Peripheral serotonin uptake is related to neural activation in the cingulate cortex

Introduction

Maximal serotonin transporter (5-HTT) densities have been found in the cingulate cortex, a cortical region that has been critically implicated in emotion processing and the pathophysiology of Major Depressive Disorder. Furthermore, serotonin (5-HT) re-uptake inhibition is the first line strategy in the treatment of depression.

Objectives

Since 5-HTTs are not restricted to neuronal cells, 5-HT uptake velocity (Vmax) can be easily measured on blood platelets subserving as peripheral model of neuronal 5-HTT function and related measures of neural activation.

Aims

To determine whether peripheral 5-HTT uptake velocity is related to neural activation in the cingulate cortex during emotion processing.

Methods

48 healthy subjects underwent an fMRI paradigm comprising emotional (angry/fearful faces and scenes) and neutral stimuli (simple shapes). 5-HT Vmax was determined in platelets. Subjects were genotyped for a common triallelic polymorphism in the promoter region of the 5-HTT gene (5-HTTLPR).

Results

Significant negative correlations between Vmax and BOLD-signal in the anterior and posterior portion of the cingulate cortex have been found. Cluster maxima within both regions were detected in the subgenual anterior cortex (−1.5, 28.5, −3.5, t = −3.77) and the ventral posterior cingulate cortex (−4.5, −49.5,14.5, t = −3.06). Genotype did not impact on this relationship.

Conclusions

Our results indicate a clear dependency between a peripheral marker, platelet 5-HT uptake velocity, and neural activity in portions of the cingulate cortex for the first time.

FC04-06 - Candidate gene association study of suicidality in treatment resistant MDD

Suicidal behaviour runs in families and the existence of genetic vulnerability to suicidality is well-established. Mental disorders, especially depression, are present in more of 90% of suicides. The incidence of treatment emergent suicidal ideation in major depression (MDD) varies from 4% to 20%, depending on the definition of suicidal ideation and sample characteristics.

In the present study, we further elucidated the impact of depression candidate genes in treatment emergent suicidal ideation in MDD. One hundred-seventy MDD patients were collected in the context of a resistant depression study and treated with antidepressants at adequate doses for at least 4 weeks. MDD subjects were genotyped for SNPs within the COMT gene, BDNF, DTNBP1, 5HT1A, 5HT2A, GNB3, GRIK4, PTGS1, PTGS2, CREB, and cytochrome P450 CYP1A2, CYP2C9, CYP2C19 and CYP2D6 gene. Response, remission and treatment resistance, as well as suicidality information derived from Mini International Neuropsychiatric Interview (MINI) and Hamilton Rating Scale for Depression (HAM-D) were recorded.

A quantitative and measure of suicidal behaviour was defined using the Hamilton rating scale (score 0 to 4) and the MINI-item (yes/no) on suicidality in a large cohort of depression cases. In addition, we tested for association with ‘serious suicidal attempts’ corresponding to a HAMD score of 4 (discrete trait analyses). Results of this candidate gene approach in treatment emergent suicidal ideation in MDD will be presented and discussed.

Antidepressant self-poisonings in iran

Introduction

Tricyclic antidepressants (TCAs) are more likely to cause cardiovascular and neurological toxicity than compared to Selective Serotonin Reuptake Inhibitors (SSRIs).

Objectives

In a prospective hospital-based cohort study, we addressed the question of severity and outcome of antidepressant self-poisonings in patients who attended the Loghman-Hakim Hospital Poison Center. The severity was judged by impairment of consciousness, the outcome criteria were the requirement of inpatient treatment and endotracheal intubation as well as mortality. The aim of the study was to find out if TCA intoxications require more therapeutic efforts than SSRI intoxications.

Methods

From 28 March to 20 May 20 2006, all patients presented to the Poison Center were documented using preformatted forms by three trained nurses blinded to any study hypotheses. From 3.578 intoxications, a number of 334 patients with antidepressant or lithium self-poisoning was identified (9.3% of all poisoning cases; 233 females, 101 males; median age 24 years, min 13, max 70).

Results

As compared to SSRI single-substance intoxications (n = 17), TCA single-substance intoxications (n = 73) were associated with (1) a significantly lower level of consciousness (p = 0.005); (2) a significantly higher admission frequency (80.8% vs. 35.3%; p < 0.001) and (3) a higher intubation frequency (13.7% vs. 0%; p = ns). SSRI multiple-substance intoxications were associated with a significantly lower level of consciousness than SSRI single-substance intoxications (p = 0.042), while there was no significant difference between TCA multiple- and single-substance intoxications.

Conclusions

This study suggests that an overdose with SSRIs results in a more favorable clinical outcome than an overdose with TCAs.

JS02-01 - Psychiatric intensive care

Psychiatric disorders per se or treatment resistance can cause life-threatening conditions. More than 25 years have passed since the term “psychiatric intensive care unit” (PICU) was introduced in the United Kingdom. This system is comprised of security units for psychiatric patients with suicidal or violent behaviour, providing a locked environment with more resources regarding personnel and care. The PICU concept at the Department of Psychiatry and Psychotherapy in Vienna, Austria, represents a progress towards optimal care of patients with serious psychiatric illnesses who also have critical somatic illnesses. One third of the patients are transferred from inpatient facilities of medical departments such as internal medicine, emergency medicine, trauma surgery or anesthesiology. Our PICU is dedicated to somatically, critically ill patients who have psychiatric symptoms (e.g., agition, aggression, impulsivity, delusions, catatonia, confusion, reduced consciousness, impaired self-reliance) complicating recovery from their critical, somatic condition. Generally, the dosages for antipsychotics are not higher than those at normal psychiatric wards. Benzodiazepine dosages of about 30mg diazepam equivalents per day are frequently used. In the years 2008 and 2009, 10% of all patients at the Viennese PICU were treated with electroconvulsive therapy. Delirium requires immediate therapy of underlying intracerebral pathologies, extracerebral illnesses or toxic features. Involuntary commitment, physical restraints and urinary catheterization were applied in approximately 50% of the patients, nasogastric tube or central venous catheter in 20%. In every case, intensive care nursing, monitoring of vital functions and specific experience at the interface between psychiatry and somatic medicine are required.

Polypharmacy in psychiatric inpatients: Data from amsp (arzneimittelsicherheit in der psychiatrie), a european pharmacovigilance system

Introduction

Psychotropic polypharmacy is widely used in routine clinical practice although there is still a substantial deficit in established knowledge about combination and augmentation treatments. Polypharmacy is related with a higher risk of adverse drug reactions and incompliance.

Methods

On two reference days per hospital and per year, the following data are recorded for all patients on the wards under AMSP surveillance: all drugs applied on that day with the daily dosage for psychotropic drugs, ICD diagnosis, age, and sex. Data is stored at the study center in Munich. We evaluated data from 2000 (N = 5669) and 2007 (N = 8346).

Results

From 2000 to 2007 inpatient prescriptions including three or more drugs increased significantly from 59.4% to 69.3% (chi2: 144.913; df:1; p < 0.001). Furthermore the percentage of inpatients being prescribed three or more psychotropics increased significantly from 36.5% in 2000 to 47.97% in 2007 (chi2: 180.01; df:1; p < 0.001).

Investigating further, which inpatients, diagnosed according to ICD-10, tend to be treated with more than two psychotropics, we found that this was more common in inpatients, who had an F2., F3. or F9. ICD-10 diagnosis. Especially inpatients with a bipolar disorder (F31.) showed an extremely high rate for psychotropic polypharmacy with three or more psychotropic drugs, with rates of 63,8% in 2000 and 75,2% in 2007.

Conclusion

Polypharmacy is still gaining ground. Our results show that psychotropic agents are commonly used in combination; therefore further studies evaluating assumable positive results of psychotropic combinations are needed.

SS06-01 - Are we getting the most out of combination therapy in the short-term and long-term treatment of mania?

The extensive research into the treatment of bipolar disorder over the last 20 years means that we, as clinicians, have never been in a better position to treat patients with bipolar disorder. Yet despite the availability of modern, evidence-based treatment guidelines, bipolar disorder remains an everyday treatment challenge. Newly diagnosed patients requiring treatment for the first time are not always adequately controlled with single-agent therapy and, similarly, combination therapy is also frequently necessary as maintenance treatment. But with this recognition comes the new challenge of identifying when monotherapy is not enough, which agents to combine, when and for how long? How do we know?

Joined by an internationally respected faculty, Professor Siegfried Kasper chairs a discussion to help answer some of the key questions facing clinicians today:

What response can be anticipated from recommended first-line monotherapies for acute mania?

How do we know whether the response we observe when we prescribe a first-line treatment in a manic patient is adequate?

To what extent can a partial non-response to monotherapy be improved by the addition of a second agent?

What's the benefit of maintaining combination treatment once patients are stable and how long should I continue?

Does adding an antipsychotic to a mood stabiliser increase the risk of adverse events, in the short term or in the long term?

Drawing on latest guideline recommendations, recent clinical research, case studies and their extensive clinical experience, the panel will debate these interesting questions and shed light on how we can optimize both acute and maintenance treatment in this patient group.

Although the design of maintenance studies in bipolar disorder has significantly evolved in recent years, individual study designs continue to differ in important ways, with important implications. What may appear to be small differences between study designs, such as the type of most recent episode experienced by the patients or the stabilisation criteria used in the trial, can have big implications for study outcome. It is thus becoming increasingly important to be able to evaluate the results of trials within the context of the design and determine what they mean for treatment practice. Our panel will therefore also discuss the extent to which the design of bipolar maintenance studies can influence the results achieved and share their views on what this means for treatment now, and in the future.

Are we, and more importantly our patients, getting the most out of combination therapy for bipolar mania? Come and debate the issues with the panel, share your views and see what can be achieved.

Depression

Depression is one of the thoroughly evaluated diseases in psychiatry with regard to diagnosis as well as treatment variables. Like in other medical conditions, early treatment should be aimed and watchful waiting which is for instance also not done in the treatment of high blood pressure or diabetes, has not been proven to be a sophisticated approach based on neurobiological considerations. Like in other diseases, it is apparent that days of untreated depression may result in brain damage like reduced volume size of the hypocampus. The course of illness of depression shows that life events are less important in later stages of the illness than in earlier. The introduction of the group of selective serotonin reuptake inhibitors (SSRI) marked a revolution in the treatment of depression, since it was possible to treat patient for the first time effectively with a more minor side effect profile with this approach. Substantially more patients could be reached and the association with this phenomenon and the reduction of the suicide rates in different countries like Sweden, Austria and Hungary has been discussed. Dual reuptake inhibitors effecting both the serotonergic as well as the noradrenergic pathways and the dopaminergic noradrenergic medication bupropion have been introduced in the filed with specific angles of treatment goals like pain or somatic symptoms. With the introduction of agomelatine, a unique mechanism of action with the combination of melatonergic agonistic as well as serotonergic antagonistic activities has been achieved. With this approach a more potent influence on the circadian rhythm has been shown compared to other, previously used antidepressant properties. Deep brain stimulation and vagus nerve stimulation for treatment refractory depressed patients yield promising results. More thorough characterisation of the underlying pathophysiology of depression including brain imaging results as well as molecular biological variables will yield further inside of the understanding and treatment of depression.

Biological alterations during remission of major depressive disorder

Introduction

The natural course of Major Depressive Disorder (MDD) encompasses the occurrence of alternating intervals of major depressive episodes and remission. While several abnormalities in neural circuits related to acute MDD have been identified, the neural mechanisms underlying stable remission remain obscure.

Objectives

Acute MDD is characterized by increased amygdala and subgenual anterior cingulate cortex (sACC) activation and decreased connectivity between the amygdala and the sACC. Consequently, we expect those regions to be affected during remission.

Aims

To determine whether active counter-regulatory mechanisms are implicated in the maintenance of full remission once antidepressant treatment has been discontinued.

Methods

Functional and structural magnetic resonance imaging was used to measure brain activation and volume of the amygdala and the sACC. Images were obtained from 38 healthy subjects without any psychiatric life-time diagnosis and 38 gender-matched drug-free remitted MDD patients. Furthermore, correlation analyses were performed with clinical variables.

Results

Patients with rMDD exhibited lower activation in the amygdala and the sACC and increased functional coupling between the amygdala and sACC compared to controls. This connectivity was particularly pronounced in patients characterized by a long cumulated time of depressive episodes. Similarly, structural connectivity results showed increased association between the amygdala and sACC volume in rMDD patients compared to controls.

Conclusions

Remitted MDD is related to neural alterations within a neural circuit encompassing the amygdala and the sACC compared to controls. These findings suggest active counter-regulatory mechanisms likely contributing to the maintenance of remission once treatment has been discontinued.

Serotonin - 1A binding in the subgenual anterior cingulate cortex is associated with regional grey matter volume in striatum and temporal areas

Introduction

The subgenual part of the anterior cingulate cortex (sgACC) has been frequently reported to be structurally and cytoarchitectually changed in major depressive disorder (MDD) and is also a promising target in deep brain stimulation in treatment-resistant MDD. Furthermore, substantial evidence demonstrates a high density of serotonin-1A (5-HT1A) receptors in the sgACC, a key area involved in emotional processing.

Objectives

Here, we investigated the relationship between the 5-HT1A receptor in the sgACC and changes in regional grey matter volume with voxel-based morphometry.

Methods

PET ([carbonyl-11C]WAY-100635) was used to quantify 5-HT1A receptor binding (BPND) together with structural magnetic resonance images from 32 healthy subjects (mean 26.68 ± 5.1 years; 17 women). Regression analysis was performed in SPM8 (p < .001 uncorr.) using sgACC 5-HT1A BPND as regressor, controlling for sex, age and total grey matter volume (GMV).

Results

5-HT1A BPND in the sgACC was positively associated with regional GMV in the medial temporal gyri (T=4.37) and nucleus accumbens bilaterally (T = 4.19). Furthermore, sgACC 5-HT1A binding was negatively correlated with GMV within the inferior temporal gyri (T = 5.22) and putamen bilaterally (T = 5.12).

Conclusions

Our findings demonstrate structural relationships between sgACC 5-HT1A receptor binding and grey matter volume in the ventral striatum as well as in temporal regions, which both exhibit close neuronal connections with the sgACC. Moreover, the GMV of the ventral striatum has been reported to be decreased in patients with MDD. Conclusively, our results underpin the role of serotonergic neuronal transmission in cytoarchitectural processes within regions involved in the modulation of mood.

Meta-analysis on the dissection table

Introduction

Determination of the best evidence involves a systematic, comprehensive review and synthesis of the research literature as performed in high-quality meta-analysis. In a recently published multiple-treatment meta-analysis by Cipriani and collegues (Lancet, 2009) the authors finally concluded to favour sertralin over escitalopram due to lower costs.

Objectives/aims

Based on the example published by Cipriani et al. we tried to highlight possible pitfalls, the clinican with limited time might not be able to spot easily whilst skimming the results of meta-analysis.

Results

Escitalopram had the best efficacy and tolerability profile in the study. Sertraline was recommanded as first choice because of the most favourable balance between benefits, acceptability and acquisition costs. Analyzing study-design, statistical procedures and knowledge such as the early launching of generics of escitalopram lead to a different view of the interpretation by Cipriani and collegues.

Conclusions

We concluded that the findings of Cipriani et al. have limited generalizability due to problematic study design issues including statistical concerns. Despite the fact that meta-analysis might provide best evidence-based information, the findings of the latter should always be interpreted with caution as the quality of them can only be as good as the studies included and the study design implemented.

Efficacy and safety of silexan, a new, orally administered lavender oil preparation, in subthreshold anxiety disorder

A number of studies has been performed recently on the efficacy and tolerability of silexan, a novel preparation from lavender oil for oral use, in the treatment of anxiety disorders and related conditions with particular attention to subthreshold generalized anxiety disorder (GAD). Three randomized, double-blind clinical trials were identified which investigated the efficacy of silexan in subsynromal anxiety disorder (vs. placebo; 10 weeks’ treatment), in GAD (vs. lorazepam; 6 weeks), and in restlessness and agitation (vs. placebo; 10 weeks) according to DSM-IV and ICD-10 criteria. One open-label pilot study assessed the potential of the medicinal product in neurasthenia, posttraumatic stress disorder and somatization disorder (6 weeks). All trials assessed the participants’ anxiety levels using the Hamilton Anxiety Scale (HAMA) or the State Trait Anxiety Inventory (STAI) as well as measures of co-morbidity and clinical global impressions. Across all trials 280 patients were exposed to silexan 80 mg/day, 37 were treated with lorazepam 0.5 mg/day and 192 received placebo. Average within group HAMA total scores at baseline ranged between 24.7 and 27.1 points. Patients treated with silexan showed average HAMA total score decreases by between 10.4 ± 7.1 and 12.0 ± 7.2 points at week 6 and by between 11.8 ± 7.7 and 16.0 ± 8.3 points at week 10. In subthreshold GAD silexan was significantly superior to placebo, with a mean value difference of at least 4 points (lower bound of 95% confidence interval (CI)) after 10 weeks. In GAD silexan and lorazepam showed comparable HAMA total score reductions (90% CI for mean value difference: -2.3; 2.8 points). The decrease of anxiety levels was accompanied by a reduction of restlessness and co-morbidity, and by improvements in general well-being. The anxiolytic effect of silexan is superior to placebo and comparable to lorazepam in subthreshold and threshold GAD, respectively. The medicinal product also improved associated symptoms like restlessness, disturbed sleep and somatic complaints, and had a beneficial influence on general well-being and quality of life. Silexan may offer interesting perspectives particularly in the treatment of subthreshold GAD.

Are there structural brain changes following 10 days of SSRI administration investigated by voxel-based morphometry?

Introduction

There is evidence that psychiatric diseases are accompanied by structural alterations in the human brain, partly reversible by pharmacological treatments. Several studies including Tost et al. (Nat.Neurosci.2010;13(8):920-2) investigated the effect of psychotropic drugs on neuronal plasticity pointing towards rapid pharmacologically induced brain grey matter variations, apart from already presumed slow structural changes within weeks. Here, we investigated the short-term (days) structural effects of SSRIs.

Objective

To identify structural changes of grey and white matter following 10d of oral administration (citalopram/escitalopram vs. placebo) in 18 healthy subjects investigated by magnetic resonance imaging (MRI) using voxel-based morphometry (VBM).

Methods

Study design: Randomized, cross-over, placebo-controlled, double-blind study.

Subjects: 18 healthy caucasian subjects (6 female 24.8 ± 2.5 years, 12 males 28.9 ± 6.7 years) MRI: 3 MRI scans/subject (3 Tesla scanner)

Treatment: 10d of oral medication intake of either 20 mg citalopram/d, 10 mg escitalopram/d or placebo in alternating order of administration

Data analysis: VBM, as implemented in SPM8.

Statistical analysis: analysis of variance (ANOVA, FWE corrected), post-hoc pair-wise comparisons.

Results

ANOVA (grey matter: F(2,48) = 18.85, p < 0.05; white matter: F(2,48) = 17.79, p < 0.05) did not reveal suprathreshold clusters in grey or white matter.

Conclusion

This VBM-study does not support previous short-time (days) MR findings of pharmacologically-induced structural alterations in the brain, considering the lack of significant changes in grey and white matter volumes following 10d of SSRI administration. This divergence may be caused by dissent pharmacological effects of SSRIs compared to other psychotropic drugs.

Increased functional coupling between basalganglia and cingulate and prefrontal cortex during resting state conditions in remitted major depressive disorder

Introduction

Converging evidence suggests alterations of neural activation in the basal ganglia to represent neural correlates of Major Depressive Disorder (MDD). While a previous study reported increases of functional connectivity in resting state activity between the caudate nuclei and the posterior cingulate cortex in acutely depressed patients, it remains unclear whether this finding persists during full remission once antidepressant treatment has been discontinued.

Objectives

To investigate patterns of functional coupling between the basal ganglia and cortical regions during resting-state conditions.

Aims

To determine whether increases of functional connectivity between caudate nuclei, putamen, and pallidum with cortical regions, in particular the cingulate cortex, pertain during remission of MDD.

Methods

Forty-three remitted depressed (rMDD) patients and thirty-five healthy controls were recruited at Medical University of Vienna, Vienna, Austria, and performed a six minute resting-state fMRI scan. Seed time series were extracted from the preprocessed data using individual masks for the basal ganglia and correlated with all nodes in a surface based analysis using FreeSurfer, AFNI and SUMA. The resulting correlation coefficients were then Fisher-transformed, group results were determined by comparing group mean smoothed z-scores with a two-sample t-test.

Results

Increased resting-state functional connectivity was revealed between basal ganglia and cingulate as well as prefrontal cortex in the rMDD group compared to healthy controls.

Conclusions

Our preliminary results revealed increased functional coupling between the basal ganglia and wide parts of the cingulate and prefrontal cortex to possibly represent a specific neural pattern during remission of MDD.

Extended-release quetiapine fumarate (quetiapine XR) versus risperidone in the treatment of depressive symptoms in schizophrenic or schizoaffective patients

Introduction

Depressive symptoms are associated with poor outcomes, increased risk of relapse and high suicide rates in patients with schizophrenia and schizoaffective disorder (1, 2).

Objective

Assess the efficacy of quetiapine XR (QTP-XR) versus risperidone on depressive symptoms in schizophrenia and schizoaffective disorder.

Methods

A randomised, open-label, parallel-group, flexible-dose study (NCT00640562).

Primary endpoint

LSM change from baseline to Week 12 in Calgary Depression Scale for Schizophrenia (CDSS) (3) score. Secondary endpoints: change in HAM-D and PANSS scores, and adverse events (AEs). No scorrection for multiplicity was done for the secondary endpoints.

Results

216 patients received QTP-XR (n = 109; 400–800 mg/day) or risperidone (n = 107; 4–6 mg/day). From baseline, QTP-XR significantly reduced CDSS, HAM-D and PANSS negative total scores compared with risperidone (QTP-XR vs risperidone: -7.31 versus -5.53, p = 0.0107; -14.68 versus -11.53, p = 0.0005; -8.23 versus -5.45, p = 0.0008, respectively). No major differences in AEs were observed between QTP-XR and risperidone. Four serious AEs were experienced with QTP-XR and 5 with risperidone. Two patients receiving QTP-XR died (unrelated to study drug). Prolactin levels were significantly reduced from baseline with QTP-XR versus risperidone (-9.15 ng/mL and +22.18 ng/mL respectively; p < 0.0001). No important differences were seen in other laboratory parameters.

Conclusions

In this study, QTP-XR was superior to risperidone at reducing depressive symptoms in schizophrenia or schizoaffective disorder according to CDSS, HAM-D and PANSS negative scores.

Reduced connectivity in the uncinate fiber tract between the frontal cortex and limbic subcortical areas in social phobia

Introduction

Several fMRI and resting-state connectivity studies have demonstrated alterations in the limbic system and frontal areas in social anxiety disorder (SAD).

Aims

Here we used high-resolution whole-brain diffusion tensor imaging (DTI) to examine differences in anatomical connectivity between patients and controls in the white matter.

Methods

We examined 14 SAD patients (age 26.3 ± 9.0y) and 15 healthy controls (age 25.6 ± 3.3y) using DTI on a 3T Trio MRI scanner (Siemens, Germany). DTI acquisition with 1.6 mm isotropic resolution was performed in 30 directions and a maximum b-value of 800. Fractional anisotropy (FA) maps were obtained using FSL. Group analysis was performed in SPM8 (two sample t-test).

Results

The figure shows a coronal slice through the uncinate fasciculus. Arrows point to areas where SAD patients show decreased FA-values compared to controls (p < 0.05). Note that these areas are limited to the uncinate fasciculus and are found bilaterally.

Conclusion

Reduced FA-values indicate a reduction in anatomical connectivity strength. Our study thus clearly shows reduced connectivity strength in the uncinate fasciculus connecting frontal regions with limbic areas as the amygdalae and hippocampus. This reduced structural connectivity supports functional data demonstrating alterations of brain activation in the amygdala and prefrontal regions in social phobia.

Cortisol plasma levels are associated with serotonin - 1A receptor binding in postmenopausal women

Introduction

Alterations of the serotonin-1A receptor (5-HT1A) and the hypothalamic-pituitary-adrenal (HPA) axis have been reported in depression and anxiety disorders. We previously showed a strong negative correlation between cortisol plasma levels and 5-HT1A receptor binding potential (BP) in patients with social anxiety disorder but not in healthy controls using PET [1].

Objectives

To investigate the relationship of cortisol and the 5-HT1A BP in postmenopausal women, a population that is at increased risk of suffering from depressive symptoms.

Methods

Subjects: 19 postmenopausal women, aged 55.26 ± 4.98, medication free, no current substance abuse or hormone replacement therapy.

PET

Dynamic measurements (50 frames, 90 min) were performed using the radioligand [carbonyl-11C]WAY100635 and a GE-Advance scanner. PET data were normalized to a ligand-specific template [2]. Regions-of-interest (ROI) were defined as given in [3]. TACs within ROIs were averaged and the 5-HT1A receptor BP was quantified using Logan-plot and PMOD 3.1. Measurement of total cortisol plasma levels was done using electrochemoluminescence.

Results

We found negative correlations between cortisol and 5-HT1A BP in the midbrain (Spearman's rs = −0.54, p = 0.02), the median raphe nucleus (rs = −0.47, p = 0.04) and the nucleus accumbens (rs = −0.505, p = 0.03).

Conclusions

In line with our previous findings [1], the observed negative association between cortisol plasma levels and 5-HT1A BP might reflect an increased vulnerability for mood disorders in postmenopausal women.

Treatment Resistance in Depression

Due to the advancement of antidepressant medication, more patients receive treatment in everyday practice, and response/remission is not achieved in the majority of the patients. Several attempts to validate the definition of treatment resistance have been undertaken and the criteria usually encompased to treatment sequences are that two different classes of antidepressants given in a sufficient dosage for a sufficient time have to be administered. Clinically, it is evident that this defintion does not include the treatment refractory patients which could be defined as not responding to numerus trials including electroconvulsive therapy. The goal to improve treatment through the use of predicitve biomarkers has not as yet been obtained and will be the challenge for the future. The clinical variables predicting treatment resistance include comorbid anxiety disorders as well as melancholic features. Although there is a plethora of hints in textbooks that switching the mechanism of action should be obtained when a patient does not respond to one medication, the few controlled trials which have been undertaken to challenge this notion revealed that staying on the same antidepressant mechanism of action for a longer time is more beneficial. In previous times, the conjunctive use of agents such as lithium or thyroid augmentation have been proposed, however the new data achieved with atypical antipsychotics demonstrate a more rapid improvement. Techniques such as brain stimulation or vagus nerve stimulation have also shown promising early results. Treatment resistance continues to be a major barrier achieving remission in patients with major depressive disorder and a thorough re-evaluation of the condition and its treatment is needed.

In vivo molecular imaging reveals distinct distributions of the serotonin transporter, the major inhibitory and excitatory serotonin receptors

Introduction

Based on evidences in molecular neuroimaging, postmortem and genetic studies, impaired serotonergic neurotransmission has been implicated with affective disorders. Moreover, a growing number of evidences showed strong interrelations within the serotonergic system suggesting a common mechanism in the modulation of receptor and transporter densities.

Objective

Here we directly investigated the regional expression of the 5-HT1A, 5-HT2A and 5-HTT using PET and the three highly selective and specific radioligands [carbonyl-11C]WAY-100635, [18F]Altanserin and [11C]DASB in healthy subjects.

Methods

A total of 55 healthy subjects (5-HT1A: 36 subjects, 18 males, age = 26.0 ± 4.9; 5-HT2A: 19 subjects, 11 males, age = 28.2 ± 5.9; 5-HTT: 8 males, age = 28.12 ± 3.6) were included in this study. Binding potential (BPND) values were quantified according to the AAL parcellation scheme.

Results

BPND values averaged over both hemispheres ranged from 0.40–6.35 for the 5-HT1A receptor; 0.01–2.01 for the 5-HT2A receptor and 0.09–2.05 for the 5-HTT, respectively. There was a specific topological pattern according to the ratio between the 5-HT1A, 5-HT2A receptors and 5-HTT (“fingerprints”).

Conclusions

Such information can be essential for detecting potential local alterations in the ratio between different binding proteins on a network level in pathological conditions.

Moreover, these data might provide further insight in area-specific effects of frequently prescribed selective serotonin re-uptake inhibitors (SSRI): 1)

FC25-04 - Comorbid mood and anxiety disorders in adult ADHD patients

Introduction

ADHD is a highly heritable neurodevelopmental syndrome with significant lifetime risk for psychiatric comorbidities. Several psychiatric conditions are significantly more common in patients with ADHD than in control subjects.

Methods

To evaluate the incidence of comorbid affective disorders, patients with adult ADHD who were first seen at the outpatient clinic of the Department of Psychiatry and Psychotherapy were evaluated for symptoms of major depression, brief recurrent depression, bipolar depression and anxiety disorders. Patients aged between 18 and 75 years were included into the study. All patients were evaluated according to DSM IV TR criteria. So far, from February 2007 until May 2010, 330 patients (192 males and 138 females) were included into the study.

Results

The mean age of the patients at diagnosis was 33, 7 years for males (range: 18-75) and 35, 9 years for females (range: 18–64). Affective disorders were most frequently diagnosed as comorbid conditions in our patients and occurred in 26% of the patients in our sample. 13% had a minor depressive episode, 7% a major depressive episode and 6% were diagnosed with bipolar disorder. 21% of our patients were diagnosed with one or several comorbid anxiety disorders.

Conclusion

Most adults with ADHD are not diagnosed properly and therefore remain untreated although they are usually diagnosed and treated for comorbid psychiatric disorders. In the present study, we systematically analyzed comorbid anxiety and depression in a sample of adult ADHD outpatients in order to estimate the incidence of these disorders in an undiagnosed patient population.

Antipsychotics in obsessive-compulsive disorder - an auspicious approach for treatment-resistant patients?

Introduction

Because only 40 – 60% of all patients with obsessive-compulsive disorder (OCD) respond to selective serotonin reuptake inhibitors (SSRIs), the evaluation of alternative therapy methods in the presence of treatment resistance has high clinical relevance. In this context, many studies have examined additive medication with antipsychotics.

Method

All double-blind randomised controlled trials (DBRCTs) that evaluated the efficacy of a combination therapy of antipsychotics and SSRIs in treatment-resistant OCD were covered by systematic literature searches.

Results

A total of ten DBRCTs were identified (four for quetiapine, three for risperidone, two for olanzapine and one for haloperidol) with a participant collective comprising in total 316 treatment-resistant OCD patients. After the augmentation therapy, significantly more subjects in the intervention group (antipsychotic + SSRI), 32% of the patients, fulfilled the response criterion (reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ≥ 35%) than in the control group (placebo + SSRI) (relative risk (RR) = 2.08; 95% CI: 1.3 – 3.32). The standardised mean difference (SMD) of the Y-BOCS reduction between the pooled two study-groups revealed an effect size of 0,62. The sub-group analyses showed significant efficacy only for haloperidol and risperidone. Further significant differences existed regarding the duration of SSRI medication before the augmentation phase.

Conclusion / Discussion

Based on the favourable benefit-risk-ratio, risperidone can be regarded as the agent of first choice for augmentation treatment with an SSRI. Overall, about one third of patients benefit from this therapy option. However, further scientific studies are needed before sufficiently empirically secured pharmacological treatment recommendations can be expressed.