first hospitalization and then followed-up after 15 years.

RESULTS

With respect to the clinical picture at the time of first hospitalization ICD-10 schizoaffective disorders were distinguishable from both schizophrenia and affective disorders. However, with respect to the long-term outcome ICD-10 schizoaffective disorders had a prognosis similar to that of affective disorders.

CONCLUSION

Differing prognosis implies that schizoaffective disorders should be distinguished from schizophrenia and suggests their subcategorization under affective disorders.

Long-term inter-episode stability of syndromes underlying mania

OBJECTIVE

To explore the stability of diverse manic presentations across manic recurrences.

METHOD

A total of 253 bipolar patients who experienced two or more hospitalizations, because of consecutive manic (or mixed) episodes, during a 20-year period were included. All patients had second hospitalizations with an mean interval of 773 days, while 126 and 91 patients had third and fourth hospitalizations with mean intervals of 1559 and 2237 days from the index hospitalization, respectively. Seven symptom scores, previously factor-validated, were calculated.

RESULTS

Depressive mood, irritable aggression, psychomotor/thought inhibition, mania, emotional lability/agitation and psychosis were moderately correlated across the index and subsequent hospitalizations.

CONCLUSION

A majority of diverse manic presentations were stable across manic recurrences. The stability was not restricted to two consecutive recurrences but appeared widespread over the long-term course of bipolar disorder. The finding may serve for the development of more effective long-term treatment strategies and a clinically more reasonable subtyping of mania.

Negative Symptome schizophrener Patienten aus der Perspektive der Psychiater, der Patienten selbst und deren Angeh�rigen

Clinical experience shows that negative symptoms are affected by environmental factors. Thus, different assessors with different information about patient behavior in different environments may come to different findings of negative symptoms. In this regard, the present study evaluates to what extent the assessment of negative symptoms by schizophrenic inpatients and their relatives compares to interview-based assessments by experts. Therefore, 33 schizophrenic patients were rated by patients themselves, their relatives, and psychiatrists. Negative symptoms were assessed with comparable assessment scales using the modified version of the Scale for the Assessment of Negative Symptoms (SANS) for patients or relatives and the original SANS for psychiatrists. Analyses revealed that the total SANS summary scores as rated by patients and relatives were comparable to scores rated by psychiatrists. Scores on SANS subscales of "alogia" and "attention deficits" differed significantly among the three ratings, while psychiatrists rated the patients' impairments as lower than did the patients themselves or their relatives. These findings indicate that patients' and relatives' ratings could be used to reduce information variance and improve the validity of interview-based, assessed negative symptoms.

Course and outcome of first-admitted patients with acute and transient psychotic disorders (ICD-10:F23). Focus on relapses and social adjustment

OBJECTIVE

The aim of the present study was to investigate course and outcome of acute and transient psychotic disorders (ATPD).

METHOD

A sample of 73 first-hospitalized patients was evaluated after three to seven years in order to determine the frequency of relapses and to assess social adjustment.

RESULT

Forty-two percent experienced no relapse, 46% experienced relapses without developing marked deficits in social adjustment and 12% had relapses associated with a severe social impairment. At discharge from first hospitalization the last group was distinguishable from the other two with respect to negative and depressive symptoms as well as the total score of the Strauss-Carpenter scale.

CONCLUSION

Only a minority of first-hospitalized patients with ATPD develop a severe social impairment after three to seven years. This subgroup, however, is not compatible with the concept of a "transient" psychotic disturbance, but rather with an early manifestation of a chronic schizophrenic disorder.

Combined action of the ACE D- and the G-protein beta3 T-allele in major depression: a possible link to cardiovascular disease?

Although it is well established that depression is a major risk factor for the development of coronary artery disease and that cerebrovascular disease can be a major contributing factor for the development of depression, the information about the interplay between the central nervous system and cardiovascular disease is still limited. We investigated the angiotensin I converting enzyme (ACE) ID and the G-protein beta3-subunit (Gbeta3) C825T polymorphism in 201 patients with unipolar major depression and 161 ethnically and age-matched controls. Both gene variants have earlier been associated with either cardiovascular disease or affective disorders, making them good candidates for a combined analysis. We found a significant increase in the Gbeta3 T allele (OR = 1.61, 95% CI 1.17-2.2, P = 0.0035) and a marginal altered genotype distribution of the ACE ID polymorphism with decrease in the II genotypes (chi(2) = 6.43, df=3, P = 0.04) in the patients' group. Analysing the data for both genes we found that the combined actions of ACE and Gbeta3 genotypes accumulate in carriers of the ACE D allele (ID and DD) and Gbeta3 TT homozygotes with ID/DD-TT carriers showing a more than five-fold increase in risk for major depression (crude OR = 5.83, 95% CI 1.99-17.08, P = 0.0002). As our study was carried out with depressive patients without serious cardiac impairment at the time of the investigation, we are presently unable to predict whether this combined action of the ACE ID/DD-Gbeta3 TT genotype is increasing the risk for both disorders. Nevertheless our study reports for the first time that the same allelic combination of two genes that have been shown to increase the risk for myocardial infarction (Naber et al, 2000) increase the vulnerability for depressive disorder.

[Diagnostic shifts of functional psychoses in the transition from ICD-9 to ICD-10]

In order to identify diagnostic changes caused by the transition from ICD-9 to ICD-10, in a sample of 218 first hospitalised patients from the years 1980 and 1981, ICD-9 diagnoses were compared with ICD-10 diagnoses. For this comparison, functional psychoses were classified into five main diagnostic groups. Results showed a decreased frequency of the diagnostic groups schizophrenia, schizoaffective psychoses, and paranoid psychoses and an increased frequency of the diagnostic groups acute psychoses and affective psychoses. With the exception of acute psychoses and schizoaffective psychoses, a high agreement between ICD-9 and ICD-10 diagnoses was found, and the Kappa value was 0.70. With regard to the homogeneity of psychopathological symptoms, ICD-10 diagnoses showed no improvement over ICD-9 diagnoses. Nevertheless, ICD-10 diagnoses have gained in predictive validity because schizophrenia was further narrowed to cases with a more unfavourable outcome.

Frequency of manic symptoms during a depressive episode and unipolar 'depressive mixed state' as bipolar spectrum

OBJECTIVE

To report the frequency of intra-episode manic symptoms in depressive episodes, and to evaluate unipolar depressive mixed state (DMS) as bipolar spectrum.

METHOD

A total of 958 (863 unipolar, 25 bipolar II, and 70 bipolar I) depressive in-patients were assessed in terms of manic symptoms at admission, and several clinical variables using standardized methods.

RESULTS

The frequency of manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility) was significantly higher in bipolar depressives than in unipolar depressives. Unipolar depressives with DMS - defined as having two or more manic symptoms - had more similarities to bipolar depressives than to other unipolar depressives in clinical variables such as onset age, family history of bipolar disorder, and possibly suicidality.

CONCLUSION

Depressive mixed state is frequent, particular in bipolar depressives. Unipolar depressives with DMS may be better classified into bipolar spectrum.

The boundary between mixed and manic episodes in the ICD-10 classification

OBJECTIVE

To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.

METHOD

In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.

RESULTS

Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.

CONCLUSION

The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.

Are bipolar I depressive patients less responsive to treatment with antidepressants than unipolar depressive patients? Results from a case control study

The increasing evidence that bipolar and unipolar affective disorders have different biological etiologies and courses of illness has been associated with an intensifying interest in specific treatment regimens for both disorders during the last decade. In this context, the question arose whether antidepressants exert similar efficacy in the acute treatment of bipolar compared to unipolar depression. Although the clinical impression does not indicate substantial differences in the efficacy of antidepressants between these groups of patients, empirical databases concerning this topic are rare. The present study compared the efficacy of antidepressants in 50 unipolar and 50 bipolar depressed inpatients (ICD-9 criteria) under naturalistic treatment conditions. Both groups of patients were matched for age, gender and duration of illness. Clinical assessments of status at the time of admission and at discharge were used to rate response to antidepressant treatment. Analyses of the data revealed that both groups of patients needed the same time for treatment response and did not show any significant differences in outcome measures at discharge. These findings do not concur with the hypothesis formulated by some experts in the field of affective disorders that antidepressants are less effective in the acute treatment of bipolar depressed patients compared to unipolar depressed patients.

Neuroleptic malignant syndrome due to atypical neuroleptics: three episodes in one patient

Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal complication of antipsychotic medication. The risk of developing NMS under atypical neuroleptics seems lower than under typical neuroleptics. However, the use of atypical neuroleptics in modern psychopharmacotherapy is increasing, so the incidence of NMS under these drugs may also increase. Here, we will describe three episodes of NMS that fulfilled the DSM-IV criteria for NMS (APA, 1994). The epivodes of NMS occured under treatment with clozapine, risperidone, and amisulpride. These episodes had some atypical features that will be discussed with regard to the pathophysiological mechanisms leading to NMS.

Are antidepressants less effective in the acute treatment of bipolar I compared to unipolar depression?

BACKGROUND

Using our routine documentation system we evaluated the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I depressed patients compared to unipolar depressed patients.

METHOD

Based on the data from 2032 consecutively admitted inpatients with unipolar or bipolar I depression we compared the efficacy of antidepressants in both groups. The outcome was assessed by the Global assessment scale (GAS), the duration of hospitalisation and the Apathic-, Depressive- and Manic Syndrome subscales of the Association for Methodology and Documentation in Psychiatry system.

RESULTS

Cohorts were comparable in treatment regimens and severity of depression at admission. At discharge, there were no statistically significant differences between bipolar I and unipolar depression for the outcome criteria Depressive Syndrome scale, GAS score and days in hospital. Bipolar patients showed a slightly decreased score of the Apathic Syndrome scale at discharge, also reflected by a slightly elevated score of the Manic Syndrome scale.

LIMITATIONS

This study did not check for differences in side effects such as switching or cycling commonly attributed to the use of tricyclic antidepressants in bipolar patients. Naturalistic data were obtained prospectively, analysis, however, was done retrospectively, thus limiting, but not completely excluding a possible selection bias.

CONCLUSION

Evaluating different outcome criteria, our naturalistic data of a large cohort seem to reject the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I compared to unipolar depressed patients.

Deficit states in schizophrenia and their association with the length of illness and gender

The present study investigated the association between the frequency of deficit states (DS) and the length of illness and gender in schizophrenic patients. The following hypotheses were examined: 1) there is an association between the length of schizophrenic illness and the frequency of DS and 2) the frequency of DS in patients with comparable length of illness is higher in males than in females. Patients, included in the study, were consecutively hospitalized and diagnosed according to ICD-9 criteria (ICD-9: 295-295.9). Psychopathological assessment was performed in a standardized manner. Group differences were evaluated by using the t-test or the chi-square statistics. Variables with a possible impact on the occurrence of DS were entered into a backward multiple logistic regression model. 622 patients (total = 3914) were classified as having a DS. Logistic regression analysis revealed that the risk of having a DS was increased with a longer duration of illness (OR =1.68) and was reduced for female gender (OR = 0.56). The findings are in line with the hypothesis that apart from a neurodevelopmental origin, the schizophrenic illness may also have a progressive neurodegenerative component, which clinically emerges as DS.

Suicidality in bipolar compared to unipolar depressed inpatients

The aim of the present analyses was to evaluate differences in suicidality (past suicide attempts, suicidal thoughts at time of admission and completed suicides during the hospital stay) between bipolar and unipolar depressed inpatients. Apart from a higher frequency of past suicide attempts in bipolar depressed patients (26.6% in bipolar vs. 17.8% in unipolar patients), findings do not indicate any further differences in suicidality (suicidal thoughts (about 40% in both groups) and completed suicides during the hospital stay (0.8% in both groups)) between bipolar and unipolar patients. Factors with a predictive value for suicidal thoughts at the time of admission were a positive family history for affective disorders, past suicide attempts, and the depressive and paranoid hallucinatory syndrome (all associated with an increased risk). Female gender, an older age at hospitalisation and a longer duration of the illness were found to be associated with a lower probability for having suicidal tendencies at the time of admission. The risk for committing suicide during the hospital stay was increased if the patients had a history of past suicide attempts and suicidal thoughts at the time of admission. A more pronounced depressive syndrome at time of admission was slightly associated with a lower risk of committing suicide.

Long-term course of schizophrenic, affective and schizoaffective psychosis: focus on negative symptoms and their impact on global indicators of outcome

OBJECTIVE

The aim of this study was to compare indicators of outcome between different types of psychosis and to verify whether or not negative symptoms (NS) have a special relevance for schizophrenia.

METHOD

This is a follow-up study on functional psychosis according to ICD-9. Patients were assessed standardized at the time of first hospitalization and about 12.5 years later.

RESULTS

Comparison of global outcome parameters and NS revealed that schizophrenia had the poorest outcome of all types of psychosis. NS had the highest impact on global functioning and the severity of illness in schizophrenia. NS assessed at the first hospitalization were associated with the different outcome parameters only in schizophrenia at follow-up.

CONCLUSION

The course of schizophrenia is a more deteriorating one than that of affective or schizoaffective psychosis. The findings point to the special relevance of NS for the outcome and their relative specificity for schizophrenia.

Dipole localization of P300 and normal aging

At present, our understanding of how normal aging affects in vivo brain function is rudimentary. Therefore, the aim of the present study was to investigate age effects on auditory P300 topography. A recently developed dipole source model for P300 distinguishes overlapping P300 subcomponents and enhances reliability as well as validity of the measurement. 67 healthy subjects were examined using the P300 dipole model in addition to the scalp data measurement. The results show that P300 subcomponents reflect functionally different processes concerning age changes of P300 activities. Temporo-parietal P300 is smaller in older subjects, whereas frontal P300 is not attenuated. Age affected both P300 subcomponents' latencies. Therefore, the functionally different alteration of P300 subcomponents might be the reason for P300 topography changes with the P300 maximum more frontally in older age.

Mood-stabilisers reduce the risk of developing antidepressant-induced maniform states in acute treatment of bipolar I depressed patients

BACKGROUND

The aim of this study was to give further support to the available evidence that mood stabilizers can reduce the risk of antidepressant-induced maniform switch phenomena in bipolar I depressed patients.

METHODS

Medical records of 158 patients with bipolar I depression were analysed for the incidence of switch phenomena from depression to maniform states (mania and hypomania). The impact of mood stabilizers on reducing the risk of switching was analyzed using logistic regression analyses.

RESULTS

Maniform switches during inpatient treatment were observed in 39 (25%) patients out of the total of 158 patients. Results indicate that especially patients receiving tricyclic antidepressants are at risk of switching to maniform states. This risk was shown to be significantly less when patients also received a mood stabilising medication (lithium, carbamazepine or valproic acid).

LIMITATIONS

This was a retrospective study with patients receiving naturalistic treatment. A prospective, double-blind design would probably lead to more conclusive findings.

CONCLUSIONS

Treatment with mood stabilizers may be a potent strategy to reduce the risk of antidepressant-induced maniform switches in bipolar I depressed patients.

[What do medical students in the 6th clinical semester know about psychiatric emergencies?]

OBJECTIVE

The aim of the present study was to evaluate the knowledge of medical students in psychiatric emergencies.

METHODS

Medical students were questioned concerning their knowledge about psychiatric emergencies, shortly before finishing their theoretical part of the medical training program.

RESULTS

Findings indicated that medical students have significant deficits in psychiatric knowledge. Nevertheless, most students reported to be interested in psychiatry and to acknowledge the importance of psychiatric knowledge for general practioners.

CONCLUSIONS

The reasons for the reported deficits cannot be sufficiently explained by a lack of interest in psychiatry or a negation of the importance of knowledge in psychiatry for general practioners and may hint to conceptual problems in the organisation of the medical training programs.

Impact of duration of symptoms prior to first hospitalization on acute outcome in 998 schizophrenic patients

The hypothesis that a longer duration of symptoms prior to first hospitalization is associated with a poorer treatment response was prospectively investigated in 998 first-hospitalized schizophrenic patients. Results indicate that most indicators of outcome were worse when the duration of symptoms was long. This was also true when age, gender, as well as the acuteness of illness were controlled for in the analyses.

Epidemiological evidence for a low abuse potential of zolpidem

The abuse risk of new non-benzodiazepine hypnotics such as zolpidem has been discussed in a number of recent publications. We performed a Medline analysis which showed that, to date, 15 cases of abuse or dependence have been published. In 6 patients, the abuse was secondary to other forms of abuse or dependence. Other data from medical statistics and pharmacoepidemiological studies suggest the abuse potential of zolpidem to be much lower than that of other hypnotics. We conclude that zolpidem is a relatively safe drug compared to conventional hypnotics. Patients with other substance abuse histories may be considered as risk patients for later abuse of zolpidem.

Deficit syndromes in schizophrenic patients 15 years after their first hospitalisation: preliminary results of a follow-up study

This study is a follow-up study on broadly defined schizophrenic disorders. Patients were assessed standardized at the time of their first hospitalization (admission and discharge) and reassessed in an standardized manner 15 years later. The aim of the analyses presented here was to evaluate the frequency of patients with markedly expressed negative symptoms in terms of deficit syndrome and to analyze which of the variables assessed at the time of first hospitalization were predictive concerning deficit syndromes at follow-up. Results indicate that nearly one third of patients have developed a deficit syndrome 15 years after their first hospitalization. These patients are characterized by severe impairments in important areas of life, such as partnership or employment. Furthermore, apart from more pronounced negative symptoms, these patients also have more paranoid-hallucinatory symptoms than schizophrenic patients without deficit syndromes. Predictive signs for non-development of a deficit syndrome 15 years later were good global functioning, female gender, pronounced depressive symptoms and good treatment response concerning negative and paranoid-hallucinatory symptoms at first hospitalization. A longer duration of symptoms prior to first hospitalization, lack of a partnership, pronounced negative symptoms at admission and at discharge were predictive of developing a deficit syndrome. Results are discussed with regard to the literature and to methodological limitations.

Are low basal serum levels of the thyroid stimulating hormone (b-TSH) a risk factor for switches into states of expansive syndromes (known in Germany as "maniform syndromes" in bipolar I depression?

Switching over from depression into states known an "maniform" in Germany ("expansive syndromes") been frequently, observed and appears to be partially related to the type of antidepressive medication. Apart from the medication, some evidence suggests that additional factors such as thyroid function may be relevant for the switchover. With this background, the aim of the present study was to evaluate the hypothesis that depressed bipolar patients with lower basal TSH serum levels (b-TSH) on admission at the hospital as inpatients are at a higher risk of switching from depression into "maniform" states than depressed bipolar patients with higher b-TSH. From a total of 158 bipolar depressed patients, 16 patients developed mania during their hospital stay. After dividing the sample of patients at the median b-TSH into one group with lower b-TSH (N = 78) and another group with higher b-TSH (N = 79), we found that the switchover rate to mania was significantly higher in the group of patients with lower b-TSH (15.4%) than in the group of patients with higher b-TSH (5.1 %). These findings suggest that lower b-TSH may be a risk factor for switching over from depression into "maniform" states in bipolar depressed patients.

The loudness dependency of the auditory evoked N1/P2-component as a predictor of the acute SSRI response in depression

RATIONALE

A serotonergic dysfunction is supposed to play a pathogenetic role in depression, but there is a considerable number of non-responders in the acute treatment of depression with serotonergic agents like SSRI. Thus, an indicator of central serotonergic activity could lead to a more specific pharmacological treatment of depression. In animal and human data there is a growing amount of evidence that a strong loudness dependency of late auditory evoked potentials (LDAEP) is an indicator of low serotonergic activity and vice versa.

OBJECTIVE

In 29 depressive inpatients (DSM-III-R diagnosis 296.x in 28 patients, 300.4 in one patient), the hypothesis was tested that a strong LDAEP prior to treatment can predict a better clinical outcome under SSRI treatment over 4 weeks.

RESULTS

Patients with a strong pre-treatment LDAEP had a significantly greater decrease of depressive symptoms (Hamilton Scale for Depression) after 4 weeks than patients with a flat LDAEP. Significantly more responders fell into the group with a high LDAEP. Contrary to what might be expected, a second recording in a subsample of 19 patients after 4 weeks of treatment failed to show changes in the LDAEP.

CONCLUSION

Our finding confirms the hypothesis that a strong LDAEP, indicating a low serotonergic activity, is related to a favorable response to acute SSRI treatment in depression. The LDAEP is a promising tool for the prediction of response to serotonin agonists in depression and it seems to be of clinical importance.

Prevalence and background factors of depression in first admitted schizophrenic patients

OBJECTIVE

The aim of this study was to investigate the prevalence and background factors of depression in first admitted schizophrenic patients.

METHOD

The study is an analysis of 998 consecutively admitted schizophrenic patients with their first hospitalization. Patient's characteristics were prospectively assessed using standardized instruments at the time of first admission and discharge.

RESULTS

High prevalence rates of depressive symptoms were found. Depressed schizophrenic patients were more likely to have suicidal tendencies, were older, more frequently married, less frequently single and unemployed and had more family members with psychiatric disorders other than schizophrenia than the non-depressed patients. Positive, negative and extrapyramidal symptoms do not have a substantial influence on depression in these patients.

CONCLUSION

The study suggests that depression represents a distinct psychopathological dimension of the acute illness in first admitted schizophrenic patients. In particular, in light of the suicidal tendencies, recognition and treatment of depression is an important clinical task.

[Decision-making and delusion. A study on decision-making in delusional, depressive and healthy subjects]

Delusion as a phenomenon was always in the focus of psychiatric interest. Explanations for its origin reach from disturbed perception or affect to deficits in cognition. In our study we investigated 20 deluded, 20 depressive and 20 healthy subjects in order to find out differences in decision making, while a neutral test situation. Our hypothesis was that deluded subjects need less information for decision making and tend less to change their decision, made before, than both control groups will do this. For examination our hypothesis a modified version of "Probabilistic Inference Task" by Philips and Edwards was performed. In summary we found that deluded subjects need less information for decisions making than the control groups. Furthermore, decision making of deluded subjects seems more impulsive and less referring to formal logical criteria than it was found in depressed and healthy volunteers.

Neurochemical substrates and neuroanatomical generators of the event-related P300

The present review focuses on the current knowledge of the neurochemical processes and neuronal structures involved in the generation of P300. The increasing knowledge in this area facilitates the physiological interpretation of P300 findings as well as the link between P300 research and other research findings in biological psychiatry. Concerning the question of neurochemical substrates, the glutamatergic, GABAergic, cholinergic, noradrenergic, dopaminergic and serotonergic influences on P300 are reviewed. The knowledge of the generating structures of P300 is summarized from intracranial studies, magnetoencephalographic investigations, lesion and animal studies.

Antidepressant-associated maniform states in acute treatment of patients with bipolar-I depression

Medical records of 158 patients with bipolar depression were analysed for the incidence of a switch from depression to maniform states (mania and hypomania). Relation to psychopharmacological treatment was investigated. Thirty-nine (25%) patients of the total sample had switched to a maniform state during the treatment period in the hospital. Among that group the phenomenon occurred in 23 patients (15%) as a hypomania and in 16 patients (10%) as a mania. Patients with a switch were significantly more often treated with tricyclic antidepressants (TCA) than patients without switch (79.5% vs 51.3%). Mood stabilising medication might reduce the risk for switching, especially in patients treated with TCA; however, it seems not totally sufficient, since 59% of the switched patients received mood stabilisers. The switch phenomenon was not associated with sociodemographic or clinical data.

The serotonin syndrome scale: first results on validity

As a modification of the diagnostic criteria of the serotonin syndrome proposed by Sternbach, we developed the Serotonin syndrome scale for the operationalized assessment of both the presence and the severity of the core symptoms of the serotonin syndrome. In a first study on the validity of this scale, the relationships between the serotonin syndrome score (SSS) and both the paroxetine plasma levels (n = 42) and the loudness dependence of the auditory evoked potentials (LDAEP; n = 24) were investigated in depressed patients treated with paroxetine. A strong LDAEP is supposed to indicate low central serotonergic neurotransmission, and vice versa. The SSS was positively related to paroxetine plasma levels and negatively to the LDAEP. Both results support the validity of the serotonin syndrome scale. Using a SSS > 6 as diagnostic criterion, mild serotonin syndromes were diagnosed in 5 of our 42 patients. The Serotonin syndrome scale may become a useful tool for clinicians and scientists dealing with the serotonin syndrome.