Retinal single-layer analysis with optical coherence tomography (OCT) in schizophrenia spectrum disorder

BACKGROUND

Volume reductions in brain structures of patients with schizophrenia spectrum disorder (SSD) have repeatedly been found in voxel-based morphometry MRI studies. Hence, an underlying neurodegenerative etiological component of SSD is currently being discussed. In recent years, the imaging method of optical coherence tomography (OCT) has shown its potential in evaluating structural changes in the retina in patients with confirmed neurodegenerative disorders, providing a window into the brain.

METHODS

Twenty-six patients with schizophrenia or schizoaffective disorder and 23 age- and sex-matched healthy controls were examined with the Heidelberg Spectralis OCT system to derive a single-layer analysis of both retinas. The segmentation of retinal layers was manually corrected to minimize artifacts and software imprecisions.

RESULTS

Compared to the control group, SSD patients showed reduced thickness and volume measurements for nearly all retinal layers, and these differences reached significance for macular volume, macular thickness, retinal nerve fiber layer (RNFL) and inner nucleiform layer (INL). Furthermore, a significant correlation between the duration of illness and the total volume of the RNFL was found.

CONCLUSION

Our OCT measurements demonstrate reduced single retinal layer thickness in patients with SSD. In the context of the MRI volume changes, our results provide further evidence that structural changes seen in the brain of patients are also observable in the retina, potentially allowing further insights into the different components of the nervous system that are altered in this highly etiologically complex disorder.

[Use of summaries of product characteristics (SmPC) among family doctors and pharmacists in the context of the aut-idem regulation: Results of an exploratory cross-sectional survey]

INTRODUCTION

Summaries of product characteristics (SmPC) of same-substance medications may feature content-related differences. This may cause difficulties regarding informed consent in the case of prescriptions of drugs in the context of the aut-idem regulation. A survey among family doctors (FD) and pharmacists (PH) was conducted in order to evaluate the usage behaviour of SmPCs, sources used to obtain information about drugs and the awareness of the existence of differences between SmPCs of same-substance medications.

METHODS

An exploratory/non-representative, questionnaire- and telephone-based, semi-structured cross-sectional survey was performed (June to August 2018).

RESULTS

Participation rate of FD and PH was 29.8 % (34/114) and 73.0 % (73/100), respectively. In the previous month, all PH and 82.4 % of FD said that they had used a SmPC at least once (p=0.001). FD used SmPCs 6.4±4.9 and PH 65.0±52.5 times a month (p<0.001). In both occupational groups SmPCs were used most frequently to obtain information about dosing and/or type of application (FD: 97.1 %; PH: 98.6 %) and contraindications (97.1 % and 86.3 %, resp.). In both samples, the internet was the most frequently used drug information source (FD: 97.1 %; PH: 98.6 %), followed by the Rote/Gelbe Liste (97.1 % and 71.2 %, resp.) and the SmPCs of the original product (52.9 % and 65.8 %, resp.) or generic drug (52.9 % and 61.6 %, resp.). Only 32.4 % of the FD vs. 79.5 % of PH believed that differences might exist between SmPCs of same-substance medications (p<0.001). FD stated that they never (11.8 %) or rarely (85.3 %) use SmPCs for informed consent. It was indicated that the aut-idem substitution is excluded in 10.3 %±5.0 (FD) and 9.6 %±6,1 (PH) of issued or received prescriptions.

DISCUSSION

The results of the present survey indicate a low utilization rate of SmPCs by FD and little awareness of the existing differences of SmPCs of same-substance medications in this occupational group. Both aspects may impede proper information of patients, particularly in cases of aut-idem prescriptions of substances for which many same-substance medications with different SmPCs are available.

CONCLUSION

Physicians should use SmPCs regularly and keep themselves informed about differences between SmPCs of same-substance medications.

[Different number of contraindications between summaries of product characteristics (SmPC) of drugs with the same active ingredients - an analysis of data from SmPCs of neuropsychiatric drugs]

OBJECTIVE

In the case of prescriptions of pharmaceuticals in the context of the aut-idem-regulation the physician frequently does not know, which same-substance medication is dispensed in the pharmacy; the contemplable same-substance medications may differ in numerous features which raises questions regarding the obligation to give information and medical liability for medical malpractice. Currently, systematic evaluations regarding differences between summaries of product characteristics (SmPCs) of same-substance medications are missing. To determine size and type of those differences SmPCs of most (neuro)psychiatric drugs that are approved in Germany were evaluated regarding the number of listed contraindications (CI).

METHODS

Basis for the selection of substances was the Anatomical Therapeutic Chemical (ATC) Classification System (group ATC N Nervous System). Substances that are approved in Germany for the treatment of mental disorders according to ICD-10 F were included. Brand-name medications and SmPCs were searched by means of further in- and exclusion criteria via the online services of PharmNet.Bund, Gelbe Liste, Rote Liste^®/Fachinfo-Service^® and communication with the manufacturer.

RESULTS

N = 941 SmPCs (=116 substances) were evaluated. Considering only the group of SmPCs with > 1 brand-name medication (n = 78; 67.2 %) differences in the number of CIs were found in more than the half of substances (N = 43; 55.1 %). Considering indication groups most groups of SmPCs of same-substance medications with differences in the numbers of CIs were found in - considering only substances with > 1 brand-name medication - hypnotics and sedatives (77.8 %), anxiolytics (75.0 %), drugs for treatment of substance use disorders (66.7 %), antidepressants (61,9 %), anticonvulsant drugs and mood stabilizers (53.8 %), followed by antipsychotics (41.2 %), antidementia-drugs (20.0 %), and psychostimulants (0 %). Largest ranges regarding the number of CIs were found in the SmPCs of morphine (14), amitriptyline (8), chlorprothixene (6), lorazepam (6) and citalopram (4).

CONCLUSION(S)

In numerous (neuro-)psychopharmacologic substances differences exists between the SmPCs of the associated same-substance medications regarding the number of CIs. Due to the outstanding evaluation of content aspects of these differences and legal evaluation the relevance of this result for clinical practice is not yet clear.

Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation

We examined the association between the duration of untreated psychosis and outcome for patients with delusional infestation. This multi-centre international study included 211 consecutive patients. Illness severity was evaluated at first presentation and outcome was measured with the Clinical Global Impression scale (CGI) at baseline and follow-up. A regression analysis showed a clear clinical and statistically significant association between shorter duration of untreated psychosis and better outcome at follow-up. Patients with a duration of untreated psychosis of less than one year showed a CGI-S change from 5.37 to 2.07; those with a duration of untreated psychosis of 1-5 years a change from 5.48 to 2.59, and those with a duration of untreated psychosis of >5 years a change from 5.59 to 3.37. This difference of 1.1 CGI points between the groups resembles a clinically relevant difference in patient outcome. Our results suggest that longer duration of untreated psychosis in patients with delusional infestation is associated with significantly less favour-able clinical outcomes.

Psychiatrists' and dentists' knowledge and attitudes regarding adverse drug reactions of psychotropic drugs

Psychotropic drugs may induce impairments in the mouth, jaw and face area. Currently, appropriate pharmacoepidemiologic data are missing. Therefore, a questionnaire-based telephone survey of two non-representative samples of psychiatrists and dentists was conducted. Most of the psychiatrists (79.7%) and dentists (76.5%) indicated that psychotropic drugs may induce dental adverse drug reactions (ADR); in both samples there was an approximately equally sized, relevant proportion of participants who did not believe in the risk of dental ADR of psychotropic drugs (psychiatrists 20.3%; dentists 23.5%). About one third of the participants of both samples (psychiatrists 34.9%; dentists 35.9%) felt that dental ADRs of psychotropic drugs are a serious health problem. The majority of both groups (psychiatrists 97.8%; dentists 97.0%) had never reported a dental ADR. Most psychiatrists and dentists appeared to be aware of the risk of dental ADRs by psychotropic drugs. A relevant proportion of participants of both groups considered psychotropic drugs to be irrelevant regarding dental ADRs; therefore, there may be information needs in both groups. The willingness to report dental ADRs of psychotropic drugs was low in both groups; the evaluation of the actual relevance of this drug-related risk is impeded by the absence of reports of suspected ADRs.

Regional gray matter volume and structural network strength in somatic vs. non-somatic delusional disorders

BACKGROUND

Monothematic delusional disorders are characterized by a single tenacious belief. They provide a great opportunity to study underlying brain structures in the absence of confounding symptoms that accompany delusions in schizophrenia. Delusional beliefs include persecution, jealousy or somatic delusions including infestation. It is unclear whether specific delusional content is associated with distinct neural substrates.

METHODS

We used magnetic resonance imaging in patients presenting with somatic vs. non-somatic delusional disorders. Patients with delusional infestation (DI, n=18), and individuals with non-somatic delusional disorders (n=19) were included, together with healthy volunteers (n=20). Uni- and multivariate techniques for structural data analysis were applied to provide a comprehensive characterization of abnormal brain volume at both the regional and neural network level.

RESULTS

Patients with DI showed lower gray matter volume in thalamic, striatal (putamen), insular and medial prefrontal brain regions in contrast to non-somatic delusional disorders and healthy controls. Importantly, these differences were consistently detected at regional and network level. Compared to healthy controls, patients with delusional disorders other than DI showed lower gray matter volume in temporal cortical regions.

CONCLUSION

The data support the notion that dysfunctional somatosensory and peripersonal networks could mediate somatic delusions in patients with DI in contrast to delusional disorders without somatic content. The data also suggest putative content-specific neural signatures in delusional disorders and in delusion formation per se.

Retinal changes in patients with major depressive disorder - A controlled optical coherence tomography study

BACKGROUND

Recent studies on the pathophysiology of major depression (MD) indicate that degenerative and inflammatory processes may play a role. This finding is supported by magnetic resonance imaging (MRI)-based meta-analysis that show volume reductions in circumscribed areas of the brain in patients with MD. Using optical coherence tomography (OCT), retinal changes have been demonstrated in neurodegenerative disorders. In light of this inflammatory/degenerative hypothesis, we tested whether patients with MD exhibit retinal alterations that might correlate with the severity and duration of the disease.

METHODS

Patients with MD and age- and gender-matched healthy controls were recruited for the measurement of the total volume and thickness of their retina as well as the thicknesses and volumes of five different retinal layers using single-layer-analysis provided by the spectral-domain-OCT.

RESULTS

OCT data from 28 patients with MD and 20 healthy controls were available for evaluation. The exploratory intra-individual group comparison of the two eyes showed a small but significant difference in the retinal total volume (right = 8.69mm³; left = 8.72mm³; p = 0.03) only in patients with MD. There were no other significant differences between the patients with MD and the healthy controls with respect to the OCT measurements.

LIMITATIONS

The small group size as well as the absence of correction for multiple testing due to the exploratory design should be considered as limitations of our study.

CONCLUSION

While retinal total volume differs between the eyes of patients with MD, the comparison of retinal parameters between these patients and age- and gender-matched healthy volunteers did not show any differences.

[Psychiatric Emergencies in the Preclinical Emergency Medicine Service in Ulm, Germany in 2000 and 2010, and Practical Consequences]

Background Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided.

Mild Hypothermia in a Child with Low-Dose Risperidone

Abstract. Risperidone is a widely used, second-generation antipsychotic approved for treating schizophrenia as well as for treating aggression in children and adolescents with mental retardation. The substance has a well-established risk profile including alterations of body temperature. Apart from hyperthermia with and without full-blown malignant neuroleptic syndrome, low body temperatures (hypothermia) have also been reported anecdotally, usually appearing in the context of comedication. Here, we report a case of hypothermia associated with a low-dose risperidone monotherapy in a child.

[Gender aspects in female and male physicians : Occupational and psychosocial stress]

BACKGROUND

International studies have shown that physicians have an elevated risk of developing depression or burnout syndrome. Gender aspects with regard to occupation are discussed in German politics and society. Currently, there is little data comparing female and male physicians with regard to stress at work, depression, and burnout.

OBJECTIVES

Are there differences between male and female physicians with respect to psychosocial strain, emotional exhaustion, and depression?

METHODS

In different cross-sectional studies, anaesthetists, psychiatrists and dentists filled out a questionnaire containing questions on personal data, occupation, past medical history and medication intake. Additional standardized questionnaires (Beck Depression Inventory (BDI) and Maslach Burnout Inventory (MBI)) were performed.

RESULTS

The return rate was 51.8 % (n = 3782). Male and female physicians vary significantly in social data, participation in the job, and health status. Female physicians are on average not married (p < 0.001) and have significantly fewer children (p < 0.05). Leading positions are mostly held by male physicians (p < 0.001); female physicians more often work in part-time jobs (p < 0.001). Female physicians reached higher scores of emotional exhaustion (MBI) (p < 0.01) and depression (BDI) (p < 0.001).

DISCUSSION

The study shows big differences between male and female physicians with respect to their occupation, personal life, and psychosocial wellbeing. Female physicians more often report burnout and depression. Causes might be family and job strain, gender aspects in hierarchy, as well as different recognition and interpretation of symptoms.

[Arterial Hyper- and Hypotension associated with psychiatric medications: a risk assessment based on the summaries of product characteristics (SmPCs)]

Introduction Psychiatric medications are well-known triggers of clinically relevant blood pressure changes. Therefore, we aimed at creating ranking lists for their risk of causing arterial hyper- or hypotension. Methods We analyzed 784 Summaries of Product characteristics (SmPCs, available online from "Rote Liste" or "Gelbe Liste" websites) from 105 psychiatric medications registered in adult psychiatry in Germany and extracted the standardized reported risks of increasing or decreasing arterial blood pressure. Results According to the SmPCs, atomoxetine had the highest risk of arterial hypertension ("very frequent", > 10 %), and another 15 substances followed in the category "frequent" (> 1 %): duloxetine, milnacipran, venlafaxine, bupropion, citalopram, tranylcypromine (particularly with certain diets), reboxetine, methylphenidate, clozapine, paliperidone, risperidone, buprenorphine+naloxone, memantine, galantamine, and rivastigmine. Conversely, 7 substances, namely amitriptyline, tranylcypromine, chlorprothixen, flupentixol, levomepromazine, olanzapine and trimipramine had the highest reported risk of low blood pressure ("very frequent"), and another 25 substances had the risk "frequent". No risk of hypertension or hypotension was documented for many other substances. Incidentally, we observed that the reported effects on blood pressure for single substances (e. g. citalopram) markedly differed between the SmPCs from different manufacturers, rendering a clear risk assessment impossible for many medications. Discussion According to the German SmPc, many psychiatric medications are associated with the risk of arterial hypertension and, even more so, hypotension. We hardly observed substance group effects, such as high blood pressure with noradrenergic antidepressants. Commonly used tables summarising secondary causes of arterial hypertension should be revised in terms of psychiatric medications. Our rank orders of risk may aid choosing the best psychiatric medications in patients with known hypertension or at risk for syncope, as well as when blood pressure changes occur under psychiatric pharmacotherapy. A definitive risk assessment however requires controlled studies.

Cortical features of distinct developmental trajectories in patients with delusional infestation

BACKGROUND

Although there is strong neuroimaging evidence that cortical alterations are a core feature of schizophrenia spectrum disorders, it still remains unclear to what extent such abnormalities occur in monothematic delusional disorders. In individuals with delusional infestation (DI), the delusional belief to be infested with pathogens, previous structural MRI studies have shown prefrontal, temporal, parietal, insular, thalamic and striatal gray matter volume changes. Differential contributions of cortical features of evolutionary and genetic origin (such as cortical thickness, area and folding) which may distinctly contribute to DI pathophysiology are unclear at present.

METHODS

In this study, 18 patients with DI and 20 healthy controls (HC) underwent MRI scanning at 1.0T. Using surface-based analyses we calculated cortical thickness, surface area and local gyrification index (LGI). Whole-brain differences between patients and controls were investigated.

RESULTS

Surface analyses revealed frontoparietal patterns exhibiting altered cortical thickness, surface area and LGI in DI patients compared to controls. Higher cortical thickness was found in the right medial orbitofrontal cortex (p<0.05, cluster-wise probability [CWP] corrected). Smaller surface area in patients was found in the left inferior temporal gyrus, the precuneus, the pars orbitalis of the right frontal gyrus, and the lingual gyrus (p<0.05, CWP corr.). Lower LGI was found in the left postcentral, bilateral precentral, right middle temporal, inferior parietal, and superior parietal gyri (p<0.01, CWP corr.).

CONCLUSION

This study lends further support to the hypothesis that cortical features of distinct evolutionary and genetic origin differently contribute to the pathogenesis of delusional disorders. Regions in which atrophy was observed are part of neural circuits associated with perception, visuospatial control and self-awareness. The data are in line with the notion of a content-specific neural signature of DI.

From Imaging the Brain to Imaging the Retina: Optical Coherence Tomography (OCT) in Schizophrenia

Optical Coherence Tomography (OCT) is a noninvasive imaging method, which provides an in vivo image of the retina. It allows for quantitative measurements of retinal and macular thickness, including single-layer analysis. Because the retinal nerve fibre layer comprises the first axons of the visual pathway and is unmyelinated, it can be considered a unique anatomical model, which may provide insight into the pathophysiological processes of diseases with a neurodegenerative character. In fact, past OCT studies have emphasized the role of the visual pathway as an ideal structure for exploring neurodegeneration and have demonstrated the potential of the method as an instrument for longitudinally monitoring structural changes in neurological disorders such as multiple sclerosis. Progress in signal processing and advancements to the OCT technique enables the illustration of structural changes in the retinal layers in a quick, reproducible, and objective manner with a spatial resolution comparable to those of histological slices.Findings from computer-based magnetic resonance imaging analyses and neuropathological studies support the hypothesis of a degenerative component of certain psychiatric disorders such as schizophrenia. Studies in schizophrenia incorporating OCT are currently rare and have yielded further heterogeneous results. This article elucidates the method of OCT and the retina's role as a "window to the brain". Furthermore, in delineating the degenerative components of schizophrenia, we discuss the possible applications of OCT in the schizophrenia population.

Association between haemorrhages and treatment with selective and non-selective serotonergic antidepressants: Possible implications of quantitative signal detection

Inhibition of serotonin uptake in platelets seems to be the crucial mechanism underlying SSRI-associated haemorrhages. This effect is also present in antidepressants featuring non-selective serotonin reuptake inhibition (non-SSRI). Impact of selectivity of serotonin reuptake and/or affinity to the serotonin reuptake transporter on the bleeding risk have not yet been studied sufficiently. We retrieved country- and SSRI-/non-SSRI-specific data from the Uppsala Monitoring Centre and used a case/non-case approach to calculate substance-specific reporting odds ratios (ROR) to evaluate the statistical association of treatment with SSRI/non-SSRI and haemorrhages. Country-specific analysis revealed no clear trends towards an increased risk of bleeding related to particular agents of group SSRI/non-SSRI (sporadically ROR>1 for citalopram, duloxetine, escitalopram, fluvoxamine, paroxetine, sertraline, St. John's wort). There was a clear trend in the total dataset towards a "reduced protective effect" (suggested by ROR<1) on the development of haemorrhages with agents featuring comparatively high affinity to the 5-HTT and/or selective serotonin reuptake inhibition (as with escitalopram, citalopram, duloxetine or venlafaxine) in comparison to agents with lower affinity or non-selective serotonin reuptake inhibition (as with mirtazapine or doxepin). Comparison of group-specific aggregated data (SSRI vs. non-SSRI) revealed significant differences regarding the "protective effect" on the development of haemorrhages between groups SSRI vs. non-SSRI in favour of non-SSRI in nearly all countries as well as in the total dataset. Our findings provide preliminary evidence that agents with increased affinity to the 5-HTT and/or selective serotonin reuptake inhibition may be associated with an increased risk of bleeding.

[Psychiatric Emergencies in the Emergency Room of the Ulm University Hospital in 2000 and 2010]

Objective: Despite of the importance of psychiatric emergencies (PE) requiring treatment at an emergency room (ER) little is known about their frequency and current trends in terms of quantity and quality. Methods: A retrospective analysis of all PE treated at the ER of the University Hospital Ulm (Germany) in 2000 and 2010. Results: 6 % (2000) or 5 % (2010) of the ER cases were PE. Despite an increase from 369 to 430 cases (+ 16,5 %) their share decreased because of an even stronger increase of other emergencies (+ 33 %). The most frequent PE in 2000 was alcohol intoxication (37,7 %), while it was intoxication with prescribed and/or illicit drugs in 2010 (47,9 %). Patients with alcohol intoxications were significantly younger in 2010 as compared with 2000. Suicide attempts were seen in every fourth PE. They were significantly more frequent in 2010. PEs were generally more frequent in the evening and over the night. Conclusion: This study provides first insight into current trends in PE treated at the ER in Germany. Our data provide an empirical starting point for optimizing clinical care, although the study is limited by its retrospective and mono-centric design.

Frequency of delusional infestation by proxy and double delusional infestation in veterinary practice: observational study

BACKGROUND

Nothing is known about the prevalence of delusional infestation in veterinary practice and the consequences for psychiatrists.

AIMS

We attempted to examine the frequency of delusional infestation among pet owners presenting their animals to veterinary clinics.

METHOD

We conducted a survey among 32 663 veterinary clinicians who were members of the Veterinary Information Network.

RESULTS

The respondents had seen 724 suspected cases of delusional infestation by proxy in a pet. The clients were mainly White, female and 30-60 years old. They presented mainly dogs and cats, and the alleged infestation was mainly with arthropods or worms. Also, 252 clients claimed to be affected themselves; we termed this 'double delusional infestation'.

CONCLUSIONS

Delusional infestation is seen frequently in veterinary practice. Psychiatrists need to be aware that patients may have pets they believe are infested.

Risk of bleeding related to selective and non-selective serotonergic antidepressants: a case/non-case approach using data from two pharmacovigilance databases

INTRODUCTION

There is increasing evidence for an association between treatment with selective serotonin reuptake inhibitors (SSRI) and an increased risk of bleeding events. The most important underlying mechanism appears to be inhibition of serotonin uptake in platelets, an effect that is also present in antidepressants with non-selective serotonin-reuptake inhibition (NSRI). Accordingly, also NSRI may be associated with an increased risk of bleeding. However, there is little data in this regard.

METHODS

Based on data (spontaneous reports of adverse drug reactions) from 2 pharmacovigilance databases (WHO-database/Vigibase™; BfArM/AkdÄ-database in Germany) we used a case/non-case approach and calculated reporting odds ratios (ROR) as measures for disproportionality regarding the association of treatment with an agent of the group SSRI/NSRI and haemorrhages.

RESULTS

Whereas both positive control agents (ASS and diclofenac) were statistically associated with haemorrhages in both databases (ASS: BfArM/AkdÄ, ROR 13.62 [95% CI 12.76-14.53]/WHO, ROR 12.96 [95% CI 12.75-13.16]; diclofenac: BfArM/AkdÄ, ROR 3.01 [95% CI 2.71-3.21]/WHO, ROR 2.11 [95% CI 2.05-2.16]), none of the agents of the group SSRI (ROR<1) was associated with haemorrhages. In group NSRI, only St. John's wort/hypericum was associated with haemorrhages (WHO-database, ROR 1.31 [95% CI 1.06-1.63]).

DISCUSSION

Signal detectioning in 2 pharmacovigilance databases suggest that serotonin reuptake inhibition is not associated with an increased risk of bleeding. However, underreporting may have accounted for the evaluated absent associations, particularly concerning SSRI. Regarding the detected increased risk of bleeding associated with hypericum, pharmacokinetic drug-drug interactions may be relevant independent of serotonin reuptake inhibition.

[Animal hoarding: a mental disorder with implications for public health]

Animal hoarding (AH) is a mental disorder that is characterised by an excessive number of kept animals, inability to maintain minimal standards of animal care and hygiene, and deficient insight into the thereby developing failures and problems. Although AH as a disease concept is neither represented in the DSM-5 nor the ICD-10, it may be classified as a subform of the hoarding disorder (DSM-5 300.3) that was implemented in the DSM-5 as an obsessive-compulsive disorder. Due to the hygienic deficiencies of the living spaces and the insufficient keeping of animals there is an increased risk of epizootic diseases and zoonoses. Specific epidemiological studies do not exist, however, women seem to be affected more frequently. AH is diagnosed mostly in late adulthood. Besides thorough somatic and psychiatric medical diagnostics, cooperation with the veterinary offices and authorities is usually necessary. Comorbid mental disorders (particularly depressive, obsessive-compulsive and personality disorders) are frequent. Currently, no evidence-based therapies exist. Social therapy and cognitive-behavioural psychotherapeutic interventions as well as sufficient treatment of comorbid mental disorders are recommended.

Rapid relapse in depression following initialization of oral contraception with ethinyl estradiol and chlormadinone acetate

OBJECTIVE

Female sexual hormones (estrogens and gestagens) may affect neurocognitive functioning and mood. Thus, the use of oral hormonal contraceptives (OHC) bears the risk of psychiatric adverse drug reactions such as depression and psychosis. However, the available empiric evidence regarding this connection is conflicting, and, moreover, female sex hormones seem to feature also mood-stabilizing and antidepressive effects. Hence, individual susceptibility factors and preparation-specific pharmacologic properties might play a pivotal role in the development of mood disturbances related to OHC. Single case reports provide empiric data for further systematic approaches.

METHODS

A clinical case is presented and discussed.

RESULTS

A 36-year-old female patient with recurrent major depressive disorder developed rapid relapse in depression after initialization of OHC with ethinyl estradiol 30 μg/chlormadinone acetate 2 mg. This OHC combination was described to particularly feature positive effects on depressive mood.

CONCLUSIONS

OHC may induce serious mood disturbances and should be administered with care, particularly in patients with affective disorders.

[Botulinum toxin for the treatment of major depressive disorder]

OBJECTIVE

Botulinum toxin (BTX) plays an important role in the treatment and prophylaxis of migraine and is also used for the treatment of focal dystonia, spasm, hypersalivation, and hyperhydrosis. Recent clinical trials suggest that BTX treatment of muscles involved in the development of negative emotions may also have an antidepressant effect. This article gives a systematic review of the literature regarding BTX in the treatment of major depression.

METHODS

We screened the databases of Medline and Scopus using the search terms [("botulinum toxin" OR "botox") AND ("antidepressant" OR "depression" OR "depressed")]. The website www.clinicaltrials.gov was screened with the same search terms in order to detect current studies.

RESULTS

As of April 2013, we identified 3 studies that evaluated the antidepressant effects of BTX in the treatment of major depression. An improvement in mood after treatment with BTX was seen in a case series of 10 depressed patients. In a randomised, placebo-controlled study of thirty patients assigned to a verum (BTX, n = 15) or placebo (saline, n = 15) group, treatment with BTX has also shown a positive effect on mood. Another prospective, open-label study evaluated the antidepressive effect of BTX in 25 subjects with major depression. On www.clinicaltrials.gov we identified 2 ongoing studies, which are currently investigating the antidepressant effect of BTX.

CONCLUSION

Recently published studies have shown a reduction of depressive symptoms after treatment of the glabellar frown lines with BTX injections. Further clinical studies in larger patient samples are necessary to prove the efficacy and safety of BTX injections used for the treatment of depressive disorders.

Abuse of methylphenidate in Germany: data from spontaneous reports of adverse drug reactions

To retrieve insights into abuse/dependence of methylphenidate (MPH) in Germany, a query of a pharmacovigilance database was performed (observation interval: 1993 until 2012). From 1190 reports of any ADR related to MPH, n=23 (2%) cases of MPH abuse were identified (mean age 29 years; male sex 78%; mean daily MPH-dosage 111 ± 126.6 mg). As oral application was predominant (70%), the majority of reported cases of MPH abuse might be due to pharmacologic neuroenhancement.

Source-based morphometry reveals distinct patterns of aberrant brain volume in delusional infestation

Little is known about the neural correlates of delusional infestation (DI), the delusional belief to be infested with pathogens. So far, evidence comes mainly from case reports and case series. We investigated brain morphology in 16 DI patients and 16 healthy controls using structural magnetic resonance imaging and a multivariate data analysis technique, i.e. source-based morphometry (SBM). In addition, we explored differences in brain structure in patient subgroups based on disease aetiology. SBM revealed two patterns exhibiting significantly (p<0.05, Bonferroni-corrected) lower grey and higher white matter volume in DI patients compared to controls. Lower grey matter volume was found in medial prefrontal cortex, anterior cingulate cortex, medial temporal lobe structures (parahippocampus and hippocampus), sensorimotor cortices, bilateral insula and thalamus and inferior parietal regions. Higher white matter volume was found in medial and middle frontal and temporal cortices, left insula and lentiform nucleus. Grey matter volume was abnormal in both "psychiatric" (primary DI and DI associated with an affective disorder) and "organic" DI (DI due to a medical condition). In contrast, aberrant white matter volume was only confirmed for the "organic" DI patient subgroup. These results suggest prefrontal, temporal, parietal, insular, thalamic and striatal dysfunction underlying DI. Moreover, the data suggest that aetiologically distinct presentations of DI share similar patterns of abnormal grey matter volume, whereas aberrant white matter volume appears to be restricted to organic cases.

Electroconvulsive therapy in patients with diagnoses other than major depression and/or difficult characteristics: a combined psychiatric-anesthesiological approach based on a retrospective chart analysis

Though electroconvulsive therapy (ECT) requires a close cooperation between anesthesiology and psychiatry, literature lacks of approaches that consider both disciplines in parallel. Special problems might be posed by patients with complicated features or ECT-indications other than treatment-refractory depression (TRD). Considering these patients there is a particular paucity of data, especially regarding anesthesiological aspects. Therefore, we sought (1) to discuss special issues of the peri-interventional management of non-TRD-cases from a combined psychiatric-anesthesiological point of view and (2) to assess the efficacy of ECT in the classical indication of TRD as compared to cases undergoing ECT for other indications or under difficult conditions (non-TRD) by means of Clinical Global Impression-Improvement (CGI-I) scale scores. A retrospective chart analysis of patients treated with ECT between the years 2009 and 2011 at the University of Ulm, Department of Psychiatry, was conducted. Special anesthesiological efforts were necessary in cohort non-TRD. There was no difference in the clinical outcome between cohort non-TRD (n=7) and TRD (n=22) with a median CGI-I score of 2 ("much improved") in both groups. Close cooperation between psychiatry and anesthesiology is indispensable in non-TRD patients. Our results provide preliminary evidence that ECT is equally effective in the standard indication of TRD compared to other indications.

Intoxications with the monoamine oxidase inhibitor tranylcypromine: an analysis of fatal and non-fatal events

Tranylcypromine (TCP) is a non-selective and irreversible monoamine oxidase inhibitor and an effective agent in the treatment of major depression. It features a complex pharmacologic profile and overdoses might induce severe intoxications. To identify typical clinical presentations of TCP-intoxications, range of associated TCP-dosages and possible differences between fatal and non-fatal intoxications a systematic review of all previously published cases of TCP-intoxications was conducted. We detected n=20 reports of TCP-intoxications in the literature (fatalities n=10). Mean age was 36.7 years (median 37); the majority of patients were female (60%). Frequent findings in patients with TCP-intoxications were disturbance of consciousness/cognitive dysfunction (90%), cardio-vascular symptoms (55%), hyperthermia (50%), respiratory distress (45%), delirium (45%), muscular rigidity (30%) and renal failure (20%). Suicidal intent was present in n=18 (90%) patients. First clinical symptoms related to TCP-intoxication developed on average in less than 1 day. The average dosage related to TCP-intoxication was 677 mg. The highest survived TCP-dosage was 4000 mg and the lowest fatal dosage was 170 mg. Patients with fatal intoxications were on average older (40.5 vs. 32.8 years) and developed a more rapid onset of symptoms (0.2 vs. 0.8 days). Death occurred after a mean time of 0.6 days; symptom relief in patients with non-fatal intoxications developed on average after 3.2 days. Considering the large dose spectrum between survived and lethal TCP-dosages individual susceptibility factors might play a role regarding the severity of clinical symptoms independently of the ingested dosage.

[Nephrotoxicity and long-term treatment with lithium]

With particular focus on clinical, pathophysiologic and epidemiologic aspects this systematic review article presents the available data on nephrotoxic effects of a long-term treatment with lithium. Lithium may lead to tubular dysfunction (LITD = nephrogenic diabetes insipidus, hyperchloremic metabolic acidosis, increased natriuresis) and lithium-induced nephropathy (LIN) with reduced glomerular filtration rate (GFR). The histopathologic finding of LIN is chronic tubulo-interstitial nephritis. LITD frequently presents with polydipsia/-uria and reduced urine osmolality, while LIN features a wide clinical spectrum ranging from clinically asymptomatic presentations with reduced GFR to end-stage renal failure. LIN seems to feature slow progression and is significantly less frequent than LITD. Regular monitoring of renal function is indispensable for patients treated with lithium. Patients with reduced GFR under treatment with lithium should always be presented to a nephrologist. Currently, there are no guidelines for the handling of patients with LIN and ongoing treatment with lithium. Thus, regarding continuation of lithium-treatment an individual benefit/risk assessment is necessary.

Abnormal gray and white matter volume in delusional infestation

Little is known about the neural basis of delusional infestation (DI), the delusional belief to be infested with pathogens. Case series and the response to anti-dopaminergic medication indicate disruptions in dopaminergic neurotransmission in the striatum (caudate, putamen), but did not allow for population-based inference. Here, we report the first whole-brain structural neuroimaging study to investigate gray and white matter abnormalities in DI compared to controls. In this study, we used structural magnetic resonance imaging and voxel-based morphometry to investigate gray and white matter volume in 16 DI patients and 16 matched healthy controls. Lower gray matter volume in DI patients compared to controls was found in left medial, lateral and right superior frontal cortices, left anterior cingulate cortex, bilateral insula, left thalamus, right striatal areas and in lateral and medial temporal cortical regions (p<0.05, cluster-corrected). Higher white matter volume in DI patients compared to controls was found in right middle cingulate, left frontal opercular and bilateral striatal regions (p<0.05, cluster-corrected). This study shows that structural changes in prefrontal, temporal, insular, cingulate and striatal brain regions are associated with DI, supporting a neurobiological model of disrupted prefrontal control over somato-sensory representations.

Agomelatine and hepatotoxicity: implications of cumulated data derived from spontaneous reports of adverse drug reactions

Considering the antidepressant agomelatine (AGM) there is a discrepancy between the widespread knowledge of the potential of AGM to cause hepatotoxic adverse drug reactions (ADR) and the availability of corresponding published data. This impedes an adequate assessment of the hepatotoxicity profile of AGM. We conducted a query of the database of a German Medical Regulatory Body (BfArM) and analyzed spontaneous reports of hepatotoxic ADR. We identified n=58 cases of AGM-related hepatotoxic ADR. Most frequent ADR was asymptomatic increase of liver enzymes (79%); n=6 patients (10%) with AGM-related toxic hepatitis were reported. Characteristics of patients: female sex (69%), age > 50 years (mean 54 years), polypharmacy (57%), and presence of cardiovascular risk factors (58.5%). Most of the hepatotoxic ADR (90%) were reported to have improved/recovered after discontinuation of AGM. Our evaluation suggests that AGM features a potential to cause severe forms of hepatotoxicity and emphasizes that a pre-existing liver disease is a contraindication for treatment with AGM. Secondly, increased age, female sex and polypharmacy may be risk factors for the development of AGM-related hepatotoxic ADR.

[Succinic semialdehyde dehydrogenase deficiency: an inheritable neurometabolic disease]

Succinic semialdehyde dehydrognase deficiency (SSADHD) is a neurometabolic disease with autosomal recessive inheritance. Although only about 450 cases are known worldwide, SSADHD is a frequent paediatric disorder of the neurotransmitter metabolism. SSADHD is caused by a mutation of the Aldh5a1-gene resulting in a dysfunction of the enzyme succinic semialdehyde dehydrogenase. This is followed by an accumulation of γ-aminobutyric acid and succinic semialdehyde that is alternatively metabolised via succinic semialdehyde reductase to γ-hydroxybutyric acid. The clinical phenotype is unspecific with pronounced interindividual variability. However, delayed acquisition of motor and language developmental milestones as well as epilepsy, mental retardation, sleep disorder, ataxia, muscle hypotonia, and behavioural disturbances are frequent. First symptoms frequently occur in the first year of life while the general course of the disease is non-progressive. Currently, no causal therapy exists.

[Liquid ecstasy in general psychiatry: a case series]

BACKGROUND

In emergency medicine and anesthaesiology liquid ecstasy (LE), the street name for GHB, GBL or 1,4-B, has become infamous for causing severe intoxications and withdrawal. In general psychiatry, however, it is little known. Therefore, we set out to gather data about the role of LE in general psychiatry, typical users and common clinical problems associated with the use of LE.

METHODS

We retrospectively identified and studied all patients with a reported the use of LE seen at the Department of Psychiatry, University of Ulm, Germany, between 1998 and 2011.

RESULTS

In 14 years, 19 users of LE were identified, the first dating from 2005. The majority reported a use of GBL (63 %), GHB was less common, and 1,4-B was not reported. Patients were predominantly young men (median age 25 years, 79 % men) with a history of multiple substance abuse. Ten patients had only a former use of LE, the other nine patients used it at the time of presentation. Of these, every third patient had to be transiently treated in an intermediate care unit, usually because of very severe and sudden withdrawal symptoms. Otherwise, detoxification was possible in psychiatry, but often required high doses of benzodiazepines. Three patients met the criteria for dependence from GBL.

CONCLUSIONS

In recent years, a small number of users of LE is seen also in general psychiatry, The problem is rather the severity of withdrawal than the number of cases. Close cooperation with intermediate care units is needed. In any case of coma of unknown origin or delirium with sudden onset LE use or withdrawal has to be taken into consideration, respectively. Many clinical problems result from the fact that LE cannot be detected in routine drug screenings. According to our experience, withdrawal from LE can be controlled with benzodiazepines.

Withdrawal and discontinuation phenomena associated with tranylcypromine: a systematic review

Tranylcypromine (TCP) is an effective antidepressant with a complex pharmacological profile and a relevant risk of abuse and dependence. Withdrawal phenomena (WP, in the case of TCP-abuse/dependence) or discontinuation phenomena (DP, in the case of absent TCP-abuse/dependence) subsequent to abrupt termination of TCP are a potentially severe clinical syndrome. We conducted a systematic review of all previously published WP/DP cases following abrupt termination of TCP in order to identify typical clinical presentations and risk factors of WP/DP and frequency of TCP abuse or dependence within these patients. By searching the Medline and Scopus databases we identified n=25 cases (cohort WP: n=18, cohort DP: n=7). Delirium was found in n=13 patients (cohort WP: 10/55.6%; cohort DP: 3/42.9%), n=6 demonstrated WP/DP without delirium (WP: 6/33.3%; DP: 0/0%) and n=5 rapid relapse in depression (WP: 1/5.6%; DP: 4/57.1%). Mean time until development of WP/DP was 1.9 (WP) and 2.2 (DP) days. Mean duration of WP/DP was 5.7 (WP) and 11.3 (DP) days. All patients of cohort WP were described to feature TCP-abuse/dependence. Patients with delirium were on average older (41.8 years vs. 37.8 years) and featured higher mean prescribed (71.0 mg vs. 38.3 mg) and actually taken daily TCP dosages (285.8 mg vs. 187.7 mg). In conclusion, even termination of lower daily dosages of TCP may result in delirium. Thrombocytopenia features diagnostic value in patients with deliria of unknown etiology. TCP should be administered with great care, especially in dependence-prone patients.·

Aseptic gingivitis related to quetiapine hemifumarate

Quetiapine hemifumarate (QF) is widely used in psychiatry and is associated with regularly occurring side effects such as dizziness and metabolic problems. Apart from these typical adverse events the agent has attracted attention for several rare phenomena (priapism, cholestasis, rhabdomyolysis) that indeed feature anecdotal character, but are nevertheless indispensable for a comprehensive understanding of the factual risk profile of quetiapine. We present the first report of aseptic gingivitis associated with QF in a patient with mental retardation.

Non-fatal and fatal liver failure associated with valproic acid

Little is known about hepatotoxicity associated with valproic acid (VPA), a widely used substance in neuropsychiatry.All reported cases to the German Federal Institute for Drugs and Medical Devices between 1993 and 2009 of VPA-induced serious hepatic side effects were evaluated.A total of 132 cases of serious VPA-associated liver failure were identified. Approximately one third (34.8%) occurred under VPA monotherapy, while the majority was seen with VPA plus co-medication, most frequently antiepileptics (34.8%) and benzodiazepines (16.7%). A subgroup of 34 cases (25.8%) had a fatal outcome, the largest number reported to date. Of these, 32.4% were under VPA monotherapy and 67.6% under VPA plus concomitant medication. Within the study period a significant increase in the total number of reported cases and the subgroup of fatal cases was found.This first pharmacovigilance study of VPA-associated liver failure indicates a higher rate of non-fatal and fatal liver failure when VPA is given with co-medication as compared to monotherapy. However, co-medication per se does not increase the risk of fatalities.

"Krokodil":revival of an old drug with new problems

In order to summarize current knowledge about the drug "Krokodil" a systematic review including a literature search of the databases PubMed, Embase, Scopus, and Google was conducted in December 2011. According to information acquired, "Krokodil" is a mixture of several substances and was first reported to have been used in Russia in 2003. The core agent of "Krokodil" is desomorphine, an opioid-analogue that can be easily and cheaply manufactured by oneself. Self-production results in a contaminated suspension that is injected intravenously. Due to its pharmacologic features, desomorphine shows a high potential to cause dependence. Against the background of first possible cases of "Krokodil" use in Western Europe, it appears advisable to provide information regarding the fatal consequences of "Krokodil."

Successful treatment of schizophrenia with melperone augmentation in a patient with phenotypic CYP2D6 ultrarapid metabolization: a case report

Introduction

There are limited treatment options for people with schizophrenia with cytochrome P450 2D6 ultrarapid metabolizer status who do not respond to amisulpride.

Furthermore, the literature does not provide evidence-based guidelines for this particular constellation.

Case presentation

We report the case of a 50-year-old Caucasian female patient with schizophrenia and cytochrome P450 2D6 ultrarapid metabolizer status who experienced an insufficient antipsychotic effect with amisulpride. She was successfully treated with melperone-augmented haloperidol.

Conclusion

This report yields melperone-augmented haloperidol as a possible pharmacological strategy in the described situation. In addition, our observations support the available evidence for the potential of melperone to act as an inhibitor of cytochrome P450 2D6.

Delusional infestation: treatment outcome with antipsychotics in 17 consecutive patients (using standardized reporting criteria)

OBJECTIVE

The multietiological nature of delusional infestation (DI) implies that therapy needs to be customized according to the various forms of DI (primary/secondary). Usually, treatment of DI is difficult to achieve in psychiatric settings because of the patients' nonpsychiatric concept of the illness.

METHODS

We analyzed the data of all consecutive DI patients seen in the Psychiatric Outpatient Department of the General Hospital Bruneck/Italy from 1998 to 2010, including structural brain imaging findings. Standardized reporting criteria are applied for the presentation of the cases in a naturalistic setting.

RESULTS

Our sample consisted of 17 patients. Notably, 15 out of these 17 patients (88%) could be engaged in an antipsychotic treatment trial. With different, mainly second-generation antipsychotics, all but one patient profited from antipsychotics, at least after substances were changed: 12 (71%) of the cases reached full remission, and another 2 (12%) had partial remission. The average duration of treatment was remarkably long: 3.8 years. Eight cases were classified as secondary to a brain disorder or medical condition, four cases were classified as secondary to psychiatric disorders and five cases fulfilled the criteria for primary DI (i.e., delusional disorder somatic type). All cases secondary to a brain disorder/medical condition showed macroscopic brain lesions mainly in the basal ganglia.

CONCLUSIONS

Our study confirmed previous experience that an excellent clinical outcome can be achieved in unselected patients with different DI forms provided that patients can be engaged in antipsychotic treatment. Although studies in DI are difficult to conduct, randomized controlled trials would be desirable to evaluate specific antipsychotic medication in DI in general and in the different forms of DI. More sophisticated investigations (single photon emission computed tomography and positron emission tomography) than structural brain imaging (magnetic resonance imaging and computed tomography) are needed to better elucidate underlying brain dysfunction in DI.

Paliperidone extended-release: does it have a place in antipsychotic therapy?

Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for treating schizophrenia worldwide in 2006 as paliperidone extended-release (PER), and became the first second-generation antipsychotic specifically licensed for treating schizoaffective disorder in 2009. However, at the same time, its comparatively high cost gave rise to concerns about the cost-effectiveness of PER as compared with its precursor, risperidone. This paper reviews the existing knowledge of the pharmacology, kinetics, efficacy, tolerability, and fields of application of PER, and compares PER with risperidone in order to determine whether it has a place in antipsychotic therapy. An independent assessment of all relevant publications on PER published until July 2010 was undertaken. PER has a unique pharmacological profile, including single dosing, predominantly renal excretion, low drug-drug interaction risk, and differs from risperidone in terms of mode of action and pharmacokinetics. High-level evidence suggests that PER is efficacious and safe in schizophrenia, schizoaffective disorder, and acute manic episodes. There is a striking lack of published head-to-head comparisons between PER and risperidone, irrespective of indication. Low-level evidence shows a lower risk for hyperprolactinemia and higher patient satisfaction with PER than with risperidone. PER adds to the still limited arsenal of second-generation antipsychotics. In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of PER which would justify its substantially higher costs as compared with risperidone. However, in terms of pharmacology, the available evidence cautiously suggests a place for PER in modern antipsychotic therapy.

Transcranial magnetic stimulation in depression--lessons from the multicentre trials

Looking at novelties and advances in medicine in particular in the treatment of major depressive disorder no principally new antidepressant treatment strategy has been established in clinical routine in the last fifty years. However, regarding the considerable issue of treatment resistance in depression, new therapeutic strategies are urgently required. In this context, repetitive transcranial magnetic stimulation above the dorsolateral prefrontal cortex has been proposed as a potential new treatment option for depression; furthermore, in October 2008 a first rTMS-device (NeuroStar TMS Therapy System) was approved by the FDA for the treatment of treatment resistant major refractory depression in adults. Yet, despite now nearly two decades of research in this field, no final answer concerning its validity for antidepressant treatment in the clinical practice is given. Numerous studies with small sample sizes and heterogeneous designs have been performed in this field yielding to different results. These were subjected to meta-analyses, assessing the antidepressant effect of rTMS, which are briefly summarized in this article. Further, multicentre-trials with larger numbers of patients were performed, which are presented and critically discussed here in more detail. This short review shall thus provide an overview of the current status of knowledge concerning rTMS in depression and it also provides some recommendations for future research in this field.