Evaluation of a new body-focused group therapy versus a guided self-help group program for adults with psychogenic non-epileptic seizures (PNES): a pilot randomized controlled feasibility study

OBJECTIVE

Psychogenic non-epileptic seizures (PNES), a common phenomenon in neurological settings, are regarded as a paroxysmal type of functional neurological disorder (FND). In a substantial proportion, PNES are disabling with poor long-term outcomes and high economic costs. Despite the clinical and financial consequences of PNES, there is still a lack of controlled clinical trials on the treatment of this challenging disorder. The study aims to evaluate the feasibility and collect first evidence of the efficacy of a group based-intervention in PNES-patients.

METHODS

A pilot randomized controlled feasibility study with a parallel-group design was performed in adult outpatients with PNES to evaluate a new body-focused group therapy (CORDIS) versus guided self-help groups. Self-assessment of dissociation (Dissociation Experience Scale-DES-20) and seizure severity (Liverpool Seizure Severity Scale-LSSS) were assessed two weeks before and two weeks after the treatment intervention and also six months after treatment as primary outcome parameters.

RESULTS

A total of 53 patients were recruited from a specialized outpatient clinic, and out of those, 29 patients completed either the body-focused group therapy program (n = 15) or a guided self-help group (SHG) therapy (n = 14). When analyzing the ITT sample (n = 22 CORDIS group, n = 20 SHG), both groups showed an effect on seizure severity and level of dissociation. In the per protocol sample (n = 13 CORDIS group, n = 12 SHG), CORDIS was superior to the self-help group for reducing seizure severity 6 months after the treatment.

SIGNIFICANCE

CORDIS is a newly developed body-focused group therapy program for adults with PNES. Further studies should include a multicentric design with a higher number of participants.

Executive Functions and Attention in Patients With Psychogenic Nonepileptic Seizures Compared With Healthy Controls: A Cross-Sectional Study

OBJECTIVE

Psychogenic nonepileptic seizures (PNESs) are considered functional neurological symptoms and are highly prevalent in specialized epilepsy clinics. The underlying mechanisms of PNES are not fully understood. Recent findings point toward possible alterations in attention and executive functions. This study aimed to extend the current knowledge of attention and executive function in patients with PNES and to assess possible relationships between seizures and dissociation, childhood trauma, and cognitive function.

METHODS

We recruited 40 patients with PNES and 40 sex-, age-, and education-matched healthy controls (HCs) in this study. Participants completed self-report questionnaires to assess early life stress (Childhood Trauma Questionnaire [CTQ]), dissociation (the German version of the Dissociative Experience Scale, or Fragebogen zu dissoziativen Symptomen), and depression (Patient Health Questionnaire-9). Executive functions and attention were assessed with the Trail Making Test (TMT), Digit Span, and Attention Network Task.

RESULTS

Compared with HCs, patients with PNES reported significantly higher levels of childhood trauma, depression, and dissociation. Patients with PNES also had reduced performance indices for Digit Span Forward (d = 0.62), Digit Span Backward (d = 0.62), and TMT (d = 0.67) but not Attention Network Task. CTQ scores positively correlated with TMT and Digit Span Backward performance in patients with PNES. Adjusting for CTQ scores attenuated the observed group difference in TMT performance. Depression and dissociation did not explain the observed findings.

CONCLUSIONS

These results contribute to the evidence of impaired executive functions in patients with PNES. Furthermore, childhood trauma scores, but not (trait) dissociation or depression scores, seem to drive group differences (HC versus patients with PNES).

Immunological substrates of depressive symptoms in patients with severe obesity: An exploratory study

In this pilot study, we explored the immune phenotype of patients with severe obesity and comorbid depressive symptoms compared to non-depressed patients with obesity and normal-weight controls. Immune cell subsets were analysed by flow cytometry and depressive symptoms assessed using the Patient Health Questionnaire (PHQ-9). Cell frequencies were correlated with depressive symptom scores and waist-to-hip ratio (WHR). Patients with obesity and comorbid depression showed significantly lower numbers of circulating cytotoxic natural killer cells, dendritic cells and CD8⁺ effector memory T cells, compared to normal-weight controls. Regulatory T cells and CD4⁺ central memory T cells were increased compared to non-depressed patients with obesity and compared to normal-weight controls, respectively. Frequencies of cytotoxic natural killer cells and CD4⁺ central memory T cells significantly correlated with PHQ-9 scores, but not with WHR. Reduced numbers of dendritic cells were observed in both patient groups with obesity and correlated with PHQ-9 scores and WHR. These findings provide evidence for an altered immune composition in comorbid obesity and depression, supporting a pathobiological overlap between the two disorders.

Simvastatin add-on to escitalopram in patients with comorbid obesity and major depression (SIMCODE): study protocol of a multicentre, randomised, double-blind, placebo-controlled trial

INTRODUCTION

Major depressive disorder (MDD) and obesity are both common disorders associated with significant burden of disease worldwide. Importantly, MDD and obesity often co-occur, with each disorder increasing the risk for developing the other by about 50%-60%. Statins are among the most prescribed medications with well-established safety and efficacy. Statins are recommended in primary prevention of cardiovascular disease, which has been linked to both MDD and obesity. Moreover, statins are promising candidates to treat MDD because a meta-analysis of pilot randomised controlled trials has found antidepressive effects of statins as adjunct therapy to antidepressants. However, no study so far has tested the antidepressive potential of statins in patients with MDD and comorbid obesity. Importantly, this is a difficult-to-treat population that often exhibits a chronic course of MDD and is more likely to be treatment resistant. Thus, in this confirmatory randomised controlled trial, we will determine whether add-on simvastatin to standard antidepressant medication with escitalopram is more efficacious than add-on placebo over 12 weeks in 160 patients with MDD and comorbid obesity.

METHODS AND ANALYSIS

This is a protocol for a randomised, placebo-controlled, double-blind multicentre trial with parallel-group design (phase II). One hundred and sixty patients with MDD and comorbid obesity will be randomised 1:1 to simvastatin or placebo as add-on to standard antidepressant medication with escitalopram. The primary outcome is change in the Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to week 12. Secondary outcomes include MADRS response (defined as 50% MADRS score reduction from baseline), MADRS remission (defined as MADRS score <10), mean change in patients' self-reported Beck Depression Inventory (BDI-II) and mean change in high-density lipoprotein, low-density lipoprotein and total cholesterol from baseline to week 12.

ETHICS AND DISSEMINATION

This protocol has been approved by the ethics committee of the federal state of Berlin (Ethik-Kommission des Landes Berlin, reference: 19/0226-EK 11) and by the relevant federal authority (Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM), reference: 4043387). Study findings will be published in peer-reviewed journals and will be presented at (inter)national conferences.

TRIAL REGISTRATION NUMBERS

NCT04301271, DRKS00021119, EudraCT 2018-002947-27.

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group.

OBJECTIVE

The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment.

METHODS

A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire.

RESULTS

We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications.

CONCLUSIONS

Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.

[Pilot Data from the Evaluation of an Integrative Body Psychotherapy Program for Patients with Psychogenic Non-Epileptic Seizures]

Psychogenic non-epileptic seizures (PNES) occur in the context of various diseases. Therefore, PNES patients represent a heterogeneous group with different causative disorders. The etiology is still poorly understood. Previous concepts assume an increased rate of trauma disorders in PNES, which has been proven several times by previous studies 1 2. The clinical picture is threatening, which means that those affected often receive intensive care measures without benefiting from them 3. PNES patients accumulate especially in epilepsy centers, since a diagnostic differentiation from epileptic seizures is possible at those specialized centers. Often, the transition from making the diagnosis in epilepsy centers to follow-up treatment in psychosomatic/psychiatric settings is difficult. A reason could be that patients and practitioners are often involved in somatic disease concepts, which might be caused by the threatening clinical picture of PNES 28. Due to this difficulties, a special outpatient clinic was set up at the Charité Berlin for people with dissociative seizures, which settles in the transition from neurology to psychosomatics and works as a cooperation project 27. Out of the ambulance, a group treatment program (CORDIS) was developed, which aims at a better care of PNES patients at the interface between neurology and psychosomatic medicine. This modularized 10-week treatment program will be presented in this article and is the subject of a currently ongoing randomized, controlled evaluation study. The pilot data from the ongoing RCT study presented here showed significant effects in the effectiveness of the program, in particular the primary and secondary outcome measures.

Childhood trauma and diagnosis of major depression: Association with memory and executive function

Cognitive function is often impaired in patients with major depressive disorder (MDD). Childhood trauma is a risk factor for developing MDD and is also associated with cognitive impairments in later life. We aimed to investigate the effects of childhood trauma on cognitive function in MDD. 68 medication-free MDD patients and 75 healthy controls (HC) participated. We tested cognitive function with the Autobiographical Memory Test, Auditory Verbal Learning Test (AVLT), Trail Making Test A and B, Rey-Osterrieth/Taylor Complex Figure Test, and Digit Span Backward. Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ). Patients and HC did not differ with respect to age, sex, education. Mean CTQ sum scores differed significantly for depressed and HC with mean 47.8 (19.2) and 31.0 (6.8), respectively. Depressed patients and HC (without taking childhood trauma into account) differed only in AVLT performance. When childhood trauma was considered, this group difference disappeared. Subsequent regression analyses revealed that higher CTQ scores but not a diagnosis of MDD were associated with less specific autobiographical memories. Associations of CTQ with other cognitive domains failed significance after correction for multiple testing. Our results suggest that cognitive function is influenced by childhood trauma in MDD. However, the effects are small.

Statistische Modelle und Versuchspläne in der Medizin

Am Ablaufsschema einer medizinischen Untersuchungsreihe werden Funktion und Bedeutung der Versuchsplanung und die Beziehung zu statistischen Modellen aufgezeigt. Nach einigen grundsätzlichen Bemerkungen zur Versuchsplanung werden die gebräuchlichsten Pläne mit den zugehörigen Modellen anhand von Beispielen näher beschrieben, und zwar Pläne mit zufälliger Zuordnung, Blockversuchspläne, Lateinische Quadrate, unvollständige Blockversuchspläne, faktorielle Versuche ohne und mit Vermengen und fraktionierte faktorielle Pläne.

Sequential Analysis of Variance for Medical Trials

The analysis of variance is one of the most widely used tools for analyzing quantitative data. It is shown here how this technique can be applied sequentially. Different sampling and test procedures are described in terms of a simple example. An attempt is made to show how these methods can be used in analyzing medical trials where the observations become available sequentially over a period of time. It is argued that sequential analysis is also applicable and practical for experiments that are performed only once, if only one would specify »properly« the hypotheses to be tested.

Mineralocorticoid receptor function in depressed patients and healthy individuals

BACKGROUND

Many studies have shown disturbed glucocorticoid receptor (GR) in depressed patients. In contrast, only few studies targeted mineralocorticoid receptor (MR) function with inconclusive results. We examined the effects of the MR antagonist spironolactone on cortisol secretion in depressed patients and healthy individuals.

METHODS

Forty-eight unmedicated depressed patients (mean age 41.6years) and 45 age- and sex-matched healthy participants (40.7years) received the MR antagonist spironolactone (300mg) or placebo with three days apart in a randomized, double-blind, within-subject cross-over design. We measured salivary cortisol before ingestion of study medication (baseline) as well as +60min, +90min, +120min, +150min and 180min after baseline.

RESULTS

Repeated-measures ANOVA for area under the curve (AUCg) cortisol revealed a treatment effect with higher cortisol after spironolactone and a treatment by group interaction. Post-hoc analyses revealed higher cortisol in depressed patients compared to healthy participants in the placebo condition. In the spironolactone condition, the cortisol levels were not significantly different.

CONCLUSIONS

Potentially, impaired MR or GR signaling could be responsible for higher cortisol levels in depressed patients in the placebo condition. However, after MR blockade that increased cortisol secretion across groups leading to higher GR occupation, we found no differences between depressed patients and healthy controls. Thus, our results argue for depression-associated alterations in MR signaling rather than disturbed GR-mediated feedback inhibition.

Association between major depression and cardiovascular risk: the role of antidepressant medication

RATIONALE AND OBJECTIVES

Major depressive disorder (MDD) is associated with an increased risk for cardiovascular disease (CVD). Apart from biological and life style factors, the use of antidepressants and their potentially adverse effects might contribute to the increased CVD risk. Therefore, we compared cardiovascular risk profiles between relatively young depressed patients without CVD with and without antidepressant medication and healthy participants.

METHODS

We investigated 44 depressed patients (with antidepressants N = 20 (13 women), mean age 43.2 years; without antidepressants N = 24 (15 women), mean age 40.0) and 41 healthy participants (matched for sex, age, education). As markers of CVD risk, blood pressure, body mass index (BMI), and plasma levels of fasting glucose, cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL), and high sensitivity C-reactive protein (h-CRP) were measured.

RESULTS

We found significant differences between groups for BMI (p < .01), systolic (p = .02) and diastolic blood pressure (p < .01), and glucose (p < .001). Post hoc analyses indicated differences between both patient groups compared to the healthy control group, but not between patients groups. Further controlling for BMI diminished the effect of diagnosis on blood pressure; however, this was not the case for glucose level. There were no between-group differences in cholesterol, LDL, HDL, and h-CRP.

CONCLUSIONS

We found a clearly increased CVD risk in this group of rather young depressed patients. Importantly, there was no significant difference in CVD risk between patients with vs. without antidepressants. This suggests that major depression per se and not antidepressant medication is associated with increased CVD risk.

Cognitive function in older adults with major depression: Effects of mineralocorticoid receptor stimulation

Memory and executive function are often impaired in older adults with major depression. Mineralocorticoid receptors (MR) are abundantly expressed in the hippocampus and in the prefrontal cortex, brain areas critical for memory and executive function. In both aging and depression, MR expression in the brain is reduced. Therefore, diminished MR function could contribute to impaired cognition in older adults with depression and might be a promising target for pharmacological intervention. Twenty-three older adults with major depression (mean age 61.6 yrs ± 8.1, n = 13 women) without medication and 24 age-, sex- and education-matched healthy participants received the MR-agonist fludrocortisone (0.4 mg) or placebo in a randomized, double-blind, within-subject cross-over design. We measured psychomotor speed, executive function, verbal learning and memory, and visuospatial memory. Compared to controls, depressed patients performed worse in psychomotor speed (group effect p = 0.01), executive function (group effect p < 0.01), verbal learning (group effect p = 0.02), and verbal memory (group effect p < 0.01) but not in visuospatial memory. There were no significant treatment effects. However, we found a group × treatment interaction in verbal learning (p = 0.04) and visuospatial memory (p = 0.02) indicating that depressed patients performed worse after fludrocortisone whereas controls performed better after fludrocortisone. Our data suggest that -in contrast to younger depressed patients-older adults with depression do not benefit from MR stimulation but deteriorate in cognitive function.

Visual Attention and Saccadic Oculomotor Control in Parkinson's Disease

BACKGROUND

In patients with Parkinson's disease (PD) we aimed at differentiating the relation between selective visual attention, deficits of programming and dynamics of saccadic eye movements while searching for a target and hand-reaction time as well as hand-movement time. Visual attention is crucial for concentrating selectively on one aspect of the visual field while ignoring other aspects. Eye movements are anatomically and functionally related to mechanisms of visual attention. Saccadic dysfunction might confound selective visual attention in PD.

METHODS

We studied visual selective attention in 22 medicated PD patients (clinical ON status, mild to moderate disease severity) and 22 age matched controls. We looked for possible interferences through oculomotor deficits. Two tasks were compared: free viewing of photographs and time optimal visual search of a hidden target. Visual search times (VST), task related dynamics of saccades, and hand-reaction and hand-movement times were analyzed.

RESULTS

In the free viewing task mild to moderately affected PD patients did not differ statistically from healthy subjects with respect to saccade dynamics. However, patients differed significantly from healthy subjects in the time optimal visual search task with 25% lower rates of successful searches. Hand movement reaction time did not differ in both groups, whereas hand movement execution time was significantly prolonged in PD patients.

CONCLUSION

Saccadic oculomotor control and hand movement reaction times were intact, whereas in our less severely affected treated PD patients, visual selective attention was not. The highly reduced successful search rate might be related to disturbed programming and delayed execution of saccades during time optimal visual search due to decreased execution of serial-order sequential generation of saccades.

Mineralocorticoid receptor stimulation improves cognitive function and decreases cortisol secretion in depressed patients and healthy individuals

Memory and executive function are often impaired in patients with major depression, while cortisol secretion is increased. Mineralocorticoid receptors (MR) are abundantly expressed in the hippocampus and in the prefrontal cortex, brain areas critical for memory, executive function, and cortisol inhibition. Here, we investigated whether MR stimulation with fludrocortisone (1) improves memory and executive function and (2) decreases cortisol secretion in depressed patients and healthy individuals. Twenty-four depressed patients without medication and 24 age-, sex-, and education-matched healthy participants received fludrocortisone (0.4 mg) or placebo in a randomized, double-blind, within-subject cross-over design. We measured verbal memory, visuospatial memory, executive function, psychomotor speed, and salivary cortisol secretion during cognitive testing between 1400 and 1700 hours. For verbal memory and executive function, we found better performance after fludrocortisone compared with placebo across groups. No treatment effect on other cognitive domains emerged. Depressed patients performed worse than healthy individuals in psychomotor speed and executive function. No group effect or group × treatment interaction emerged on other cognitive domains. Fludrocortisone decreased cortisol secretion across groups and there was a significant correlation between cortisol inhibition and verbal memory performance. Our data suggest a crucial role of MR in verbal memory and executive function and demonstrate the possibility to improve cognition in depressed patients and healthy individuals through MR stimulation.

Does fludrocortisone influence autobiographical memory retrieval? A study in patients with major depression, patients with borderline personality disorder and healthy controls

There is evidence that stimulation of mineralocorticoid receptors (MR) enhances memory in healthy subjects and in patients with major depression (MDD). In contrast, in patients with borderline personality disorder (BPD), this effect seems to be task dependent. The aim of this study was to investigate the effect of MR stimulation on autobiographical memory retrieval in healthy individuals, patients with MDD, and patients with BPD. We conducted a placebo-controlled study in an intra-individual cross-over design. Twenty-four patients with MDD, 37 patients with BPD, and 67 healthy participants completed an autobiographical memory test after receiving 0.4 mg fludrocortisone, a mineralocorticoid receptor preferring agonist, or placebo in a randomized order. Healthy subjects, patients with MDD, and patients with BPD did not differ in their autobiographical memory retrieval. Furthermore, the administration of fludrocortisone had no effect on autobiographical memory. In conclusion, the stimulation of MR does not influence autobiographical memory retrieval in healthy subjects, patients with MDD, and patients with BPD. Our results do not support a role of MR in autobiographical memory.

Hair cortisol and cortisol awakening response are associated with criteria of the metabolic syndrome in opposite directions

Findings on the association between hypothalamic-pituitary-adrenal (HPA) axis activity and metabolic risk are equivocal. Different methods of measuring HPA activity might indicate adverse vs. beneficial effects of HPA activity on metabolic risk thus contributing to heterogenous findings. In this study, we aimed to determine whether (1) the salivary cortisol awakening response (CAR) as a marker of awakening-induced activation of the HPA axis and (2) hair cortisol as a marker of long-term cortisol secretion are associated with criteria of the metabolic syndrome. Therefore, we recruited 41 healthy individuals (26 women, mean age: 41.2 years) and 44 patients with major depression (28 women, 41.4 years) and assessed CAR and hair cortisol values as well as all criteria of the metabolic syndrome (abdominal obesity, blood pressure, plasma glucose, triglycerides and high-density cholesterol levels) according to the International Diabetes Federation. CAR and hair cortisol values were divided into tertiles. Across groups, participants with hair cortisol or hair cortisone in the highest tertile showed significantly more criteria of the metabolic syndrome compared to participants in the medium or low tertile (F2,64=3.37, p=.04). These results were corroborated by significant positive correlations between mean hair cortisol values with waist circumference (r=.29, p=.03), triglycerides (r=.34, p=.01) and systolic blood pressure (r=.29, p=.04) and between mean hair cortisone and triglycerides (r=.46, p<.01). In contrast, mean CAR values correlated negatively with diastolic (r=-.29, p=.03) and systolic blood pressure (r=-.32, p=.02). Our results indicate that higher hair cortisol and hair cortisone levels but lower CAR values are associated with an unfavorable metabolic and cardiovascular risk profile.

Mood-congruent memory in depression - the influence of personal relevance and emotional context

The investigation of veridical mood-congruent memory (MCM) in major depressive disorder (MDD) has been subject of many studies, whereas mood-congruent false memory has received comparatively little attention. The present study examined the influence of valence, personal relevance and the valence of the context of the learning material on true and false MCM in 20 inpatients with MDD and 20 healthy controls. Sixty positive, negative, neutral or personally relevant nouns were either combined with a positive, negative or neutral adjective. Word pairs were presented to participants in a learning trial. In a recognition task, participants had to identify the previously studied word pairs. A MCM effect could not be found for hits. However, in exploratory analyses, word pairs containing personally relevant nouns were more rated towards old by the patient relative to the control group. Furthermore, depressed patients tended to rate items more towards old than controls when the words were presented in a negative new context. Results are in line with previous findings in depression research emphasizing the role of mood-congruent false memories for mood disorders.

Association between cortisol awakening response and memory function in major depression

BACKGROUND

While impaired memory and altered cortisol secretion are characteristic features of major depression, much less is known regarding the impact of antidepressant medication. We examined whether the cortisol awakening response (CAR) is increased in depressed patients with and without medication compared with healthy controls (HC) and whether CAR is associated with memory function in each group.

METHOD

We examined 21 patients with major depression without medication, 20 depressed patients on antidepressant treatment, and 41 age-, sex- and education-matched healthy subjects. We tested verbal (Auditory Verbal Learning Task) and visuospatial (Rey figure) memory and measured CAR on two consecutive days.

RESULTS

Patient groups did not differ in severity of depression. We found a significant effect of group (p = 0.03) for CAR. Unmedicated patients exhibited a greater CAR compared with medicated patients (p = 0.04) with no differences between patient groups and HC. We found a significant effect of group for verbal (p = 0.03) and non-verbal memory (p = 0.04). Unmedicated patients performed worse compared with medicated patients and HC in both memory domains. Medicated patients and HC did not differ. Regression analyses revealed a negative association between CAR and memory function in depressed patients, but not in HC.

CONCLUSIONS

While in unmedicated depressed patients the magnitude of CAR is associated with impaired memory, medicated patients showed a smaller CAR and unimpaired cognitive function compared with HC. Our findings are compatible with the idea that antidepressants reduce CAR and partially restore memory function even if depressive psychopathology is still present.

No effects of antidepressants on negative symptoms in schizophrenia

Negative symptoms are common in schizophrenia, but often difficult to differentiate from depression. They are associated with long-term impairment and do not respond well to current treatment approaches. Even though antidepressants are commonly prescribed in schizophrenia, their beneficial effect is still under debate. In the present study, we aimed to investigate the effect of serotonergic versus noradrenergic antidepressant add-on therapy on negative symptoms in schizophrenia. Fifty-eight patients with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and with predominant negative symptoms were randomized in a double-blind design to add-on treatment with citalopram, reboxetine, or placebo for 4 weeks. Analysis of covariance with repeated-measures design was used to compare improvement between treatment groups in scores of the Positive and Negative Syndrome Scale and the Hamilton Rating Scale for Depression. A χ² test was used to compare responder rates between treatment groups. Repeated-measures analysis of covariance revealed no differences between treatment groups over time (treatment × time, not statistically significant) for Positive and Negative Syndrome Scale subscales. Although a subgroup analysis in subjects fulfilling the criteria for minor depression was suggestive of higher responder rates in the citalopram group compared with reboxetine, the results did not reach significance level. Our findings do not support a beneficial effect of adjunctive antidepressant treatment on negative symptoms in schizophrenia. However, depressive symptoms are reduced in patients with minor depression by citalopram but not reboxetine, which is in line with previous findings.

Hair testosterone and visuospatial memory in middle-aged men and women with and without depressive symptoms

BACKGROUND

Testosterone binds to androgen receptors, which can be found abundantly in the hippocampus. Associations between testosterone levels and visuospatial memory have been reported, albeit with inconsistent results. Previous studies have used point sampling of testosterone levels (blood, saliva) rather than long-term secretion measures. Hair analysis for steroids allows for retrospective ascertainment of cumulative steroid measures over several months. We examined hair testosterone and its association with verbal and visuospatial memory in middle-aged men and women with and without major depression.

METHODS

We examined a total of 73 middle-aged individuals (35 depressed patients, and 38 age-, sex- and education-matched healthy subjects). We tested verbal (Auditory Verbal Learning Task) and visuospatial (Rey figure) memory and measured testosterone in the hair by liquid chromatography tandem mass spectrometry.

RESULTS

Hair testosterone levels did not differ between patients and controls (mean 1.35pg/mg vs. 1.40pg/mg, SD 0.61 and 0.80, respectively). In men (n=24) but not women (n=49), hair testosterone was associated with visuospatial memory in a multiple regression analysis after controlling for age, education, body mass index, and depression (adjusted R(2)=0.56).

CONCLUSIONS

With the new method of testosterone measurement in hair allowing for long-term cumulative ascertainment of testosterone secretion, we extend recent results of a male-specific role for testosterone in visuospatial memory.

[Depression and neurological diseases]

In many neurological diseases a depressive syndrome is a characteristic sign of the primary disease or is an important comorbidity. Post-stroke depression, for example, is a common and relevant complication following ischemic brain infarction. Approximately 4 out of every 10 stroke patients develop depressive disorders in the course of the disease which have a disadvantageous effect on the course and the prognosis. On the other hand depression is also a risk factor for certain neurological diseases as was recently demonstrated in a meta-analysis of prospective cohort studies which revealed a much higher stroke risk for depressive patients. Furthermore, depression plays an important role in other neurological diseases with respect to the course and quality of life, such as Parkinson's disease, multiple sclerosis and epilepsy. This article gives a review of the most important epidemiological, pathophysiological and therapeutic aspects of depressive disorders as a comorbidity of neurological diseases and as a risk factor for neurological diseases.

Cortisol response to experimental pain in patients with chronic low back pain and patients with major depression

OBJECTIVE

Chronic pain and major depression have been associated with alterations of the hypothalamus-pituitary-adrenal axis (HPA) activity. Previous studies suggested that HPA activity is diminished in chronic pain but increased in depression. However, little is known about the effects of experimentally induced acute pain on cortisol secretion in patients with chronic pain and depression.

METHODS

On three different occasions (day 1, day 8, day 90), we repeatedly examined 20 patients with chronic low back pain without depression, 22 patients with major depression without pain, and 33 healthy subjects using heat stimuli. Pain intensity was rated by participants using a visual analog scale. Salivary cortisol was assessed prior to 10 blocks of repeated painful heat stimuli, and 45 and 60 minutes afterwards.

RESULTS

In repeated measures analyses of covariance adjusting for age, sex, and time of examination, we found a significant effect of group (P < 0.01) and post-hoc tests confirmed that patients with chronic pain had lower cortisol area-under-the-curve values compared with healthy controls and depressed patients at all time points (all P values <0.01). However, cortisol secretion in depressed patients did not differ from controls.

CONCLUSIONS

Across groups, experimental heat pain stimuli did not elicit a significant cortisol response. Chronic pain appears to be associated with low cortisol secretion. The mechanisms linking chronic pain with low cortisol deserve further study.

Introducing a novel method to assess cumulative steroid concentrations: increased hair cortisol concentrations over 6 months in medicated patients with depression

Depression has been linked to increased cortisol concentrations using point measures taken from urine, blood, or saliva samples. However, with regard to hypercortisolism-induced consequences, long-term cumulative cortisol burden is of relevance. Our objective was to use hair analysis as a new method to assess cortisol exposure over 6 months in depressed patients and healthy controls. We examined 23 depressed patients (8 men and 15 women, mean age: 41.6 years ( ± standard deviation (SD), 13.1 years); mean duration of current depressive episode 9 months ( ± SD, 13 months)) and 64 healthy controls, matched for age and gender. Cortisol concentrations in two 3-cm hair segments from near to the scalp were analyzed, representing cortisol secretion during the 6 months prior to sampling. Compared with healthy individuals, depressed patients had higher hair cortisol concentrations in the first (mean ± SD: 26.7 ± 20.8 vs. 18.7 ± 11.5 pg/mg, p < 0.05) and second hair segment (mean ±  SD: 21.9 ± 23.7 vs. 13.4 ± 9.6 pg/mg, p < 0.05). In conclusion, hair cortisol analysis confirmed enhanced cortisol secretion in depressed patients over a prolonged time period. Because of the retrospective and cumulative nature of cortisol in hair, the assessment of hair cortisol concentration may help in addressing unanswered questions regarding hypothalamic-pituitary-adrenal axis overactivity and associated health consequences in psychiatric disorders.

Sex differences of salivary cortisol secretion in patients with major depression

Depression is associated with increased cortisol secretion and occurs more often in women than in men. Thus, it has been hypothesized that differences in cortisol secretion might, in part, be responsible for the greater risk of developing depression in women. However, only few studies have examined sex differences in baseline cortisol secretion in depressed patients and healthy controls. We examined sex effects on cortisol secretion in 52 medication-free patients with major depression (37 women, 15 men, mean ± SD age 35 ± 11 years, Hamilton Depression Scale mean score 27 ± 5) and 50 healthy age- and sex-matched control subjects. Salivary cortisol concentrations were measured at 8:00, 12:00, 16:00, and 22:00 h. Repeated measures analysis of covariance revealed a group × sex interaction (p = 0.05). Post hoc tests revealed higher cortisol concentrations in depressed compared to healthy men [F(1;29) = 7.5, p = 0.01]. No differences were found between depressed and non-depressed women. Our results do not support the hypothesis that differences in cortisol secretion between depressed and non-depressed subjects are more pronounced in women than in men. Study characteristics and methods as well as sex-specific confounding variables such as menstrual cycle, menopause and the use of oral contraceptives may account for inconclusive results across studies.

CCK-4: Psychophysiological conditioning elicits features of spontaneous panic attacks

INTRODUCTION

Cholecystokinin-tetrapeptide (CCK-4) is an established model to generate subjective panic anxiety. CCK-4 injection also results in consistent and dose-dependent rise of stress hormones. Effects other than upon subjective panic and stress hormone activity have barely been examined. The purpose of the study was to investigate CCK-4 effects on emotional facial expression and especially on fear relevant facial muscles establishing therewith a more objective method to measure subjective panic anxiety.

METHODS

20 healthy male subjects were randomly and double-blindedly assigned in two groups (dose groups), each of which was investigated three times once with placebo and twice with 25 μg or 50 μg CCK-4 respectively. Subjects of each group were randomly assigned in two different balanced orders of investigations: CCK-CCK-Placebo vs. Placebo-CCK-CCK. Facial muscle and hypothalamo-pituitary-adrenocortical (HPA)-axis activity were recorded.

RESULTS

CCK-4 led dose-dependently to an increase of panic anxiety, an activation of fear relevant facial muscles and a rise of stress hormones. Whereas placebo administration before CCK-4 revealed no significant panic and stress response, during placebo following CCK-4 stimulations a psychophysiological conditioning effect could be observed without rise in HPA-axis activity.

DISCUSSION

Our findings indicate the possibility to measure different intensities of panic anxiety and conditioning effects with a facial EMG method. Dissociation of HPA-activity and fear relevant facial muscle activity is in accordance with former results about spontaneous panic attacks.

Modulation of the mineralocorticoid receptor as add-on treatment in depression: a randomized, double-blind, placebo-controlled proof-of-concept study

Preclinical and clinical studies have suggested a role of the mineralocorticoid receptor (MR) in the response to antidepressants. We tested in a proof-of-concept study whether adding fludrocortisone (an MR agonist) or spironolactone (an MR antagonist) accelerates onset of action and improves efficacy of escitalopram in patients with major depression. We included 64 in- and outpatients with major depression (Hamilton Depression Scale-17 score>18) in a double-blind, randomized, placebo-controlled trial. Patients were randomized in a 2:2:1 fashion to fludrocortisone (0.2 mg/d, n=24) or spironolactone (100 mg/d, n=27) or placebo (n=13) for the first 3 weeks during a 5-week treatment with escitalopram. No differences in mean HAMD change scores and in time to response emerged between treatments. However, among the responders, patients treated with fludrocortisone responded faster (Breslow test, p=0.05). The mean number of days to response was 16.0+/-2.6 days vs. placebo 22.2+/-2.0 vs. spironolactone 22.6+/-2.3 (F=3.78, p=0.03). In the whole group, plasma cortisol increased during spironolactone and decreased during fludrocortisone treatment (F=2.4, p=0.04). In patients treated with fludrocortisone, non-responders had elevated cortisol values compared to responders throughout the study period (F=5.1, p=0.04). Stimulation of MR with fludrocortisone as adjunct to escitalopram accelerated the response in the group of responders while no effect emerged in the sample as a whole. A larger randomized controlled trial is warranted.

Cognitive impairment in major depression: association with salivary cortisol

BACKGROUND

Cognitive deficits and elevated cortisol are hallmarks of depression. Cortisol acts via mineralocorticoid and glucocorticoid receptors, which have their highest density in the hippocampus, a brain area closely related to cognitive function. Several studies have separately examined cortisol secretion and cognitive deficits in depression. However, only few studies have assessed their association in the same patients producing inconclusive results.

METHODS

We examined 52 medication-free patients with major depression (37 women, 15 men; mean age 35 +/- 11 years; Hamilton Depression Scale mean score 27 +/- 5) and 50 healthy control subjects, matched for age, gender, and years of education. We applied several neuropsychological tests. Salivary cortisol levels were measured on the same day at 08:00, 12:00, 16:00, and 22:00 hours.

RESULTS

Compared with healthy subjects, patients had significantly higher cortisol levels and were impaired in verbal memory, visuospatial memory, working memory, and selective attention. In depressed patients, but not in healthy control subjects, we found a negative correlation between salivary cortisol levels (area under the curve) and hippocampus-related neuropsychological domains (verbal memory, visuospatial memory) and executive function.

CONCLUSIONS

Cognitive deficits, especially those closely related to hippocampus function, appear to be related to cortisol secretion in depressed patients. Elevated cortisol may downregulate mineralocorticoid and glucocorticoid receptors in the hippocampus, which could, in part, be responsible for cognitive deficits in depressed patients.

Abnormal excitability of premotor-motor connections in de novo Parkinson's disease

The dorsal premotor cortex (PMd) is abnormally active in patients with idiopathic Parkinson's disease. This has been interpreted as a functional correlate of adaptive plasticity within the motor system to compensate for deficient activation of striato-mesial-frontal projections in these patients. Whether abnormal PMd activity influences excitability in the primary motor cortex (M1) in untreated Parkinson's disease patients and how this premotor-motor interaction might be altered by l-dopa is unclear. To this end, we studied the effects of 1 Hz premotor repetitive transcranial magnetic stimulation (rTMS) on M1 excitability in 10 previously untreated non-tremulous Parkinson's disease patients before (day 1) and after (day 8) their first ever l-dopa treatment and compared the results with those of a group of nine age- and sex-matched healthy controls. In each rTMS session, 1200 pulses of 1 Hz rTMS were applied at an intensity of 80% active motor threshold (AMT) to the PMd contralateral to the clinically more affected side in Parkinson's disease patients and to the left PMd in healthy controls. Intracortical paired pulse excitability of ipsilateral M1 was probed using a TMS paired pulse paradigm where subthreshold conditioning pulses (80% of AMT) were given 2-15 ms prior to a suprathreshold test pulse. In Parkinson's disease patients, abnormal baseline intracortical excitability at an interstimulus interval (ISI) of 5 ms was normalized by premotor rTMS. In contrast, rTMS led to an increased excitability at an ISI of 5 ms in healthy controls. Premotor rTMS effects lasted longer (for at least a week) in patients. These results show that the modifiability of premotor-motor connections is abnormal in untreated Parkinson's disease. A single dose of l-dopa reversed, i.e. normalized, the direction of excitability changes in M1 following premotor rTMS in Parkinson's disease patients, suggesting that dopamine depletion directly or indirectly influences premotor-motor interactions in Parkinson's disease. The rTMS conditioning approach described here provides a promising tool to delineate further the excitability changes in frontal motor areas in response to progressive degeneration of nigrostriatal dopaminergic neurons and also to chronic l-dopa treatment in Parkinson's disease.

Psychometrische Erfassung charakteristischer subjektiver Zeichen und Symptome der Schizophrenie mit dem Eppendorfer Schizophrenie-Inventar (ESI)

Zusammenfassung. Theoretischer Hintergrund: Das Eppendorfer Schizophrenie-Inventar (ESI) erfasst charakteristische subjektive Zeichen und Symptome der Schizophrenie und kann so zur Verbesserung der Diagnostik beitragen, z.B. bei der Früherkennung und -behandlung psychotischer Störungen. In der vorliegenden Arbeit werden zwei Validierungsstudien zum ESI präsentiert. Fragestellung und Methode: Studie I hatte das Ziel, nach objektivierbaren Korrelaten der mit dem ESI erfassten subjektiven Phänomene zu suchen; N = 100 akut erkrankte Schizophrene wurden eingeschlossen. In Studie II wurde die diagnostische Spezifizität des ESI durch Gruppenvergleiche geprüft (37 ersterkrankte und 30 chronifizierte Schizophrene, 31 Alkoholkranke, 37 Depressive, 34 Zwangskranke, 30 Gesunde). Ergebnisse und Schlussfolgerungen: Studie I erbrachte zahlreiche plausible Korrelationen zwischen ESI-Skalen und anderen klinischen Fragebögen, neuropsychologischen Tests, fremdbeurteilten psychopathologischen und neurologischen Symptomen. Studie II bestätigte die differentialdiagnostische Validität des ESI.

[Do strong static magnetic fields in NMR tomography modify tissue perfusion?]

Findings obtained in humans and test animals raised the question whether strong static magnetic fields as used in NMR-tomography may affect tissue perfusion. In two test series including 20 subjects, each skin blood flow at the thumb was determined by heat clearance, and forearm blood flow was measured by venous occlusion plethysmography. For comparative purposes, measurements were carried out bilaterally at both extremities. The experiments consisted of three sections that lasted 10 min each. During the second section the thumb or the forearm were unilaterally exposed to magnetic fields of 0.9 to 1 T and 0.4 to 0.5 T, respectively. The results of this section were compared with the values obtained during the experimental sections prior to and after the exposure to the magnetic field. The results were also compared with the blood flow measured at the contralateral extremity. Neither at the skin of the thumb nor at the forearm were there changes in local blood flow attributable to the magnetic fields applied.

Exercise and protein intake effects on urinary 3-methylhistidine excretion

A 28-day study was conducted with 13 adult men to determine the effect of weight lifting exercise and protein intake level on urinary 3-methylhistidine (3MH) excretion. Subjects were fed the RDA for protein [0.8 g/(kg BW X d)] or 3 X RDA; there were no-exercise and exercise groups at each intake. Comparisons of last 14-day, least-squares means among groups did not reveal differences in data treated by lean body weight [3MH/(kg LBW X d)] or by urinary creatinine excretion [3MH/(kg UCE X d)], but 3MH/(kg LBW X d) excretions were higher for exercise than no-exercise subjects. Regression analyses revealed linear, increasing trends in the 3MH/(kg LBW X d) data for RDA-exercise (p less than 0.03), 3 X RDA-exercise (p less than 0.01), and 3 X RDA-no-exercise (p less than 0.01) groups; 3MH/(g UCE X d) group data plots overlapped. Our findings for 3MH/(kg LBW X d) indicate that a weight lifting program was associated with increased 3MH excretions from adult males. As an index of skeletal muscle catabolism, an increase in 3HM excretion represents an increase in tissue catabolism. No significant effect of 3 X RDA protein intake on last 14-day 3MH excretions was observed; however, linear increases in 3MH/(kg LBW X d) for 3 X RDA-no-exercise subjects suggests a relationship. Trends of exercise- or protein intake-enhanced 3MH excretion could be masked by data as 3MH/(g UCE X d) if exercise or 3 X RDA protein intake can expand the body creatine pool independent of skeletal muscle mass.

Log-linear-model analysis of the association between disease and genotype

In this paper, log-linear-model analysis is employed to provide further insight into the disease-genotype association problem, as discussed by Norwood and Hinkelmann (1978, Biometrics 34, 593-602). It is shown how this approach can take account of the structure of the data when testing hypotheses about the type of association, by specifying the form of recurrence risks and allowing estimation of such recurrence risks by maximum likelihood. The notation of conditional recurrence risk is introduced and its usefulness is illustrated.