Search

Extensive, selective literature review of 2500 articles from the last years (up to December 2007) predominantly from Medline and Cochrane, using as search terms "antipsychotic or schizophrenia or individual drug names (amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone)" and the terms "BMI, weight gain, metabolic syndrome, diabetes, lipid(s), cholesterol, triglycerides" was conducted. Regardless of the advantages ascribed to atypical antipsychotics and the special effectiveness of clozapine in patients resistant to therapy and at risk for suicide, the probability of weight gain is considerably increased for some of these substances. Patients with schizophrenia have a considerably reduced life expectancy associated with an increased prevalence of cardiovascular risk factors. There is a lack of practical guidelines integrated into clinical psychiatric care for the management of cardiovascular risk factors. The monitoring of patients treated with atypics, which has been recommended in the APA/ADA Consensus Paper in light of these facts, is insufficiently established in clinical practice. A regular monitoring can convey self control and motivation to the patient. In the case of corresponding risk constellations further decisions regarding indication and therapy have to be considered. Especially patients with a high cardiovascular risk profile are highly recommended to participate in a weight-management program for prevention purposes. Such a special program should include elements of dietetic treatment and behaviour and exercise therapy. First controlled studies suggest an effective prevention of weight gain and metabolic changes when applying such a structured program. The practice oriented step by step concept presented here is meant to provide points of reference for the implementation of required medical and psychoeducative measures facilitating the management of weight and further cardiovascular risk factors in the context of psychiatric care in patients with schizophrenia.

Beta-adrenoceptor blockers belong to the most successful drug classes of medicine. Mainly they are used in internal medicine. 40 years ago beta-adrenoceptor blockers have occasionally been used in psychiatry for the treatment of anxiety disorders. Over the past four decades, the effects of beta-adrenoceptor blockers in the treatment of schizophrenic and manic psychoses, withdrawal syndromes and aggressive behaviour with temper outbursts has been investigated. Beta-adrenoceptor blockers are also used in the treatment of side-effects of psychopharmacological agents like neuroleptic or antidepressant-induced tachycardias, lithium-induced tremor, antipsychotic-induced akathisia or tardive dyskinesia as well. Since the mid-nineties it has been attempted to improve the efficacy of antidepressant agents by means of the 5-HT-(1a)-receptorantagonist pindolol. Presumedly memory consolidation of traumatic events can be enhanced by adrenergic activation. Therefore some open clinical trials investigated the effects of propranolol, a lipid soluble drug, which crosses the blood-brain barrier easily, to reduce the manifestation of PTSD. The present review presents the results of the literature with respect to the indications for beta-blockers in psychiatry. Considering evidence-based-medicine criteria beta-blockers are indicated to treat lithium-induced tremor, antipsychotic-induced akathisia and to reduce aggressive behavior of patients with brain-injuries.

Significantly increased plasma total homocysteine levels (t-Hcys) appeared in treated Huntington disease (HD) patients compared to controls and untreated HD subjects. Because the protein Huntingtin interacts with the homocysteine metabolism modulating enzyme cystathionine beta-synthase, we hypothesize that homocysteine promotes neurodegeneration in HD.

Introduction: This study was designed to investigate to what extent guidelines regarding the pharmacological treatment of patients suffering from schizophrenia-like psychosis are adopted in a naturalistic treatment setting. Methods: Medical records of n=819 patients undergoing inpatient treatment for schizophrenia-like psychosis in 11 psychiatric hospitals in northwestern Germany were retrospectively analyzed and findings were compared to current schizophrenia guideline recommendations. Results: The prescription rate of second generation antipsychotics increased from 47.1% on admission to 62.5% at discharge. Only half the patients (52.3%) received antipsychotic monotherapy while 47.7% took between 2 and 4 antipsychotic substances at a time. Dosage increases occurred most frequently (in 60%) within the first week of inpatient treatment, 16.6% experienced an elevation between days 15 and 29. A change within the atypical medication was found in 19.3%. Clozapine prescriptions increased throughout the treatment but were combined with other antipsychotic substances in the majority of cases. Conclusion: Under naturalistic conditions guideline recommendations for treatment of schizophrenia-like psychosis are adhered to only partially. Combination therapy with 2 or more antipsychotic drugs is quite common despite a clear recommendation for monotherapy.

Repetitive transcranial magnetic stimulation (rTMS) is a tool that enables clinicians and neuroscientists to modulate cortical activity in a non-invasive way. High-frequency rTMS has predominantly an activating effect on the stimulated brain region while low-frequency rTMS has an inhibitory effect. In addition to its usefulness as a research tool and in neurological diagnostics, rTMS may prove useful as a therapeutic option in psychiatry, especially in disorders that are associated with regional changes in cortical activity. For instance, rTMS is under current investigation in the treatment of depression and negative symptoms of schizophrenia. A hypofrontality or a fronto-limbic imbalance associated with both syndromes could be corrected by activating, high frequency rTMS. Conversely, a regional hyperactivity in the temporo-parietal cortex has been described in subjects suffering from auditory hallucinations and tinnitus. Low frequency, inhibitory rTMS is currently evaluated as a therapeutic option in these subjects. In addition to the effects on the directly stimulated brain area, other biological effects of rTMS may exert a beneficial influence on brain function. Amongst these are a modulation of cortico-cortical circuits (e. g. fronto-cingular and fronto-parietotemporal circuits), effects on monoaminergic neuromodulation and neuroendocrine effects. The current knowledge about the therapeutically relevant neurophysiological and neuroendocrine effects of rTMS are reviewed. An improved understanding of the neurophysiological basis of the therapeutic effects of rTMS and of the pathophysiology underlying neuropsychiatric diseases may lead to optimized therapeutic rTMS applications and new clinical indications for rTMS.

Extensive, selective literature review of 2500 articles from the last years (up to December 2007) predominantly from Medline and Cochrane, using as search terms "antipsychotic or schizophrenia or individual drug names (amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone)" and the terms "BMI, weight gain, metabolic syndrome, diabetes, lipid(s), cholesterol, triglycerides" was conducted. Regardless of the advantages ascribed to atypical antipsychotics and the special effectiveness of clozapine in patients resistant to therapy and at risk for suicide, the probability of weight gain is considerably increased for some of these substances. Patients with schizophrenia have a considerably reduced life expectancy associated with an increased prevalence of cardiovascular risk factors. There is a lack of practical guidelines integrated into clinical psychiatric care for the management of cardiovascular risk factors. The monitoring of patients treated with atypics, which has been recommended in the APA/ADA Consensus Paper in light of these facts, is insufficiently established in clinical practice. A regular monitoring can convey self control and motivation to the patient. In the case of corresponding risk constellations further decisions regarding indication and therapy have to be considered. Especially patients with a high cardiovascular risk profile are highly recommended to participate in a weight-management program for prevention purposes. Such a special program should include elements of dietetic treatment and behaviour and exercise therapy. First controlled studies suggest an effective prevention of weight gain and metabolic changes when applying such a structured program. The practice oriented step by step concept presented here is meant to provide points of reference for the implementation of required medical and psychoeducative measures facilitating the management of weight and further cardiovascular risk factors in the context of psychiatric care in patients with schizophrenia.

Beta-adrenoceptor blockers belong to the most successful drug classes of medicine. Mainly they are used in internal medicine. 40 years ago beta-adrenoceptor blockers have occasionally been used in psychiatry for the treatment of anxiety disorders. Over the past four decades, the effects of beta-adrenoceptor blockers in the treatment of schizophrenic and manic psychoses, withdrawal syndromes and aggressive behaviour with temper outbursts has been investigated. Beta-adrenoceptor blockers are also used in the treatment of side-effects of psychopharmacological agents like neuroleptic or antidepressant-induced tachycardias, lithium-induced tremor, antipsychotic-induced akathisia or tardive dyskinesia as well. Since the mid-nineties it has been attempted to improve the efficacy of antidepressant agents by means of the 5-HT-(1a)-receptorantagonist pindolol. Presumedly memory consolidation of traumatic events can be enhanced by adrenergic activation. Therefore some open clinical trials investigated the effects of propranolol, a lipid soluble drug, which crosses the blood-brain barrier easily, to reduce the manifestation of PTSD. The present review presents the results of the literature with respect to the indications for beta-blockers in psychiatry. Considering evidence-based-medicine criteria beta-blockers are indicated to treat lithium-induced tremor, antipsychotic-induced akathisia and to reduce aggressive behavior of patients with brain-injuries.

Neurological disorders of different etiology may cause identical clinical symptoms requiring additional diagnostic procedures for a precise differential diagnosis. Focal epileptic seizures have been shown to cause increased signal intensities in T2 and diffusion-weighted magnetic resonance images (MRI), mimicking other neurological disorders or diseases such as viral encephalitis. In some cases even the combination of neuroimaging and cerebrospinal fluid (CSF) analysis is not sufficient to obtain the final diagnosis, since epileptic seizures may cause pleocytosis as well. Some epilepsy centers presented cases of focal status epilepticus with severe but reversible MRI changes. These cases indicate that MRI-changes following focal seizures are reversible over a different time window compared to MRI changes associated with other etiologies, such as viral infection. This data further suggest that in cases where focal seizures can not be ruled out, a follow-up MRI scan within a few days following the onset of symptoms significantly improves the precision of the differential diagnosis. Recently new scientific data were reported in this review.

Recent data suggest that repetitive transcranial magnetic stimulation (rTMS) is effective in treating depressive symptoms to a lesser extent compared with classical electroconvulsive therapy. However, rTMS represents an economical and well tolerable procedure in relation to the expenditure of electroconvulsive therapy with anaesthesia. Usually, rTMS is applicated as an add-on-therapy accompanying psychopharmacological treatment. So far, it has predominantly been used for patients with long-standing and so called treatment-refractory symptoms. However, even in the early phase of a depressive episode rTMS would be possibly more effective. In many cases, the standard procedure-application of up to 10 rTMS-sessions will not be enough to produce therapeutic benefit. Therefore rTMS series including up to 20 sessions are recommended. Long-term studies are needed to clarify the role of rTMS for relapse prevention and to determine the optimal frequency and duration of rTMS in such an indication. Although numerous results of newer studies suggest a moderate antidepressive effect of rTMS, its application in daily clinical routine practice cannot be recommended yet. Larger, accurate designed and controlled studies, especially involving patients of old age, are needed to evaluate the true tolerability and effectiveness of rTMS as a new treatment option for depressive symptoms.

Inappropriate use of headache medication (15 times/month) for the treatment of headache episodes may contribute to the development of chronic headache which is refractory to most treatments. Physicians experienced in the treatment of migraine and other headaches are well aware that the daily intake of antipyretic or antiinflammatory analgesics, opioids, ergot alkaloids and "triptans" may result in chronic daily headache. Conversely, if a patient complains of chronic headache and takes pain medication every day, this headache is most likely to be caused and sustained by the medication and will vanish or improve with abstinence. Treatment includes drug withdrawal followed by structured acute therapy and initiation of migraine prophylactic treatment.

While questioning patients about aggravation of the headache by routine physical activity, sensitivity of walking stairs and lifting a heavy object versus head movements and bending down in terms of aggravating the headache was aimed to be determined. Eighty-one migraine patients were questioned about the aggravation of their headaches with two sets of question groups. (The first set: walking stairs and lifting a heavy object; The second set: rotating the head side to side and bending down). 38 and 72 patients gave clear answers to the first and second set of questions respectively. Clear information was obtained from the first and second group of questions by 38 and 72 patients respectively. Some patients with severe migraine headaches may prevent themselves from rigorous daily activities while they could bend or make sudden head movements inadvertently during the attack. We think that aggravation of the headache due to head movements or bending down during migraine attacks seems more sensitive than walking stairs or lifting a heavy object to migraine patients.

We reviewed the epidemiology of headache disorders for the most frequent primary headache-syndromes: migraine, tension-type headache and trigemino-autonomic headache syndromes. In the last years scientific data about headache disorders have increased. New studies investigated not only the prevalence of headaches, but also economic costs of this disorder. Epidemiologic headache research also investigates the quality of life.

A 43-year-old woman was admitted after a suicide attempt with 1.5 g atenolol. Physical and neurological examination showed no abnormality, but psychiatric examination revealed symptoms of a major depression. Four weeks prior to admission a valsartan-hydrochlorothiazide combination had been added to the antihypertensive medication.Laboratory tests, electrocardiography, chest-x-ray, electroencephalography and cranial computerised tomography showed no abnormality.The depressive disorder resolved within ten days after discontinuation of valsartan and hydrochlorothiazide without specific treatment. Blood pressure was normal under treatment with metoprolol.Depressive drug reactions can produce a substantial morbidity. This case of a drug induced affective disorder should heighten the awareness of unusual reactions to valsartan-hydrochlorothiazide therapy.

Wernicke's encephalopathy is a serious neurologic disorder caused by vitamin-B1 or thiamine deficiency. The classical triad of clinical symptoms described by Wernicke (gait ataxia, ophthalmoplegia, and confusion) are found in only a third of patients upon initial examination. Typical findings upon MR imaging in patients with Wernicke's encephalopathy are well documented, with signal intensities in the medial thalami and periaqueductal regions of the midbrain. We report a case of Wernicke's encephalopathy revealing an unusual contrast enhancement. It is therefore important to note that the acute stage of Wernicke's encephalopathy may be associated with an intense contrast enhancement upon MR-imaging reflecting the disruption of the blood-brain barrier and inflammatory processes caused by thiamine deficiency. As a consequence from the guideline for managing Wernicke's encephalopathy by the Royal College of Physicians early B-vitamin treatment in suspected is recommended cases.

Over the last 10 years an increasing amount of data regarding the prevalence of chronic daily headache (CDH) has been published. The economic implications of chronic daily headache have now grown in importance in view of the increasingly limited financial resources in the health care system. In addition to recording data regarding the prevalence of this disease, epidemiological studies have also dealt with analysing and evaluating the quality of life of the afflicted patients. According to population-based data from the USA, Europe and Asia, approx. 4-5% of the population suffer from chronic daily headache. These have been equated up until now with chronic tension-type headache (CTTH). More recent epidemiological studies have resulted in an adaptation of this point of view. Currently it is assumed that approx. 2-3% of the population suffer CTTH, which preferably affects females (approximately twice as frequently); approx. 2 % suffer chronic migraine (transformed migraine = TM) and 0.2 % are afflicted with a so-called new daily persistent headache or very rarely a hemicrania continua.

We undertook this study to evaluate the effects of needle acupuncture on cardiac autonomic nervous system (ANS) function in patients with minor depression or anxiety disorder. Patients (n = 36) were randomly distributed into a verum acupuncture (VA) group (needles were applied at classical acupuncture points, e. g. He7, Pe6, Du20, Bl62, Ex6) or a placebo (PL) group (needles were applied only epidermal at non-acupuncture points). Both groups underwent standardized measurements of the 5-minute resting heart rate variability (HRV), which were performed before the first and after the 9th acupuncture session of an acupuncture series, and also three times (before the start and 5, respectively, 15 minutes after needle application) during the third acupuncture session. Demographic data between the VA and PL group did not differ. Before the start of acupuncture there were also no significant differences in HRV data between these groups. Compared to PL the VA group showed a significant decrease of the mean resting heart rate both, 5 and 15 minutes after needle application, combined with a trend towards an increase of the high frequency (HF; 0.15 - 0.4 Hz) and a decrease of the low frequency (LF; 0.04 - 0.15 Hz) spectral power. The latter effects resulted in an overall significant decrease of the mean LF/HF ratio in VA compared to PL treated patients. This pattern of findings suggests that in patients with minor depression or anxiety only verum acupuncture 1.) leads to a relative increase of cardiovagal modulation of heart rate and 2.) facilitates the physiological regulatory ANS function in response to alterations of external or internal environment. Clinical implications of these findings are discussed.

In a cross-over study we investigated the effects of sildenafil (single doses of 25- or 50mg) on cardiovascular autonomic nervous system (ANS) function assessed by serial recordings of blood pressure, conventional 12-lead electrocardiograms and standardized, time-and frequency domain indices of heart rate variability (HRV) in 21 men with erectile dysfunction. More than half of these patients had multiple comorbidities. Sildenafil induced significant mean reductions from baseline in resting blood pressure, accompanied by a reflex increase in heart rate. There were no significant changes after administration of sildenafil in any other of the ANS function indices. These preliminary findings suggest that sildenafil does not significantly affect cardiac ANS function in patients with erectile dysfunction.

In a placebo-controlled, randomized, modified double-blind study we investigated the effects of body needle acupuncture (n = 10) in 43 patients with minor depression (ICD 10 F32.0, F32.1) and 13 patients with generalized anxiety disorders (ICD10 F41.1). The severity of the disease was assessed by the Clinical Global Impression Scale (CGI). Treatment response was defined as a significant improvement in CGI. An intent-to-treat analysis was performed to compare treatment responses between verum- and placebo acupuncture. After completing an total of 10 acupuncture sessions the verum acupuncture group (n = 28) showed a significantly larger clinical improvement compared to the placebo group (Mann-Whitney test, p0.05). There were significantly more responders in the verum-compared to the placebo group (60.7% vs. 21.4%; chi-square test, p0.01). In contrast, no differences in the response rates were evident just after 5 acupuncture sessions. A multivariate analysis with the independent factor acupuncture (verum vs. placebo) and the results of the results of the additional rating scales (total score of HAMA, HAMD, Bf-S, BL) as dependent variables (ANOVA, 1:54 D.F.) revealed a clear trend towards lower HAMA scores in the verum group after completing 10 acupunctures (F3.29, p = 0.075). This corresponds well to the high response rate of 85.7% in patients with generalized anxiety disorders, in whom verum acupuncture was applied. Our results indicate that needle acupuncture (Du.20, Ex.6, He.7, Pe.6, Bl.62) leads to a significant clinical improvement as well as to a remarkable reduction in anxiety symptoms in patients with minor depression or with generalized anxiety disorders. The total sum of acupuncture sessions and the specific location of acupuncture needle insertions might be important factors for bringing about therapeutic success.

Between January 1995 and June 1996, 24 inpatients at our hospital (mean age 55.6 years) were treated with electroconvulsive therapy (ECT). Clinical improvement was observed in 80% of the patients, including those without risk factors (NRG, n = 16), as well as those with concomitant cardiovascular diseases (RG, n = 8). During a mean period of observation of 224 days after the end of ECT 7 patients (35%) relapsed. The rate of relapse was higher in RG than in NRG patients (57.1 vs 23.1%). In all cases ECT was well tolerated; 285 applications of ECT did not result in mortality or persistent morbidity. However, RG patients may be at increased risk for the development of minor cardiovascular complications, which were noted in three RG patients (37.5%), but only in one patient (6.2%) in the NRG (Fisher's test, P = 0.09). Taken together, our results demonstrate that ECT is a safe treatment regimen for depression even in medically ill patients of old age.

The true prevalence of neurosyphilis in HIV-infection is unknown, since a sufficiently sensitive and specific test is lacking. In a prospective study we found reactive serum TPHA and FTA-ABS IgG tests in 95 (31%) of 307 HIV-infected patients. Three of 11 patients with latent syphilis revealed reactive CSF-VDRL tests, six others only demonstrated CSF abnormalities. Resolution of CSF abnormalities during a six month follow up after high dose antibiotic therapy led to the diagnosis of oligosymptomatic or asymptomatic neurosyphilis in all nine patients. Thus, the specificity of the CSF-VDRL was 100%, but the sensitivity was only 33%. The overall prevalence of neurosyphilis was 2.9%, increasing to 9.5% in patients with a reactive serum TPHA. Our study emphasizes the importance of antibiotic therapy for presumptive neurosyphilis in HIV-infected patients with latent syphilis and CSF abnormalities but nonreactive CSF-VDRL tests, even if they are neurologically asymptomatic or present with complaints inconclusive of neurosyphilis.

In a controlled prospective study we used peripheral autonomic surface potentials (PASP) and an autonomic test battery (valsalva, 30:15 ratio, deep breathing, sustained handgrip, Schellong test) to evaluate HIV-1 associated autonomic dysfunction (HIVAD) in 38 HIV-seropositive patients. Criteria of exclusion were drug or alcohol abuse, concurrent infections, neoplasms, wasting syndrome and neurotoxic medication. We found increased PASP onset latencies and lower PASP amplitudes even in asymptomatic HIV-infected patients (p0.0125, Bonferroni corrected p-value). A mild or marked HIVAD was detected in 21% of the patients each. Heart rate and blood pressure responses were similarly affected. HIVAD was not related to HIV-1 associated changes in sural and tibial nerve conduction parameters. Our data suggest that HIVAD is a frequent complication of HIV-1 infection and that HIV-1 plays a direct role in its pathogenesis. Sympathetic and parasympathetic divisions of the ANS appear to be similarly affected.

A 22-year-old oligophrenic patient had on several occasions over several months been given various neuroleptics (haloperidol, benperidol, levomepromazine) for exacerbations of paranoid schizophrenia. For a few days before hospitalization he had become quiet and withdrawn, but on the day of admission 100 mg chlorprothixene was administered intramuscularly when he had become agitated. At admission he was somnolent, his general condition was disturbed. He had hyperhidrosis and hypersalivation, as well as tachycardia (112/min) with a normal body temperature of 37.8 degrees C. He also exhibited the cogwheel phenomenon of the limbs and neck, as well as tremor of the hands. The differential diagnosis included inflammatory disease of the brain, sinus thrombosis and, especially, malignant neuroleptic syndrome and febrile catatonia.The activities of creatine kinase (3840 U/l), GOT (75 U/l) and GPT (88 U/l) were all increased. Serum myoglobin was 77 micrograms/l. CSF contained blood and there was pleocytosis of 50/3 cells. The ECG showed sinus tachycardia. EEG, chest radiogram, computed tomography, magnetic resonance imaging and cerebral angiography showed no abnormalities. Febrile catatonia could not be excluded.4 hours after admission the patient began to respond with normal orientation. Shortly afterwards he was able to walk a few steps, i.e. there was no catatonia. But rigor, tremor, hypersalivation and tachycardia persisted and 12 hours later he developed a fever (up to 39.2 degrees C). Blood pressure varied with peak pressures up to 190/110 mm Hg. After 2 days muscle tone had clearly increased so much that voluntary movement was hardly possible. After amantadine administration (200 mg daily) the rigor improved and for the first time body temperature became normal again. There were no signs pointing to psychotic symptoms.Neuroleptic malignant syndrome is difficult to distinguish from febrile catatonia and the diagnosis can often only be made through the clinical course.