Psychotic Disorders in ICD-11

Within the efforts to revise ICD-10, the World Health Organization (WHO) has appointed a disorder-specific Working Group on the Classification of Psychotic Disorders (WGPD). The WGPD has proposed several changes to the classification criteria of schizophrenia and other primary psychotic disorders in order to increase the clinical utility, reliability and validity of the diagnostic classification. The main proposals include changes to the chapter title, the replacement of existing schizophrenia subtypes with symptom specifiers, stricter diagnostic criteria for schizoaffective disorder, a reorganization of the delusional disorders and the acute and transient psychotic disorders, as well as the revision of course specifiers. These proposed revisions are subject to field trials with the aim of studying whether they will lead to an improvement of the classification system in comparison to its previous version. The proposals are compared with revisions of the according DSM-5 chapter. The impact of novel results from neuroscience and genetics on the current proposals is discussed, also with respect to future classification strategies such as the Research Domain Criteria (RDoC) project.

Psychotic Disorders in ICD-11

For the development of ICD-11, the World Health Organization (WHO) has inaugurated a Working Group on the Classification of Psychotic Disorders (WGPD). A range of changes of the classification of primary psychotic disorders was developed by this group. While DSM-5 was published in 2013, the ICD-11 proposals are currently undergoing internet-based and clinical field trials and the final version is due in 2017. Among the major changes suggested by the WGPD for ICD-11 are the chapter titles, the replacement of the current schizophrenia subtypes by a number of symptom specifiers, a new set of course specifiers harmonized with DSM-5, transsectional diagnostic criteria for schizoaffective disorder, and a reorganization of the acute and transient psychotic disorders and delusional disorders.

Therapy of post-stroke depression – a systematic review

We performed a systematic review of randomized placebo-controlled pharmacological and non-pharmacological trials for the therapy and prevention of post-stroke depression that have been published between 1980 and 2011. We initially identified 2 260 records of which 28 studies were finally included into this review. A meta-analytic approach was hampered by considerable differences regarding the kinds of therapeutic regimens and the study durations. Modest effects favoring treatment of post-stroke depression could be found for pharmacological treatment as well as repetitive transcranial magnetic stimulation. For the prevention of post-stroke depression, antidepressant pharmacotherapy showed promising results. However, large-scale studies with better standardized study populations, optimized placebo control procedures in non-pharmacological studies, and replication in larger follow-up studies are still necessary to find the optimal therapeutic regimens to prevent and treat post-stroke depression.

Qualitätsindikatoren in der Psychiatrie

Mit Einführung des neuen Entgeltsystems in Psychiatrie und Psychosomatik sowie der Einführung neuer Versorgungsmodelle stellt sich die Frage, wie sich diese Entgelt- und Versorgungsmodelle auf die Qualität der psychiatrisch-psychotherapeutischen sowie der psychosomatischpsychotherapeutischen Behandlung auswirken. Darum bedarf es begleitend zur gegenwärtigen Einführung eines neuen Entgeltsystems für die Bereiche Psychiatrie und Psychosomatik auch der Einführung von qualitätsorientierten Versorgungsanalysen, wobei als eine der wichtigsten Voraussetzungen für eine sektorenübergreifende Qualitätsmessung konsentierte und valide Qualitätsindikatoren zu entwickeln sind. Dabei spielen neben der Abbildung der Strukturqualität psychiatrischer und psychosomatischer Versorgungseinrichtungen insbesondere Indikatoren der Prozess- und Ergebnisqualität eine zentrale Rolle, die nach Möglichkeit mit den routinemäßig verfügbaren Daten gut messbar sind, eine hohe Aussagekraft besitzen und Aspekte der Qualität der Behandlung über den gesamten Krankheitsverlauf und, wenn möglich, über Grenzen der Versorgungssektoren ambulant vs. stationär hinweg darstellen können. Dabei ist darauf zu achten, dass es nicht zu einem übermäßigen Dokumentationsaufwand zu Lasten der Behandlungsqualität kommt. In dem vorliegenden Beitrag wird ein möglicher Entwicklungsprozess für Qualitätsindikatoren in der Psychiatrie skizziert. Weiterhin werden einige Beispiele für bereits vorgeschlagene Qualitätsindikatoren für die Diagnostik und Behandlung der Schizophrenie und Depression vorgestellt. Abschließend bleibt festzuhalten, dass die aus der Entwicklung der Leitlinien abgeleiteten Qualitätsindikatoren ihre Praxistauglichkeit erst unter Beweis stellen müssen, um sinnvolle Steuerungswirkungen entfalten zu können.

Die Rolle von Qualitätsindikatoren in der psychiatrischen Qualitätssicherung und aktueller Stand der Entwicklung von Qualitätsindikatoren

Die Entwicklung von sektorenübergreifenden Qualitätsindikatoren für die Versorgung von Menschen mit psychischen Störungen wurde durch den Gemeinsamen Bundesausschuss auf den Weg gebracht. Wir beschreiben diese aktuelle Entwicklung und informieren über den Stand des Projektes zur Entwicklung von Qualitätsindikatoren durch die DGPPN für vier häufige psychische Störungen: Schizophrenie, Demenzen, Alkoholabhängigkeit und unipolare Depressionen.

Predicting Response to Repetitive Transcranial Magnetic Stimulation in Patients With Schizophrenia Using Structural Magnetic Resonance Imaging: A Multisite Machine Learning Analysis

BACKGROUND

The variability of responses to plasticity-inducing repetitive transcranial magnetic stimulation (rTMS) challenges its successful application in psychiatric care. No objective means currently exists to individually predict the patients' response to rTMS.

METHODS

We used machine learning to develop and validate such tools using the pre-treatment structural Magnetic Resonance Images (sMRI) of 92 patients with schizophrenia enrolled in the multisite RESIS trial (http://clinicaltrials.gov, NCT00783120): patients were randomized to either active (N = 45) or sham (N = 47) 10-Hz rTMS applied to the left dorsolateral prefrontal cortex 5 days per week for 21 days. The prediction target was nonresponse vs response defined by a ≥20% pre-post Positive and Negative Syndrome Scale (PANSS) negative score reduction.

RESULTS

Our models predicted this endpoint with a cross-validated balanced accuracy (BAC) of 85% (nonresponse/response: 79%/90%) in patients receiving active rTMS, but only with 51% (48%/55%) in the sham-treated sample. Leave-site-out cross-validation demonstrated cross-site generalizability of the active rTMS predictor despite smaller training samples (BAC: 71%). The predictive pre-treatment pattern involved gray matter density reductions in prefrontal, insular, medio-temporal, and cerebellar cortices, and increments in parietal and thalamic structures. The low BAC of 58% produced by the active rTMS predictor in sham-treated patients, as well as its poor performance in predicting positive symptom courses supported the therapeutic specificity of this brain pattern.

CONCLUSIONS

Individual responses to active rTMS in patients with predominant negative schizophrenia may be accurately predicted using structural neuromarkers. Further multisite studies are needed to externally validate the proposed treatment stratifier and develop more personalized and biologically informed rTMS interventions.

Value of schizophrenia treatment II: Decision modelling for developing early detection and early intervention services in the Czech Republic

Background:

Positive findings on early detection and early intervention services have been consistently reported from many different countries. The aim of this study, conducted within the European Brain Council project “The Value of Treatment”, was to estimate costs and the potential cost- savings associated with adopting these services within the context of the Czech mental health care reform.

Methods:

Czech epidemiological data, probabilities derived from meta-analyses, and data on costs of mental health services in the Czech Republic were used to populate a decision analytical model. From the health care and societal perspectives, costs associated with health care services and productivity lost were taken into account. One-way sensitivity analyses were conducted to explore the uncertainty around the key parameters.

Results:

It was estimated that annual costs associated with care as usual for people with the first episode of psychosis were as high as 46 million Euro in the Czech Republic 2016. These annual costs could be reduced by 25% if ED services were adopted, 33% if EI services were adopted, and 40% if both, ED and EI services, were adopted in the country. Cost-savings would be generated due to decreased hospitalisations and better employment outcomes in people with psychoses.

Conclusions:

Adopting early detection and early intervention services in mental health systems based on psychiatric hospitals and with limited access to acute and community care could generate considerable cost- savings. Although the results of this modelling study needs to be taken with caution, early detection and early intervention services are recommended for multi-centre pilot testing accompanied by full economic evaluation in the region of Central and Eastern Europe.

Value of schizophrenia treatment I: The patient journey

BACKGROUND

The aim of the European Brain Council project "The Value of Treatment" was to provide evidence-based, cost-effective policy recommendations for a patient-centered and sustainable coordinated care model for brain disorders. The first part of schizophrenia study examined the needs and gaps in the patients' care pathway.

METHODS

Descriptive analysis was based on an inventory of needs and treatment opportunities, using focus group sessions, expert interviews, users' input, and literature review. Three patient pathways were selected: indicated prevention, duration of untreated psychosis, and relapse prevention.

RESULTS

The analysis identified several critical barriers to optimal treatment. Available health care services often miss or delay detection of symptoms and diagnosis in at-risk individuals. There is a lack of illness awareness among patients, families, and the public; scarcity of information, training and education among primary care providers; stigmatizing beliefs. Early symptom recognition and timely intervention result in better outcome and prognosis; effective management leads to a functional recovery. In the current model of care, there is insufficient cooperation between health and social care providers, patients and families, inadequate utilization of pharmacological and psychosocial interventions, lacking patient monitoring, and low implementation of integrated community care.

CONCLUSIONS

Early detection and early intervention programs, timely intervention, and relapse prevention are essential for effective management of schizophrenia. It requires a paradigm shift from symptom control, achieving and maintaining remission, to the emphasis on recovery. Since the current services are not able to accomplish this goal, changes in mental health policies are needed.

Development of quality indicators for mental healthcare in the Danube region

BACKGROUND

Quality indicators are quality assurance instruments for the evaluation of mental healthcare systems. Quality indicators can be used to measure the effectiveness of mental healthcare structure and process reforms. This project aims to develop quality indicators for mental healthcare systems in Bulgaria, the Czech Republic, Hungary and Serbia to provide monitoring instruments for the transformation of mental healthcare systems in these countries.

METHODS

Quality indicators for mental healthcare systems were developed in a systematic, multidisciplinary approach. A systematic literature study was conducted to identify quality indicators that are used internationally in mental healthcare. Retrieved quality indicators were systematically selected by means of defined inclusion and exclusion criteria. Quality indicators were subsequently rated in a two-stage Delphi study for relevance, validity and feasibility (data availability and data collection effort). The Delphi panel included 22 individuals in the first round, and 18 individuals in the second and final round.

RESULTS

Overall, mental healthcare quality indicators were rated higher in relevance than in validity (Mean relevance=7.6, SD=0.8; Mean validity=7.1, SD=0.7). There was no statistically significant difference in scores between the four countries for relevance (X² (3)=3.581, p=0.310) and validity (X² (3)=1.145, p=0.766). For data availability, the appraisal of "YES" (data are available) ranged from 6% for "assisted housing" to 94% for "total beds for mental healthcare per 100,000 population" and "availability of mental health service facilities".

CONCLUSION

Quality indicators were developed in a systematic and multidisciplinary development process. There was a broad consensus among mental healthcare experts from the participating countries in terms of relevance and validity of the proposed quality indicators. In a next step, the feasibility of these twenty-two indicators will be evaluated in a pilot study in the participating countries.

The ICD-11 developmental field study of reliability of diagnoses of high-burden mental disorders: results among adult patients in mental health settings of 13 countries

Reliable, clinically useful, and globally applicable diagnostic classification of mental disorders is an essential foundation for global mental health. The World Health Organization (WHO) is nearing completion of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11). The present study assessed inter-diagnostician reliability of mental disorders accounting for the greatest proportion of global disease burden and the highest levels of service utilization - schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear-related disorders, and disorders specifically associated with stress - among adult patients presenting for treatment at 28 participating centers in 13 countries. A concurrent joint-rater design was used, focusing specifically on whether two clinicians, relying on the same clinical information, agreed on the diagnosis when separately applying the ICD-11 diagnostic guidelines. A total of 1,806 patients were assessed by 339 clinicians in the local language. Intraclass kappa coefficients for diagnoses weighted by site and study prevalence ranged from 0.45 (dysthymic disorder) to 0.88 (social anxiety disorder) and would be considered moderate to almost perfect for all diagnoses. Overall, the reliability of the ICD-11 diagnostic guidelines was superior to that previously reported for equivalent ICD-10 guidelines. These data provide support for the suitability of the ICD-11 diagnostic guidelines for implementation at a global level. The findings will inform further revision of the ICD-11 diagnostic guidelines prior to their publication and the development of programs to support professional training and implementation of the ICD-11 by WHO member states.

Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries

AIMS

To assess the prevalence and management of depressive disorders in people with Type 2 diabetes in different countries.

METHODS

People with diabetes aged 18-65 years and treated in outpatient settings were recruited in 14 countries and underwent a psychiatric interview. Participants completed the Patient Health Questionnaire and the Problem Areas in Diabetes scale. Demographic and medical record data were collected.

RESULTS

A total of 2783 people with Type 2 diabetes (45.3% men, mean duration of diabetes 8.8 years) participated. Overall, 10.6% were diagnosed with current major depressive disorder and 17.0% reported moderate to severe levels of depressive symptomatology (Patient Health Questionnaire scores >9). Multivariable analyses showed that, after controlling for country, current major depressive disorder was significantly associated with gender (women) (P<0.0001), a lower level of education (P<0.05), doing less exercise (P<0.01), higher levels of diabetes distress (P<0.0001) and a previous diagnosis of major depressive disorder (P<0.0001). The proportion of those with either current major depressive disorder or moderate to severe levels of depressive symptomatology who had a diagnosis or any treatment for their depression recorded in their medical records was extremely low and non-existent in many countries (0-29.6%).

CONCLUSIONS

Our international study, the largest of this type ever undertaken, shows that people with diabetes frequently have depressive disorders and also significant levels of depressive symptoms. Our findings indicate that the identification and appropriate care for psychological and psychiatric problems is not the norm and suggest a lack of the comprehensive approach to diabetes management that is needed to improve clinical outcomes.

Efficacy of high-frequency repetitive transcranial magnetic stimulation on PANSS factors in schizophrenia with predominant negative symptoms - Results from an exploratory re-analysis

Repetitive transcranial magnetic stimulation (rTMS) applied to the left frontal lobe is discussed to be a promising add-on treatment for negative symptoms in schizophrenia. The Positive and Negative Syndrome Scale (PANSS) has been used as outcome parameter in several previous rTMS trials, but studies focusing on PANSS factor analyses are lacking. For this purpose, we used the available PANSS data of the 'rTMS for the Treatment of Negative Symptoms in Schizophrenia' (RESIS) trial to calculate different literature-based PANSS factors and to re-evaluate the impact of rTMS on negative symptoms in this trial. In an exploratory re-analysis of published data from the RESIS study (Wobrock et al. 2015), we tested the impact of rTMS applied to the left dorsolateral prefrontal cortex on two PANSS factors for negative symptoms in psychotic disorders as well as on a PANSS five-factor consensus model intending to show that active rTMS treatment improves PANSS negative symptom subscores. In accordance to the original analysis, all PANSS factors showed an improvement over time in the active and, to a considerable extent, also in the sham rTMS group. However, comparing the data before and directly after the rTMS intervention, the PANSS excitement factor improved in the active rTMS group significantly more than in the sham group, but this finding did not persist if follow-up data were taken into account. These additional analyses extend the previously reported RESIS trial results showing unspecific improvements in the PANSS positive subscale in the active rTMS group. Our PANSS factor-based approach to investigate the impact of prefrontal rTMS on different negative symptom domains confirmed no overall beneficial effect of the active compared to sham rTMS.

[Schizophrenia and other primary psychotic disorders in ICD-11]

In the development of the International Classsification of Disorders (ICD-11), the World Health Organisation (WHO) has used a systematic approach with a focus on the utility of the revised classification criteria. For all major groups of mental and behavioural disorders working groups were set up, and these reviewed the scientific evidence and developed suggestions for revised classification criteria. These initial proposals, then submitted to public consultation and review, resulted in updated proposals. The chapter title for the primary psychotic disorders will be "Schizophrenia and other primary psychotic disorders". The clinical subtypes of schizophrenia will be substituted by symptom specifiers, which are applicable to all primary psychotic disorders. The role of Schneider's first-rank symptoms will be deemphasized. Course specifiers will be introduced and will be compatible with the U.S.-American classification system for mental disorders (Diagnostic and Statistical Manual, 5th revision, DSM-5). The group of Acute and Transient Psychotic Disorders will be more clearly differentiated from schizophrenia. Currently, field trials are under way both in clinical and internet-based settings to test the utility of the revised classification criteria. In early 2018, the final classification criteria of ICD-11 should be available.

[Web-based field studies on diagnostic classification and code assignment of mental disorders: comparison of ICD-11 and ICD-10]

The German Society for Psychiatry, Psychosomatics and Psychotherapy (DGPPN,) conducted a comprehensive field study (principal investigator WG) funded by the German Federal Ministry of Health in cooperation with 4 other German medical societies in the field of mental health (DGPM, DGPPR, DeGFS, DGfS) * to support WHO's development of the ICD-11 (Chapters 6 and 17). The objective of the web-based field study was to compare ICD-10 and ICD-11 (beta draft) for selected mental disorders, regarding consistency, accuracy and assessment of utility. The first study (TP1) focused on the diagnostic classification and the second (TP2) on assignment of diagnostic codes.In TP1, clinicians used either the ICD-10 Clinical Descriptions and Diagnostic Guidelines (CDDG) version or a draft version of the ICD-11 CDDG to evaluate 10 case vignettes in a randomized study implemented through the WHO GCPN **. As hypothesized, consistency was in favor of the ICD-11 (p = .02; n = 319 expert participants) though there was some variability across the different diagnostic categories. In addition, time for diagnosis was shorter (p = .01) and clinicians' judgment of utility (ease of use; goodness of fit) was better for ICD-11 (p = .047 and p < .001 respectively).TP2 focused on consistency of diagnostic code assignment for 25 short case descriptions (including explicit diagnosis and additional clinical information) using both ICD-10 and ICD-11 in a randomized web-based field study which was run on the WHO ICD-FiT *** platform. Based on 531 code assignments by120 expert clinicians, consistency for ICD-11 was significantly lower compared to ICD-10 (71 % vs. 82 %, p < .001) contrary to study hypothesis, and time required was significantly higher for ICD-11 (p < .001). Nevertheless, utility assessments were in favor of ICD-11 (p < .005).In summary, in TP1, given vignettes with more complex clinical descriptions more similar to clinical cases, ICD-11 showed advantages in the consistency of correct diagnoses among clinicians, time required to reach a diagnosis, and clinicians' ratings of clinical utility. These results provide evidence for quality improvement of the diagnostic process due to the revision of the more complete diagnostic guidelines for ICD-11. In the coding task of TP2, coding by clinicians using the ICD-10 was more consistent and faster than coding using the ICD-11. This may be a result of the greater complexity for coding use of the ICD-11 (e. g., due to 'post-coordination'), as well as greater familiarity with the ICD-10 system (which German clinicians currently use) and lack of practice with the new ICD-11 codes and tools. In spite of this, users assessed the ICD-11 system as more useful than the ICD-10, in part also because of ICD-11's more systematic and comprehensive coding tools. In addition, time needed for coding improved with practice, indicating need for intense education and training initiatives when ICD-11 is adopted and implemented into clinical practice.

Subtypes of depression and their overlap in a naturalistic inpatient sample of major depressive disorder

Subtyping depression is important in order to further delineate biological causes of depressive syndromes. The aim of this study was to evaluate clinical and outcome characteristics of distinct subtypes of depression and to assess proportion and features of patients fulfilling criteria for more than one subtype. Melancholic, atypical and anxious subtypes of depression were assessed in a naturalistic sample of 833 inpatients using DSM-IV specifiers based on operationalized criteria. Baseline characteristics and outcome criteria at discharge were compared between distinct subtypes and their overlap. A substantial proportion of patients (16%) were classified with more than one subtype of depression, 28% were of the distinct anxious, 7% of the distinct atypical and 5% of the distinct melancholic subtype. Distinct melancholic patients had shortest duration of episode, highest baseline depression severity, but were more often early improvers; distinct anxious patients had higher NEO-Five Factor Inventory (NEO-FFI) neuroticism scores compared with patients with unspecific subtype. Melancholic patients with overlap of anxious features had worse treatment outcome compared to distinct melancholic and distinct anxious subtype. Distinct subtypes differed in only few variables and patients with overlap of depression subtypes may have independent clinical and outcome characteristics. Studies investigating biological causes of subtypes of depression should take influence of features of other subtypes into account.

Methods for Predictor Analysis of Repeated Measurements: Application to Psychiatric Data

Objectives: In schizophrenia research, little attention yet has been directed on methods for analyzing data from studies with repeated measurements over time. Motivation for this research stems from a project within the German Research Network on Schizophrenia, in which an algorithm is developed to guide prodrome-based early intervention strategies in stable first episode patients.

Methods: We present two different approaches for the analysis of correlated response data, the Generalized Estimating Equations (GEE) method and the Artificial Neural Network (ANN) approach. We illustrate the methods using the data of the A.N.I. study, which is one of the largest German multicenter treatment studies in regard to the long-term treatment of schizophrenia conducted between 1983 and 1989.

Results: The results of statistical model selection prior to GEE analysis and various data presentation methods for ANNs are presented. The primary goal of our evaluation is to investigate if the defined prodromes are valid predictors for relapse. Additionally, it is shown that both methods are applicable on a realistic data set.

Conclusions: It is concluded that both methods are suitable for predictor analysis especially since all variable time points of the patients are included instead of only selected, so that it can be assumed that results are not biased. With the GEE method a test of association for each predictor can be performed whereas with ANNs a general proposition can be made for pro-dromes depending on the type of data presentation. Using the A.N.I. data the prodrome ‘trouble sleeping’ seems to be the most informative predictor. Finally, the important differences of the two methods are discussed.

Qualitätsindikatoren in der Praxis

Hintergrund: Zur Erfassung der psychiatrischen Versorgungsqualität bedarf es geeigneter Qualitätsindikatoren. Diese sollten neben der klinischen Relevanz die Perspektiven von Behandler und Patienten berücksichtigen, verschiedene Dimensionen der Behandlung abdecken und sich auf veränderbare Versorgungsaspekte beziehen. Ziel der Studie war die Entwicklung und Erprobung von Qualitätsindikatoren zur Erfassung von Prozess- und Ergebnisqualität in der stationären Depressionsbehandlung. Diese Indikatoren wurden für den systematischen Qualitätsvergleich zwischen den Kliniken (Benchmarking) genutzt. Methode: Eine Multicenter-Studie wurde von Oktober 2001 bis April 2004 in 10 psychiatrisch-psychotherapeutischen Kliniken durchgeführt. Ergebnisse: Die Behandlung von über 2000 depressiven Patienten wurde mittels BADO dokumentiert, die depressionsspezifisch modifiziert wurde. Die Ergebnisse für verschiedene Qualitätsindikatoren werden dargestellt und diese bezüglich Relevanz, Praktikabilität und Validität für die stationäre Depressionsbehandlung beurteilt. Diskussion: Die Ergebnisse bestätigen die in der Literatur diskutierten methodischen Schwierigkeiten von Qualitätsindikatoren. Für die stationäre Depressionsbehandlung werden sinnvolle Qualitätsindikatoren empfohlen. Ein Ausblick über den Nutzen der Qualitätsindikatoren und eines Krankenhausvergleichs wird gegeben.

Früherkennung des Psychoserisikos mit dem Early Recognition Inventory (ERIraos)

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

Medikamentöse Akutbehandlung schizophrener Ersterkrankungen

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

Disturbance of serotonin 5HT2 receptors in remitted patients suffering from hereditary depressive disorder

Aim: The characteristics of 5HT2 receptor binding were investigated in major depression in vivo using positron emission tomography and the radioligand F-l 8-altanserin. Methods: Twelve patients from families with high loading of depression living in a geographically restricted region were examined and compared with normal control subjects. At the time of the PET measurement all patients were remitted; in some of them remission was sustained by antidepressive medication. Binding potential was assessed by Logan’s graphical analysis method. Results: The binding of F-l 8-altanserin was about 38% lower in patients than in healthy controls (p <0.00D. A multiple regression analysis revealed that this difference was mainly induced by depression rather than by medication. Conclusions: The data suggest that 5HT2 receptors are altered in depression. We present evidence for a reduction of the receptor density, which might be usable as trait marker of subjects susceptible for depressive illness.