Silexan does not cause withdrawal symptoms even when abruptly discontinued

OBJECTIVE

Subsequent to a randomised, double-blind, double dummy clinical trial assessing the efficacy of silexan compared to placebo and paroxetine in patients suffering from generalised anxiety disorder (GAD), a 1week follow-up phase was added in order to assess possible withdrawal symptoms of silexan after abrupt discontinuation.

METHODS

Participants received silexan 80 mg/d, silexan 160 mg/d, paroxetine 20 mg/d, or placebo at a ratio of 1:1:1:1. Study medication was discontinued after the 10 week active treatment phase of the original trial. Whereas paroxetine was tapered as indicated, silexan administration was discontinued abruptly. Assessment of possible withdrawal effects was done using the Physician Withdrawal Checklist questionnaire (PWC-20).

RESULTS

During the 1 week down-titration phase, mean total PWC-20 scores had reduced by 0.19 in placebo, 0.23 in silexan 80, 0.65 in silexan 160, and 0.51 in paroxetine. The median change in all four groups was 0.00. In none of the treatment groups withdrawal effects occurred after discontinuation.

CONCLUSIONS

Values assessed for the silexan groups indicate the absence of a dependency potential of this preparation.

Continuation and long-term maintenance treatment with Hypericum extract WS 5570 after recovery from an acute episode of moderate depression--a double-blind, randomized, placebo controlled long-term trial

The efficacy and safety of Hypericum extract WS 5570 in preventing relapse during 6 months' continuation treatment and 12 months' long-term maintenance treatment after recovery from an episode of recurrent depression were investigated in a double-blind, placebo controlled multicenter trial. Adult out-patients with a recurrent episode of moderate major depression, a 17-item Hamilton Depression Rating Scale (HAMD) total score > or =20 and > or =3 previous episodes in 5 years participated. After 6 weeks of single-blind treatment with 3 x 300 mg/day WS 5570 patients with score < or =2 on item 'Improvement' of the Clinical Global Impressions (CGI) scale and a HAMD total score decrease > or =50% versus baseline were randomized to 3 x 300 mg/day WS 5570 or placebo for 26 weeks. 426 patients were evaluated for efficacy. Relapse rates during continuation treatment were 51/282 (18.1%) for WS 5570 and 37/144 (25.7%) for placebo. Average time to relapse was 177+/-2.8 and 163+/-4.4 days for WS 5570 and placebo, respectively (time-to-event analysis; p=0.034; alpha=0.025 one-sided). Patients treated with WS 5570 showed more favorable HAMD and Beck Depression Inventory time courses and greater over-all improvement (CGI) than those randomized to placebo. In long-term maintenance treatment a pronounced prophylactic effect of WS 5570 was observed in patients with an early onset of depression as well as in those with a high degree of chronicity. Adverse event rates under WS 5570 were comparable to placebo. WS 5570 showed a beneficial effect in preventing relapse after recovery from acute depression. Tolerability in continuation and long-term maintenance treatment was on the placebo level.

Efficacy of St. John's wort extract WS 5570 in acute treatment of mild depression: a reanalysis of data from controlled clinical trials

Based on the original data from two double-blind, randomized, placebo-controlled clinical trials and the acute phase of a long-term study that investigated the antidepressant efficacy of St. John's wort extract WS 5570, we present a re-analysis of a subset of patients suffering from an acute episode of mild depression according to DSM criteria. Out of a total of more than 1,200 patients included into these trials 217 had a pre-treatment total score < or =20 points on the 17-item Hamilton Rating Scale for Depression (HAMD) and were eligible for our re-analysis. They received 600, 900, or 1,200 mg/day WS 5570 or placebo for 6 weeks. In patients treated with WS 5570 the HAMD total score decreased by averages of 10.8 (600 mg/day), 9.6 (900 mg/day), and 10.7 (1,200 mg/day) points between the pre-treatment baseline value and the end of acute treatment, compared to 6.8 points in the placebo group (p < 0.01 for all pairwise comparisons of WS 5570 against placebo). This corresponded to average relative decreases by 49-57% for WS 5570 and by 36% for placebo. The rates of responders (i.e., patients with a HAMD total score decrease > or =50%) were 73%, 64%, 71%, and 37% for WS 5570 600 mg/day, 900 mg/day and 1,200 mg/day, and placebo, respectively. At the end of acute treatment 57% of the patients treated with WS 5570 600 mg/day, 33% in the 900 mg/day group and 62% in the 1,200 mg/day group, as well as 25% in the placebo group were in remission (HAMD total score < or =7 points). The analysis shows that St. John's wort extract WS 5570 has a meaningful beneficial effect during acute treatment of patients suffering from mild depression and leads to a substantial increase in the probability of remission.

Patterns and prevalence of antidepressant drug use in the German state of Baden-Wuerttemberg: a prescription-based analysis

PURPOSE

Population-based data about patterns and prevalence of antidepressant drug use is limited in Europe and presently unavailable for Germany. Therefore, we have identified patterns and prevalence of antidepressant use among outpatients on a population-based scale in the German state of Baden-Wuerttemberg.

METHODS

We conducted a historical cohort study using a computerised prescription database referring to all members of the major German public health insurance company AOK. We assessed the prevalence of antidepressant drug use over a 3-year period, calculated the number of prescription items purchased per patient and compared first-line and second-line treatments.

RESULTS

The 1-year prevalence of antidepressant drug use among more than 4,000,000 health insurance members was 7.4% (male: 4.3%; female: 10.2%). Importantly, almost 40% of the patients received only a single prescription item from 2000 to 2002. Though the use of serotonin-reuptake inhibitors (SSRIs) markedly increased by about 65% within the study period, these are primarily used as second-line drugs and still much less frequently than St. John's wort or tricyclic antidepressants such as amitryptiline or doxepin.

CONCLUSIONS

The prevalence of antidepressant drug use is higher than previously reported for other European countries. The preferred use of St. John's wort and tricyclics over SSRIs and other modern-type antidepressants in Germany is quite unique in Europe and different from the US. The identified drug use pattern leaves a major room for improvement in view of the numerous single prescription items purchased.

Reboxetine and cytochrome P450--comparison with paroxetine treatment in humans

OBJECTIVES

The noradrenaline-selective antidepressant reboxetine in vitro is a weak inhibitor of both cytochrome P450 (CYP) 2D6 and CYP3A4. Thus, in this study the pharmacokinetics of reboxetine in relation to pharmacogenetics and the effects of reboxetine compared to paroxetine treatment on the CYP2D6 and CYP3A4 phenotype were analyzed in healthy control subjects.

METHODS

Healthy male volunteers were treated with either 6 mg reboxetine (n = 26) or 30 mg paroxetine (n = 25). On Days 10/11 of treatment, serum concentrations of the antidepressants were measured and pharmacokinetic parameters calculated. Volunteers were phenotyped at the end of treatment and after at least 3 weeks washout (true phenotype) using 30 mg dextromethorphan (DM) hydrobromide given orally and measuring DM and metabolites in serum 2 h after intake. CYP2D6 and CYP2C19 genotypes were determined in parallel.

RESULTS AND CONCLUSION

Reboxetine serum concentrations showed no correlation with the CYP2D6 genotype and the CYP2D6 phenotype, whereas paroxetine concentrations showed some dependence on CYP2D6. In contrast to in vitro investigations, indicating a major role of CYP3A4 in reboxetine metabolism, reboxetine concentrations in serum showed no correlation with the respective DM metabolic ratios. There was also no correlation between paroxetine concentrations and the CYP3A4 phenotype data. The CYP2C19 genotype (only heterozygosity) had no influence on reboxetine and paroxetine pharmacokinetics. There were only minor changes in the DM metabolite pattern on treatment with reboxetine and no evidence of enzyme inhibition was obtained. In contrast and as expected, paroxetine strongly inhibited CYP2D6. Thus, reboxetine treatment has no effect on the CYP2D6 genotype and no clinically relevant drug interactions involving CYP2D6 are anticipated.

[Improvement in quality of life in the elderly. Results of a placebo-controlled study on the efficacy and tolerability of lecithin fluid in patients with impaired cognitive functions]

Lecithin, a precursor of the neurotransmitter acetylcholine, has a positive effect on brain and memory functions. In a prospective, randomized, double-blind study, the effect of buerlecithin fluid (BLF) was investigated in comparison with placebo in patients with mild cognitive disorders. A total of 96 ambulatory patients (> 55 years) were admitted to the study. Treatment duration was 84 days. In both treatment groups, a clear improvement in all the cognitive parameters tested was seen. The main target measure, the overall Sandoz Clinical Assessment Geriatric (SCAG) score improved by 18.7 (test substance) and 16.4 (placebo) points (p = 0.1620). A statistically relevant improvement of the secondary target parameter, response in the SCAG score, was achieved with BLF (85.4%) in comparison with placebo (62.5%) (p = 0.018). Furthermore, BLF demonstrated significant superiority in a number of the other target measures. The study also confirmed the very good tolerability of BLF.

Hypofrontality in neuroleptic-naive schizophrenic patients during the Wisconsin Card Sorting Test--a fMRI study

Functional neuroimaging findings of "hypofrontality" in schizophrenic patients - as tested with the Wisconsin Card Sorting Test (WCST) - are still controversial, mainly due to methodological aspects and the heterogeneity of the patient samples. To measure WCST specific and reproducible reduced cerebral activations in schizophrenic patients, we revised the study design and patient recruitment, respectively. For this purpose, we used an adequate active control task instead of an undefined rest condition to determine exclusively WCST specific cerebral activations. In addition, we focused on the investigation of modified activations between a selected group of neuroleptic-naive schizophrenic patients and carefully matched healthy controls by means of functional magnetic resonance imaging. The results indicate that neuroleptic-naive schizophrenic patients show reduced activations in the right frontal and left temporal lobe, as well as in the left cerebellum. By utilizing an active control task all unwanted activations are suppressed. Furthermore the influence of different task performances is reduced. The findings are in line with previous PET and SPECT studies and confirm the "hypofrontality" hypothesis. The findings suggest that "hypofrontality" is not caused by neuroleptic medication.

Cell-mediated side effects of psychopharmacological treatment

Both antidepressants and neuroleptics are widely used in psychopharmacological treatment. In view of the often equal efficacy of substances belonging to the same class of drugs, potential side effects have become the most important criteria for the selection of a specific drug. The therapeutic effect of antidepressants is mediated by their inhibition of the reuptake of the neurotransmitters noradrenaline and of serotonin. Significant adverse effects may occur through the interaction of the antidepressants with other receptors believed not to be related to the therapeutic action, most importantly the muscarinic acetylcholine receptor (M), the histamine-1 (H1) receptor and the alpha-1 (alpha 1) adrenergic receptor. In contrast to the classical tricyclic antidepressants, the newly available selective serotonin reuptake inhibitors neither block the M1-, H1- nor the alpha 1 receptors. Although the rate of side effects is considerably lower compared to tricyclic antidepressants, adverse effects may, however, occur through the stimulation of different serotonin receptor subtypes (5-HT2A, 5-HT2B, and 5-HT3), leading to anxiety, sleep disturbances and nausea. Neuroleptics are often administered for years or even decades in the treatment of schizophrenia or schizoaffective disorder. The main adverse effects are extrapyramidal symptoms, including parkinsonism, akathisia, dystonic reactions, and tardive dyskinesias. With the introduction of the atypical neuroleptics (e.g. clozapine, risperidone, olanzapine) it became apparent that the antipsychotic effect and the extrapyramidal unwanted effect are not always and inextricably linked. The evidence for the hypotheses of the pathogenetic mechanisms leading to extrapyramidal side effects is reviewed. Both the dopamine receptor hypersensitivity hypothesis and the hypothesis of mitochondrial respiratory chain inhibition are as yet based on indirect evidence. However, if, as suggested by the analyses of mitochondrial energy metabolism, the antipsychotic effect and the adverse effects are unrelated properties of neuroleptics, new principles should be applied in the development of novel neuroleptics. Neuroleptics might then be developed that are effectively antipsychotic but are less likely to produce limiting extrapyramidal side effects.

[Repetitive transcranial magnetic stimulation (rTMS) in the acute and long-term therapy of refractory depression--a case report]

We report on a patient with therapy-resistant major depression according to DSM-IV criteria who has been hospitalized for 60 months during the last 7 years. Not even five electroconvulsive therapy (ECT) series (61 single applications) brought lasting remission of symptoms. As cognitive deficits developed and prolonged postnarcotic recovery times were observed, further ECT was contraindicated. The left frontal cortex was chosen as the target site for repetitive transcranial magnetic stimulation (rTMS) treatment. For identification, a neuronavigational system was used that allows online monitoring of the position of the magnetic coil in relation to the individual cortex. The therapeutic progress was monitored by standardized psychiatric ratings (HAMD, BDI). In addition, cognitive performance was tested during the course of treatment. Only a few rTMS applications already caused an obvious brightening in mood, remission of depressive delusional symptoms, and an increase in personal interests and activities. After 4 weeks of daily treatment, the patient was discharged from the ward. The rTMS treatments and psychotherapeutic counseling have been continued on an outpatient basis. Thus, pharmaco- and psychotherapeutic interventions combined with rTMS led to persistent symptom remission and social reintegration.

Cerebral phosphate metabolism in first-degree relatives of patients with schizophrenia

OBJECTIVE

Most phosphorus-31 magnetic resonance spectroscopy ((31)P-MRS) studies have described measures of lower membrane anabolism or greater catabolism in the frontal lobes of patients with schizophrenia. The purpose of the present study was to evaluate whether these findings can also be detected in young subjects at genetic risk for schizophrenia.

METHOD

Fourteen children and siblings of patients with schizophrenia (mean age=16.7 years) and 14 comparison subjects (mean age=16.9 years) were included in a (31)P-MRS study of the frontal lobe.

RESULTS

The high-risk subjects had significantly lower mean ratios of phosphomonoesters to phosphodiesters (0.25 versus 0.31) and higher mean phosphodiester values (37.59% versus 34.87%) than comparison subjects.

CONCLUSIONS

These findings suggest greater phospholipid breakdown even in young first-degree relatives of patients with schizophrenia. This suggestion is discussed with respect to the membrane phospholipid hypothesis of schizophrenia.

[Psychiatric comorbidity in somatic disorders. Psychophytopharmaceuticals are worth a try]

Somatic and psychiatric illnesses are commonly associated. Cardiovascular disorders, Parkinson's disease and stroke are especially often associated with depression as also anxiety and sleep disturbances. Psychophytopharmaceuticals, which are usually well tolerated, are highly suitable for this purpose. To treat mild to moderate episodes of depression, extracts of St. John's Wort are employed, but recently reported interactions with coumarin, theophylline and also estrogen preparations, need to be considered. Unspecific anxiety states can be treated with extracts of kava. At present, no herbal preparation can be recommended for the treatment of sleep disorders, as no unequivocal proof of efficacy in patients with such problems has yet been established.

Time estimation in schizophrenia: an fMRI study at adjusted levels of difficulty

fMRI was performed in nine male schizophrenia patients and 15 healthy male controls during an auditory time estimation (timing), a frequency (i.e. pitch) discrimination task, and rest. An adaptive psychophysical approach, the weighted up-down method, was used to adjust individual performance to a level of 75% probability for correct answers. Although performing on the same level of individual difficulty, schizophrenia patients revealed less activations in prefrontal cortex and caudate nucleus, comparing time vs rest. Timing specific differences (i.e. timing vs pitch) between patients and controls were found in the posterior putamen, anterior thalamus, and right medial prefrontal cortex, with patients showing relative hypoactivity. Impairment in time estimation in schizophrenia might be mediated by specific fronto-thalamo-striatal dysfunction.

Opipramol for the treatment of generalized anxiety disorder: a placebo-controlled trial including an alprazolam-treated group

Opipramol, a drug widely prescribed in Germany, is a tricyclic compound with no reuptake-inhibiting properties. However, it has pronounced D2-, 5-HT2-, and H1-blocking potential and high affinity to sigma receptors (sigma-1 and sigma-2). In early controlled trials, anxiolytic effects were revealed. However, those studies were performed before the concept of generalized anxiety disorder (GAD) was established. Because of the interesting receptor-binding profile and promising results of the early clinical trials, the authors performed a state-of-the-art placebo-controlled trial using alprazolam as an active control. Three hundred seven outpatients with GAD were included. After a 7-day single-blind placebo washout, patients were randomly assigned to receive either opipramol (final dose, 200 mg/day), alprazolam (2 mg/day), or placebo and were treated for 28 days. The efficacy of both active compounds was higher than the effects with placebo treatment. There were statistically significant differences (p < 0.05, according to the analysis of covariance) in the main outcome criterion (baseline-adjusted final means of an intent-to-treat analysis of the total scores on the Hamilton Rating Scale for Anxiety) and in secondary efficacy parameters, with global improvement of 47% for placebo and significantly more for opipramol (63%) and alprazolam (64%). Regarding safety and tolerability, no substantial differences in the number of adverse events observed between treatment groups were obvious. Sedation seemed more pronounced with alprazolam treatment than with opipramol or placebo. In this trial, it was demonstrated for the first time that opipramol, a strong but nonselective sigma site ligand, possesses anxiolytic efficacy superior to placebo in the treatment of GAD.

[Phytochemicals as means to induce sleep]

Phytopharmacons are widely used in Germany. Whereas St. John's wort extracts are prescribed for the treatment of mild forms of depression and kava-kava for unspecified anxiety syndromes, hop, balm, lavender, passiflora and valerian are traditionally administered against nervousness and sleep disturbances. Controlled clinical trials are only available for valerian. However, no sleep inducing potential of valerian was observed, only a certain positive effect on daytime mood. Therefore, the mentioned phytopharmacons cannot be recommended for the treatment of sleep disturbances.

[Diseases of phospholipid metabolism as possible pathogenetic factors in schizophrenia. Current findings and critical evaluation]

During the last few years analyses of the lipidmetabolism have been performed on schizophrenic patients. Anabolic and katabolic metabolite-concentrations from blood and cell samples have been measured. By means of new investigation techniques, such as 31P-magnetic-resonance-spectroscopy, it is nowadays even possible to determine membrane metabolites non-invasively in vivo. Arachidonic acid deficits in peripheral cell membranes, turnover of phosphodiesters in the brain, increased phospholipase A2 (PLA2)-activity in serum and blood cells, disturbed niacin-response and abnormalities of the PLA2-gene are summarised as phospholipid-membrane-hypothesis of schizophrenia. Although there is some evidence for correlations between those findings and psychotic symptoms, the connection to the pathogenesis of schizophrenia still has speculative character. Furthermore it has to be confirmed that peripheral biochemical findings acquired in schizophrenics are transferable to the metabolism of the central nervous system. Actual results of enzyme and metabolite measurements reported in literature and current findings of our own 31P-MR-spectroscopic studies are surveyed and summarised. To point out possible connections between the phospholipid-metabolism of the central nervous system and of peripheral blood-cells, systemic approaches are considered.

Opipramol for the treatment of somatoform disorders results from a placebo-controlled trial

Although somatoform disorders are highly prevalent, so far there is no established pharmacological treatment. Opipramol is a psychopharmacon widely prescribed in Germany. Early trials with opipramol showed the drug's effectiveness in anxiety states coupled with somatic complaints. Therefore, the efficacy of opipramol in somatoform disorders was evaluated using adequate clinical trial methods. A multicentre, randomized, 6-week, placebo-controlled clinical trial was performed in a total of 200 patients suffering from somatoform disorders according to ICD-10. In the main outcome criterion, the somatic subscore of the Hamilton Anxiety Scale, and in nearly all other outcome criteria opipramol (200 mg/day) was statistically more effective than placebo. A similar number of adverse events was noted in both groups. The results of this first-placebo-controlled study in somatoform disorders suggest efficacy of opipramol in this indication but need replication.

[Phosphorus 31 magnetic resonance spectroscopy in schizophrenia research. Pathophysiology of cerebral metabolism of high-energy phosphate and membrane phospholipids]

31Phosphorus nuclear magnetic resonance spectroscopy (31P-MRS) has gained much interest in schizophrenia research in the last years, since it allows noninvasive measurement of high energy phosphates and phospholipids of the human brain in vivo. Thus, several studies have reported cerebral metabolic differences between patients and healthy controls as well as on lateralization effects and influences of epidemiological and psychopathological factors. This review gives a survey of the potential of 31P-MRS in schizophrenia research and summarizes and comments on the results of preceding studies. The discussion covers the reduction of phospholipids in patients in the context of the membrane phospholipid hypotheses, the question of an energetic hypometabolism in schizophrenics, and the influence of neuroleptic medication.

Potential treatment for subthreshold and mild depression: a comparison of St. John's wort extracts and fluoxetine

Subthreshold depressive disturbances and depressive episodes of mild severity are frequently associated with disability and socioeconomic burden, and often show an increase in symptomatology over time if untreated. Thus, there is an urgent need for antidepressant active compounds that are more readily available than those that must be obtained by prescription. To get an impression of the efficacy of the widely used phytopharmaceutical St. John's wort, the antidepressant efficacy in mild depressive disorders was compared with that of the standard antidepressant fluoxetine. The present overview includes controlled trials of fluoxetine in depression with a mean initial score on the Hamilton Rating Scale for Depression (HAM-D) < or =24, which were compared to the respective studies on St. John's wort. The mean HAM-D reduction of all St. John's wort studies was 10.2 (52.9%), and the respective figures for fluoxetine were 12.5 points and 55.5%. Thus, no relevant efficacy difference between the groups of investigations was found based on the studies included. The most important restrictions of this overview are no meta-analysis was performed, the studies were performed with heterogeneous methodological standards, and the St. John's wort extracts used were very different. However, St. John's wort might be a treatment option to reduce symptoms in patients not suffering from full-blown depressive disorder.

Frontal lobe in vivo (31)P-MRS reveals gender differences in healthy controls, not in schizophrenics

Phosphorus-31 magnetic resonance spectroscopy ((31)P-MRS) has gained much interest in schizophrenia research in recent years since it allows the non-invasive measurement of high-energy phosphates and phospholipids in vivo. However, until now only differences in metabolite concentrations between certain brain areas of schizophrenic patients and healthy controls have been examined. We investigated the influence of gender on the concentrations of different phosphorus compounds. For this purpose, well-defined volumes in the frontal lobe of 32 healthy controls and 51 schizophrenic in-patients were examined with an image selected in vivo spectroscopy (ISIS) sequence on a whole-body scanner at 1.5 T. Healthy females exhibited increased values of inorganic phosphate (P(i)) and decreased values of phosphocreatine (PCr) in comparison to their male counterparts. In schizophrenic patients such gender differences were not present. Thus, the results can be interpreted in the sense that frontal energy demanding processes are enhanced in female compared to male healthy volunteers; schizophrenia seems to reduce these gender differences.

Gabapentin leads to remission of somatoform pain disorder with major depression

Gabapentin, a novel antiepileptic drug, is effective in the treatment of partial seizures with and without secondary generalization. Evidence suggests that it may have mood-stabilizing and possibly antidepressant properties in bipolar depression. We report on a 48-year-old woman who had recurrent major depressive disorder. Following inguinal herniorrhaphy, she developed severe stabbing pain in the lower abdomen and inguinal area that progressed to constant pain in her whole body. She was depressive, hopeless, and had given up her social activities. A diagnosis of major depressive disorder and somatoform pain disorder was made. Antidepressants and carbamazepine were ineffective, and she had attempted suicide. Gabapentin resulted in remission of both the pain and the depressive mood at a dose of 1.800 mg/day.

Detecting structural changes in whole brain based on nonlinear deformations-application to schizophrenia research

This paper describes a new method for detecting structural brain differences based on the analysis of deformation fields. Deformations are obtained by an intensity-based nonlinear registration routine that transforms one brain onto another one. We present a general multivariate statistical approach to analyze deformation fields in different subjects. This method was applied to the brains of 85 schizophrenic patients and 75 healthy volunteers to examine whether low frequency deformations are sufficiently sensitive to detect regional deviations in the brains of both groups. We observed significant changes caused by volume reduction in brains of schizophrenics bilaterally in the thalamus and in the superior temporal gyrus. On the left side, the superior frontal gyrus and precentral gyrus are found to be changed, while on the right side, the middle frontal gyrus was altered. In addition, there were significant changes in the occipital lobe (left lingual gyrus) and in the left cerebellum. Volume enlargement in brains of schizophrenics was observed in the right putamen and in the adjacent white matter of the thalamic region. Our data suggest a disturbance in the nodes of a prefrontal-thalamic-cerebellar circuitry. This provides further support for the model of "cognitive dysmetria," which postulates a disruption in these nodes. We have demonstrated the application of deformation-based morphometry by detecting structural changes in the whole brain. This technique is fully automatic, thus allowing for the inclusion of large samples, with no user bias or a priori-defined regions of interest.

Increase of phosphodiesters during neuroleptic treatment of schizophrenics: a longitudinal 31P-magnetic resonance spectroscopic study

BACKGROUND

Increased levels of phosphodiesters (PDE%) and reduced relative concentrations of phosphomonoesters (PME%) have been reported in unmedicated schizophrenics, whereas findings in brain of medicated patients were not consistent.

METHODS

We determined in vivo the metabolism of phospholipids and high-energy phosphates in the left and right frontal lobes of 8 patients with schizophrenia using 31P-magnetic resonance spectroscopy (31P-MRS). Serial investigations were performed first after a neuroleptic-free period (mean 7.5 +/- 1.9 days) and second, after neuroleptic treatment (mean 20.6 +/- 11.1 days).

RESULTS

PDE% increased significantly in the left frontal lobe (32.0 +/- 5.9% versus 36.9 +/- 5.6%, p = .009) after medication. All other parameters showed no significant differences.

CONCLUSIONS

Our study suggests that neuroleptics do not decrease phospholipase A2 activity in schizophrenia. Individual neuroleptics may have different effects on phospholipase A2 activity as indicated by animal studies. An influence of neuroleptics on high-energy phosphates cannot be confirmed by our data.

31P magnetic resonance spectroscopy in the frontal lobe of major depressed patients

Most research with 31P-magnetic resonance spectroscopy (31P-MRS) in affective disorders has been done in the field of bipolar disturbances. Reduced frontal and temporal lobe phosphomonoester (PME) concentrations were measured in the euthymic state, whereas increased values were found in the depressed state. In bipolar-II patients reduced phosphocreatine (PCr) concentrations were reported in the euthymic, depressed, and manic state. The aim of the present study was to explore whether PME and PCr were also altered in the frontal lobe of major depressed, unipolar patients. Therefore, we used 31P-MRS to investigate the relative phospholipid and high-energy phosphate concentrations in the frontal lobe of 14 unipolar patients, mostly medicated, and 8 age-matched controls. We found increased PME and decreased ATP values. Other 31P-MRS parameters were not different in both groups. Phosphomonoester percentages correlated negatively with the degree of depression. Thus, the main alterations found in bipolar depressed patients could also be demonstrated in unipolar depressed patients. The results are discussed with regard to disturbed phospholipid and intracellular high-energy phosphate metabolism in depressed patients.

Impaired sensory processing in male patients with schizophrenia: a magnetoencephalographic study of auditory mismatch detection

The generation of mismatch negativity (MMN) as a component of auditory evoked event-related brain potentials has been reported previously to be severely disturbed in patients with schizophrenia. In the present study, we extended these findings to magnetoencephalography and investigated the neuromagnetic mismatch field (MMNm) in 15 male schizophrenic inpatients as compared to 16 healthy male volunteers. A standard tone of 1000 Hz and three different types of mismatch (1050-Hz tone, 5000-Hz tone, tone omission) were employed within the same paradigm, each mismatch occurring with a 10% pseudorandom probability. After correction for eye artifacts, the mean global field power of the mismatch reaction was calculated. Mismatch generation in patients with schizophrenia proved to be significantly impaired for all three conditions. This result confirms the theory of impaired auditory information processing in patients with schizophrenia at the level of the primary auditory cortex. Deficient generation of MMNm probably represents an impaired generation and/or faster decay of the sensory memory trace on the basis of disturbed sensory processing in male patients with schizophrenia.

Challenging the anterior attentional system with a continuous performance task: a functional magnetic resonance imaging approach

Combining the Continuous Performance Test (CPT) with a modern functional imaging technique provides a powerful tool for investigating neurophysiological processes in the human brain. There is increasing evidence from single photon emission tomography (SPECT), positron emission tomography (PET) and presently also functional magnetic resonance imaging (fMRI) studies proposing the existence of a distributed large-scale attentional network, mediated by the dorsolateral prefrontal and mesial frontal cortex, thalamus, basal ganglia and posterior parietal and superior temporal lobe. The aim of this study is to show that fMRI is a useful tool for in vivo localization of attentional tasks and to compare the results with established imaging techniques. Functional MRI was performed on a clinical 1.5-T system using gradient-echo acquisition. For data processing, the Statistical Parametric Mapping (SPM96) package was used. A right lateralized activation pattern in the dorsolateral prefrontal and mesial frontal cortex, the thalamus and the basal ganglia was found in a group of 12 male subjects. These findings support theories suggesting right hemispheric dominance of human attention.

Monoamine oxidase inhibitors. A perspective on their use in the elderly

Monoamine oxidase inhibitors (MAOIs) are mainly used in psychiatry for the treatment of depressive disorders and in neurology for the treatment of Parkinson's disease. While the classical, nonselective and nonreversible MAOIs, such as phenelzine and tranylcypromine, are characterised by the risk of inducing a hypertensive crisis when dietary tyramine is ingested, the selective monoamine oxidase-B (MAO-B) inhibitor selegiline (deprenyl) and, even more so, the selective and reversible monoamine oxidase-A (MAO-A) inhibitor moclobemide, are free from this potential interaction. Drug tolerability data for the elderly show that moclobemide is one of the most well tolerated compounds. Selegiline, especially when used in combination with levodopa, can cause anorexia, dry mouth, dyskinesia and, most problematic, orthostatic hypotension. For the traditional MAOIs, phenelzine and tranylcypromine, published data are insufficient to be able to give a conclusive tolerability statement regarding the use of these compounds in elderly people. Although orthostatic hypotension occurs in most patients treated with traditional MAOIs, the incidence in elderly patients with depression does not appear to be greater than that reported with tricyclic antidepressants.

31Phosphorus magnetic resonance spectroscopy of the dorsolateral prefrontal region in schizophrenics--a study including 50 patients and 36 controls

BACKGROUND

In a preliminary study we found decreased phosphodiester (PDE)% values and an increased phosphomonoester (PME)/phosphodiester ratio in the dorsolateral prefrontal region (DLPFR) of 13 chronic schizophrenics vs. 14 controls using 31phosphorus magnetic resonance spectroscopy (31P-MRS). Since these results are in contrast to the findings of other groups, we increased our study group to a total of 50 chronic schizophrenics on stable neuroleptic medication and 36 controls to minimize the possibility of a chance result due to small sample size.

METHODS

An image-selected in vivo 31P-MRS method on a Philips Gyroscan ACS II scanner working at 1.5 T was used.

RESULTS

We could confirm our earlier findings of decreased PDE% levels in schizophrenics. Additionally, we found phosphocreatine (PCr)% and PCr/adenosine triphosphate (ATP) to be increased in the schizophrenics. While no association between PME% and PDE% with neuroleptic medication was found, ATP% correlated positively and PCr/ATP negatively with the chlorpromazine equivalent dose.

CONCLUSIONS

The decreased PDE% levels might be characteristic only for chronic, neuroleptic-treated patients. The finding of altered high-energy phosphate levels can be interpreted as an indication of decreased energy-demanding processes in the DLPFR of the investigated patients compared to controls.

High-energy phosphates in the frontal lobe correlate with Wisconsin Card Sort Test performance in controls, not in schizophrenics: a 31phosphorus magnetic resonance spectroscopic and neuropsychological investigation

In recent years, a number of 31phosphorus magnetic resonance spectroscopy (P-MRS) studies on the frontal lobe of schizophrenics have been performed, reporting alterations of phospholipids and high-energy phosphates. Deicken et al. (1994b) recently found positive correlations between left frontal phosphomonoester% (PME%) levels and the performance of a specific frontal lobe task, the Wisconsin Card Sorting Test (WCST), in schizophrenics. In the present paper, the correlations between phospholipids and high-energy phosphates in the frontal lobe of 26 schizophrenics and 23 controls measured with a volume-selective P-MRS method were investigated. Overall, we could not find any correlations between WCST results and phospholipid levels, but in controls phosphocreatine% (PCr%) and PCr/adenenosine triphosphate (ATP) ratios were negatively correlated with test performance. Since PCr behaves as a buffer of ATP, in the sense that when ATP is consumed by neuronal activity PCr is catalysed rapidly to ATP, increased PCr% values and, moreover, increased PCr/ATP ratios point to a decreased ATP consumption. Thus, the correlations found between PCr% and PCr/ATP and test performance in controls point to an association between reduced performance in a specific frontal lobe task and decreased energy demanding processes at rest. This association was not found in schizophrenics, possibly due to the influence of neuroleptic medication or the disease process per se.

Cognitive stimulation with the Wisconsin Card Sorting Test: functional MR imaging at 1.5 T

PURPOSE

To determine whether functional magnetic resonance (MR) imaging can demonstrate a specific pattern of cerebral activation during cognitive stimulation by using a high-level cognitive task such as the Wisconsin Card Sorting Test.

MATERIALS AND METHODS

Thirty-one healthy volunteers underwent functional MR imaging with a 1.5-T MR imager with a standard head coil (100/50 [repetition time msec/echo time msec], 230-mm field of view, 40 degrees flip angle, 256 x 256 matrix). For stimulation, a personal computer version of the Wisconsin Card Sorting Test was used. Image analysis was done off-line, and cross-correlation coefficients between the stimulus function and the signal intensity response were calculated on a pixel-by-pixel basis and overlaid onto the corresponding anatomic MR image for each volunteer.

RESULTS

Stimulation resulted in strongly frontal activation, which included the mesial and the dorsolateral prefrontal cortexes, interconnected with Brodmann areas 44, 45, and 46. While activation was often bilateral, the largest area of activation was in the right hemisphere. Activation also was found in the basal ganglia and the mesial thalamic nuclei.

CONCLUSION

Functional MR imaging can demonstrate a specific pattern during activation with a cognitive task. Functional MR imaging has promise for more precise anatomic and functional imaging studies of brain interaction than have other imaging modalities.

[Sex specific differences in hemispheric lateralization in schizophrenia? An MEG-MRI study]

In this magnetoencephalography study the issue of hemispheric lateralisation in patients with schizophrenia was addressed using acoustically evoked neuromagnetic fields. The characteristics of dipoles in the superior temporal gyrus, the primary auditory cortex, were calculated. In contrast to other studies, alterations did not concern the localisation, but rather the orientation of dipoles. Of pathophysiological interest was that the dipoles abnormalities were found left-hemispherically in male (p = 0.02) and right-hemispherically in female patients with schizophrenia (p = 0.01) when compared to controls. The findings suggest gender-specific alterations of hemispheric lateralisation in schizophrenia.

Decreased energy demanding processes in the frontal lobes of schizophrenics due to neuroleptics? A 31P-magneto-resonance spectroscopic study

In the present investigation on 31P-magneto-resonance spectroscopic parameters in the frontal lobe, we found phosphocreatine levels and the ratio phosphocreatine/adenosine triphosphate to be increased (12.62 +/- 1.98% resp. 0.31 +/- 0.06) in 50 neuroleptic-treated schizophrenics, whereas no differences were detected in 10 neuroleptic-free patients (11.66 +/- 2.57% resp. 0.29 +/- 0.08) compared to 36 controls (11.37 +/- 1.45 resp. 0.29 +/- 0.04). This result points to a major role of neuroleptics in the metabolism of high-energy phosphates.

Brain activation during cognitive stimulation with the Wisconsin Card Sorting Test--a functional MRI study on healthy volunteers and schizophrenics

It has been demonstrated by single photon emission computed tomography (SPECT) and positron emission tomography (PET) that frontal brain regions are stimulated during performance of the Wisconsin Card Sorting Test (WCST). The WCST is also regarded as one of the standard tests for the assessment of frontal activity in brain imaging studies of schizophrenia. In this study cerebral activation was assessed by means of functional magnetic resonance imaging (fMRI). In healthy volunteers WCST stimulation resulted in a right lateralized frontal activation. In 13 chronic schizophrenics on stable neuroleptic medication, a lack of activation in the right prefrontal cortex and--as a trend--an increased left temporal activity during execution of the WCST was noted compared to controls. Since a one-slice technique was used, no information about the activation pattern in adjacent brain regions was obtained. However, as fMRI possesses a superior spatial resolution compared to SPECT and PET, the anatomical localization of the activation effect in the measured slice can be defined more precisely. Beside these methodological considerations, the results are discussed in relation to prior findings of a reduced ability of schizophrenics to coordinate cerebral function.

Abnormalities of auditory evoked magnetic fields and structural changes in the left hemisphere of male schizophrenics--a magnetoencephalographic-magnetic resonance imaging study

Functional and structural changes in 10 DSM-III-R male schizophrenics and 10 healthy volunteers were investigated using magnetoencephalographically (MEG) detected long-latency (N100 m) auditory evoked fields (AEFs) and magnetic resonance imaging (MRI). The AEFs were characterized by single moving equivalent dipoles, which were superimposed on MRIs. There were significant differences in dipole orientations and in AEF latencies in the left hemisphere of schizophrenics, when compared to the controls. The MEG-detected alterations were found to be associated with a bilateral volume reduction of the posterior superior temporal gyrus (pSTG), which was more pronounced in the left hemisphere. Separate analysis of white and gray matter has shown that the pSTG volume reduction resulted from decreased gray matter volumes without white matter changes. Both the functional and the morphological data indicate a left-hemispheric disturbance in our patients.

Safety, tolerability and efficacy of the reversible monoamine oxidase inhibitor RS-8359 in early clinical trials

The safety, tolerability and a preliminary assessment of the efficacy of the new reversible inhibitor of monoamine oxidase A, RS-8359, were evaluated in two studies in hospitalized, depressed patients. Daily doses of 100 and 200 mg divided into two equal doses were compared with moclobemide at 300 mg/day divided into two equal doses. The results indicated that all doses were safe with no evidence of significant changes in laboratory values or cardiovascular parameters. There were no appreciable changes in blood pressure or any evidence of orthostatic hypotension. Tolerability was generally good, although the 200-mg daily dose of RS-8359 and the 300-mg dose of moclobemide were both associated with a higher incidence of adverse events than the 100-mg daily dose of RS-8359. Initial titration of RS-8359 indicated that a slower escalation of doses could ameliorate early adverse events and may improve tolerability of higher doses. However, most adverse events still occurred at the 200-mg daily dose of RS-8359. The efficacy of all active treatments was similar, with no apparent advantage for the higher dose when the data were analysed on an intent-to-treat basis.

Controlled clinical trials of hypericum extracts in depressed patients--an overview

In Germany, hypericum extracts are among the most widely prescribed antidepressants. Additionally, many preparations of St. John's wort are sold on the free market and one extract is even the best selling antidepressant in the country. In contrast to synthetic antidepressants, the approval procedures are not so strict, which implies that the pharmaceutical industry is not forced to conduct clinical trials suitable for licensing. Nevertheless, numerous studies on hypericum extracts including depressed patients have been published in the last 20 years. The purpose of this paper is to review these investigations in respect of methodological considerations and to draw conclusions pertaining to the proof of antidepressant efficacy. To this effect, a computer-assisted literature research was performed and manufacturers were asked to supply the author with study results. A total of 12 placebo-controlled trials with hypericum extracts were performed, mostly with positive results. Also in comparison with synthetic antidepressants (3 studies published), a similar reduction of depressive symptomatology was seen, although the comparators were not adequately dosed. No trials in severely depressed patients have been published yet. Since most studies on hypericum have methodological flaws, further studies are warranted.

The effects of RS-8359 on cardiovascular function in healthy subjects and depressed patients

The potential liability of RS-8359 for the 'cheese' effect that is characteristic of the classical monoamine oxidase inhibitors has been compared with placebo and moclobemide in the tyramine test. Both RS-8359 and moclobemide reduce the dose of tyramine required to raise systolic blood pressure by 30 mmHg by about half, but the risk of the tyramine interaction is not clinically significant at this level. This low risk is confirmed by the very low incidence of cardiovascular adverse events reported in early clinical studies and by the lack of any material changes in blood pressure. These results indicate that no dietary restrictions will be required when RS-8359 is used clinically.

Brofaromine versus imipramine in in-patients with major depression--a controlled trial

Brofaromine is a selective and reversible inhibitor of monoamine oxidase A. The efficacy and safety of this compound as compared with tricyclic antidepressants, classical monoamine oxidase inhibitors and placebo has been demonstrated in several clinical trials. The present 6-week, double-blind, randomized trial compared brofaromine with imipramine in in-patients with major depression. Brofaromine was as effective as imipramine in the treatment of major depression, but exhibited a different side-effect profile, in particular lacking the anticholinergic and certain cardiovascular side-effects of the tricyclic imipramine, but more likely to induce sleep disturbances. In this study, in-patients were examined, since the majority of controlled clinical trials on depressed patients conducted so far have focused on the evaluation of out-patients. If one assumes that a different degree of severity of depression exists between these two patient groups, then the results of those trials conducted on out-patients cannot readily be transferred to in-patients.

Abnormalities of auditory evoked magnetic fields in the right hemisphere of schizophrenic females

Eight DSM-III-R female schizophrenics were investigated by magneto-encephalographically (MEG) detected long latency (N100m) auditory evoked fields (AEFs). In contrast to controls, in schizophrenics a lack of interhemispheric asymmetry was present, which was found to be due to alterations of the right hemisphere.

31P magnetic resonance spectroscopy in the dorsolateral prefrontal cortex of schizophrenics with a volume selective technique--preliminary findings

Pettegrew et al (Arch Gen Psychiatry 48:563-568, 1991) were the first to determine abnormalities concerning phospholipids and high energy metabolites in the dorsolateral prefrontal cortex of drug-naive schizophrenics with 31P magnetic resonance spectroscopy (MRS). Other investigations could not replicate these findings. We included in our study 13 schizophrenic inpatients and 14 age-matched controls. Whereas Pettegrew et al found increased levels of phosphodiesters and decreased levels of phosphomonoesters we measured decreased levels of phosphodiesters in the schizophrenics as compared to controls. One possible explanation for the contradictory findings of the both trials might be the different localization techniques used.

Pramipexole as adjunct to haloperidol in schizophrenia. Safety and efficacy

Pramipexole, a presynaptic dopamine D2/D3 autoreceptor agonist, has been given to haloperidol-treated patients with schizophrenia (n = 15) in an effort to ameliorate residual positive and negative symptoms that have not been satisfactorily influenced by haloperidol alone. Total scores of the positive and negative symptom scale (PANSS) decreased by more than 20% in 9 of 15 patients (reduction of total score: 22-62%). Serious adverse events did not occur. Three of the 15 patients dropped out due to worsening of schizophrenia. Insomnia, as the most frequent side effect, occurred in 4 patients. No clinically relevant electrocardiographic and laboratory changes were reported. This study supports the safety of the treatment of schizophrenia with pramipexole and haloperidol as a combination therapy. However, further clinical studies are required to support these preliminary findings.

Kava-kava extract WS 1490 versus placebo in anxiety disorders--a randomized placebo-controlled 25-week outpatient trial

101 outpatients suffering from anxiety of non-psychotic origin (DSM-III-R criteria: agoraphobia, specific phobia, generalized anxiety disorder, and adjustment disorder with anxiety) were included in a 25-week multicenter randomized placebo-controlled double-blind trial with WS 1490, a special extract of kava-kava. In the main outcome criterion, the Hamilton Anxiety Scale (HAMA), there was a significant superiority of the test drug starting from week 8 on. WS 1490 was also found to be superior with respect to the secondary outcome variables. HAMA subscores somatic and psychic anxiety, Clinical Global Impression, Self-Report Symptom Inventory-90 Items revised, and Adjective Mood Scale. Adverse events were rare and distributed evenly in both groups. These results support WS 1490 as a treatment alternative to tricyclic antidepressants and benzodiazepines in anxiety disorders, with proven long-term efficacy and none of the tolerance problems associated with tricyclics and benzodiazepines.

Serum concentrations of thyroid hormones in patients with nonseasonal affective disorders during treatment with bright and dim light

Serum concentrations of thyroxine (T4), triiodothyronine (T3), and thyrotropine were measured in 34 patients with nonseasonal affective disorders before and after 1 week of light treatment. Nineteen of these patients received bright white light (2500 lx) and 15 dim red light (50 lx) for 2 hours daily in the mornings over a 1-week period. Slight but significant reductions in the rating scores for the depressive symptomatology were found for both the bright-and dim-light groups, but there were no significant differences between the two groups. The improvement is thus most likely a placebo effect. Surprisingly, the small changes in the severity of the depressive symptoms in the group as a whole were significantly correlated to the changes in the serum levels of T4 during the weeks of bright- and dim-light treatment, respectively. The more a patient improved, the further his or her T4 level fell and vice versa. The fluctuations in the concentrations of T4 during light treatment were significantly greater in the depressed patients than in a group of 12 healthy controls who also received bright or dim light, whereas the changes in T3 were significantly smaller than those of the healthy controls. The pronounced fluctuations in T4 levels were probably not secondary to changes in mood. Rather, they are likely to reflect changes in tissue (intracellular) metabolism of T4, which may be involved in the mechanisms underlying the fluctuations in mood in these patients.

Drug treatment of depression in the 1990s. An overview of achievements and future possibilities

This article looks at the most important developments of antidepressants in the 1990s. The major properties of selective serotonin reuptake inhibitors, reversible and selective inhibitors of monoamine oxidase type A, selective serotonin and noradrenaline reuptake inhibitors, and noradrenergic and specific serotonergic antidepressants are discussed. On the basis of the specific advantages and disadvantages of these compounds, unmet medical needs in the psychopharmacological treatment of depression are considered and the profile of an ideal antidepressant is outlined, followed by some closing remarks on potential new mechanisms of action. The most important progress in the past 10 years has been the development of compounds which possess markedly reduced binding capacities at receptor sites not linked to their antidepressive actions. This development has improved tolerability, both in therapeutic use and in overdose. Three main therapeutic needs have still to be met: (i) superior efficacy to tricyclic antidepressants; (ii) a faster onset of action; and (iii) reliable effectiveness in the treatment of therapy-resistant depression.