Oral prolonged-release ketamine in treatment-resistant depression - A double-blind randomized placebo-controlled multicentre trial of KET01, a novel ketamine formulation - Clinical and safety results

INTRODUCTION

We investigated the antidepressant effects of a novel oral prolonged-release formulation of racemic ketamine (KET01) in patients suffering from treatment-resistant depression (TRD) as add-on therapy.

MATERIAL AND METHODS

Patients were randomized to an additional 160 mg/day or 240 mg/day KET01 or placebo for 14 days. The primary endpoint was change in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline to day 15. For treatment group comparisons, we used ANOVA with pairwise least squares mean difference tests in a mixed model repeated measures analysis.

RESULTS

Twenty-seven patients completed the double-blind protocol before trial premature termination due to poor recruitment during the COVID-19 pandemic. Mean (SD) MADRS scores on day 15 were 23 (10.32) in placebo, 25 (8.28) with 160 mg/day and 17 (10.32) with 240 mg/day KET01. MADRS change was numerically larger but statistically non-significant in the 240 mg/day KET01 group vs placebo on day 7 (-5.67; p = 00.106) and day 15 was (difference: 4.99; p = 00.15). In exploratory analysis, baseline leukocyte count correlated with response to KET01 (p = 00.01). Distribution of adverse event rates were comparable between the treatment arms. Safety analysis did not identify increased risk of suicidality, dissociation, hear rate, systolic and diastolic blood pressure associated with trial treatment.

DISCUSSION

Our results suggest that adjunctive oral administration of prolonged-release ketamine at a dose of 240 mg/day shows a positive, although statistically non-significant, trend towards antidepressant efficacy, however, the benefit could not be confirmed due to premature trial termination. Given its ease of use and low side effects, further trials are warranted to investigate this route of ketamine administration as a promising potential treatment of TRD.

[Analysis of Patient Characteristics in the Inpatient Treatment of Behavioural Addictions: an Exploratory Study]

INTRODUCTION

Clinical research on the treatment of behavioral addictions is still scarce. The current study aims to analyze the therapy model for behavioral addictions implemented at the Privatklinik Meiringen, a psychiatric hospital in Switzerland.

METHODS

Patient characteristics over a period of two years were analyzed, documenting abnormalities and changes in their psychological state. A total of 49 individuals between the ages of 18 and 64 were included from the inpatient setting. The patient characteristics were presented with descriptive statistics. Using validated measuring instruments, the psychological state of the patients at the time of admission and discharge was recorded and analyzed.

RESULTS

All study participants suffered from psychological comorbidities besides the diagnosis of behavioral addiction. Depression constituted the most common comorbidity, whereas the distribution and incidence of comorbidities varied depending on specific behavioral addiction present in the patient. A clear improvement in psychological distress between the first and the last surveys could be demonstrated.

CONCLUSION

The study provides an exploratory insight into the peculiarities of characteristics of patients suffering from behavioral addiction in an inpatient setting and an overview of their comorbidity spectrum. The retrospective nature of the study prevents an assessment of the effectiveness of the therapy.

Pregabalin use in forensic hospitals and prisons in German speaking countries-a survey study of physicians

Background

Pregabalin is a gamma-aminobutyric acid (GABA) analog that was approved in the EU in 2004 for the treatment of neuropathic pain, generalized anxiety disorder and epilepsy. Since its introduction, pregabalin abuse and misuse has increased significantly. In Switzerland, clinical reports suggest that pregabalin misuse is common among patients in forensic hospitals and prisons. However, data on pregabalin use is scarce, especially in these settings. Therefore, we conducted a study to explore patterns of pregabalin use among prison and forensic patients.

Methods

We used a questionnaire to survey physicians working in prison and forensic medicine in German-speaking countries. A total of 131 responses were received.

Results

According to the physicians' subjective assessment, 82.5% of them had observed a recent increase in pregabalin use by their patients and 89.1% of them reported that their patients requested pregabalin without a clear medical indication. Patients misusing pregabalin in combination with other illicit substances were observed by 93.3% of the physicians surveyed. According to 73.5% of the physicians surveyed, they had already encountered patients on pregabalin doses of more than 600 mg/day (the maximum recommended daily dose); the highest dose reported was 4,200 mg/day. According to 85.0% of physicians surveyed, they have observed patients experiencing withdrawal symptoms from pregabalin, with the most commonly reported symptoms being displeasure and high aggression. Regarding the nationality of pregabalin-misusing patients, 58.3% of the interviewed physicians reported to be rather in contact with foreign patients, mainly from Northwest Africa (Maghreb). Only 45.0% of the surveyed physicians prescribe pregabalin. Among patients who developed behavioral problems while taking pregabalin, none of the physicians (0.0%) showed a tendency to continue pregabalin at the same dose; all respondents chose to reduce/substitute/discontinue.

Conclusion

Our study has provided confirmatory evidence that the use of pregabalin presents a significant issue in forensic and prison medicine across German-speaking countries. Prescribing pregabalin in this field can compound use disorder problems and exacerbate challenges in daily life for those in forensic institutions or prisons. It is necessary that all physicians who prescribe pregabalin are clearly informed about the management (including the risks) of this drug.

Concomitant Drug Use among Opioid-Dependent Patients with and without Attention Deficit Hyperactivity Disorder: Does Methylphenidate Merit a Trial?

INTRODUCTION

Concomitant drug use is common among opioid-dependent patients in maintenance therapy. Attention deficit hyperactivity disorder (ADHD), a common comorbidity among opioid users, is associated with a higher risk of concomitant drug use. Earlier studies showed that methylphenidate (MPH) can reduce cocaine consumption among patients with ADHD. The use of MPH as an agonist-replacement or maintenance therapy in cocaine-dependent patients without ADHD is also common in Switzerland, despite a lack of supporting evidence. The aim of this study was to assess concomitant cocaine, amphetamine, MDMA, MPH, and heroin use among patients in opioid maintenance therapy either with or without comorbid ADHD. We expected stimulant consumption to be higher in patients with cocaine dependence and comorbid ADHD and that use of MPH would not lead to a reduction in cocaine consumption in patients without ADHD. We therefore evaluated correlations between use of MPH and cocaine consumption and between MPH consumption and cocaine craving within the two groups.

METHODS

This cross-sectional study included 94 opioid-dependent patients in maintenance therapy in an outpatient department of the Psychiatric Hospital of Zurich. The patients were divided into two groups based on comorbid ADHD; a group with ADHD (N = 27) and a group without ADHD (N = 67). Drug use was assessed using 3-month hair analysis.

RESULTS

We did not find significant differences in the number of patients using cocaine, amphetamine, MDMA, or heroin between groups with or without ADHD. With respect to cocaine use, 85.2 percent of patients in the ADHD group and 73.1 percent in the non-ADHD group were users. The non-ADHD group showed a significant positive correlation between the concentration of MPH and cocaine in hair samples (p < 0.05), and a positive correlation between cocaine craving and the concentration of MPH in hair samples (p = 0.065). These two trends were not evident in the ADHD group.

CONCLUSION

Among patients without ADHD, use of MPH correlates with higher cocaine consumption and craving. Conversely, no significant correlation was found between MPH and cocaine use in patients with ADHD. Our study adds to the evidence that MPH confers negative effects in cocaine users without ADHD and should thus have no place in the treatment of these patients.

Off-label and investigational drugs in the treatment of alcohol use disorder: A critical review

Compounds known to be successful in the treatment of alcohol use disorder include the aversive agent, Disulfiram, the glutamatergic NMDA receptor antagonist, Acamprosate, and the opioid receptor antagonists, Naltrexone and Nalmefene. Although all four are effective in maintaining abstinence or reduction of alcohol consumption, only a small percentage of patients receive pharmacological treatment. In addition, many other medications have been investigated for their therapeutic potential in the treatment of alcohol use disorder. In this review we summarize and compare Baclofen, Gabapentin, Topiramate, Ondansetron, Varenicline, Aripiprazole, Quetiapine, Clozapine, Antidepressants, Lithium, Neuropeptide Y, Neuropeptide S, Corticotropin-releasing factor antagonists, Oxytocin, PF-05190457, Memantine, Ifenprodil, Samidorphan, Ondelopran, ABT-436, SSR149415, Mifepristone, Ibudilast, Citicoline, Rimonabant, Surinabant, AM4113 and Gamma-hydroxybutyrate While some have shown promising results in the treatment of alcohol use disorder, others have disappointed and should be excluded from further investigation. Here we discuss the most promising results and highlight medications that deserve further preclinical or clinical study. Effective, patient-tailored treatment will require greater understanding provided by many more preclinical and clinical studies.

Psychiatric Comorbidity and Psychopathology of Methamphetamine Users—Are There Gender Differences?

Methamphetamine use disorder is associated with severe psychiatric symptoms and psychosocial problems. Women seem to be more affected than men. Therefore, this study examined psychiatric comorbidities and psychopathology, drug use patterns, and treatment outcomes in women addicted to methamphetamine compared to men. Data on methamphetamine-dependent inpatients were collected in two centers specialized for addiction treatment at admission (T0) and discharge (T1, after treatment for 24 weeks). Sociodemographic and clinical measures were collected with the semi-structured clinical interview I at baseline; the self-reported standardized questionnaire (SCL-90-R) was administered at admission and discharge and after 24 weeks. During the entire treatment procedure, treatment relevant aspects were monitored. Out of all 108 treatment-seeking participants (86 men, 22 women), 64 completed the study (51 men, 13 women; drop-out rate: 40.7% (n = 44)). Methamphetamine-dependent women used other stimulants more often than men, while men used hallucinogens significantly more frequently than women. Female inpatients differed significantly from men in various sociodemographic variables (e.g., having children, single parenting) and were significantly more often affected by current (p < 0.001) and lifetime mental stress disorders (p < 0.001), as well as specific psychiatric disorders (p < 0.001) (e.g., posttraumatic stress disorder). At discharge, mental symptoms decreased significantly in men but not in women. Both before and after treatment, women seem to be more vulnerable to psychiatric comorbidities and psychopathologic symptoms compared to men. Although this study only provides preliminary data on gender-specific characteristics of methamphetamine-dependent patients and their treatment, it seems appropriate to discuss the development of gender-specific treatment options. Further studies in this field are needed.

Technostress and Digital Competence Among Health Professionals in Swiss Psychiatric Hospitals: Cross-sectional Study

BACKGROUND

Psychiatric hospitals are becoming increasingly digitized because of the disruptive rise in technical possibilities. This digitization leads to new tasks and demands for health professionals, which can have an impact on technostress. It is unclear whether digital competence reduces technostress and how technostress affects health professionals' mental and physical health.

OBJECTIVE

This study aims to assess the association between digital competence and technostress, considering individual characteristics and the association between technostress and long-term consequences for health professionals.

METHODS

Cross-sectional data from 3 Swiss psychiatric hospitals were analyzed using multiple linear regression. The dependent variables for the models were digital competence, technostress, and long-term consequences (intention to leave the organization or the profession, burnout symptoms, job satisfaction, general health status, quality of sleep, headaches, and work ability). One model was calculated for each long-term consequence. The mean scores for technostress and digital competence could range between 0 (fully disagree) and 4 (fully agree), where a high value for technostress indicated high technostress and a high value for digital competence indicated high digital competence.

RESULTS

The sample comprised 493 health professionals in psychiatric hospitals. They rated their technostress as moderate (mean 1.30, SD 0.55) and their digital competence as high (mean 2.89, SD 0.73). Digital competence was found to be significantly associated with technostress (β=-.20; P<.001). Among the individual characteristics, age (β=.004; P=.03) and profession were significantly associated with both digital competence and technostress. Technostress is a relevant predictor of burnout symptoms (β=10.32; P<.001), job satisfaction (β=-6.08; P<.001), intention to leave the profession (β=4.53; P=.002), organization (β=7.68; P<.001), general health status (β=-4.47; P<.001), quality of sleep (β=-5.87; P<.001), headaches (β=6.58; P<.001), and work ability (β=-1.40; P<.001).

CONCLUSIONS

Physicians and nurses who have more interaction with digital technologies rate their technostress higher and their digital competence lower than those in other professions. Health professionals with low interaction with digital technologies appear to overestimate their digital competence. With increasing digitization in psychiatric hospitals, an increase in the relevance of this topic is expected. Educational organizations and psychiatric hospitals should proactively promote the digital competence of health professionals to manage expected disruptive changes.

Dextromethorphan Abuse Among Opioid-Dependent Patients

BACKGROUND

Among opioid-dependent patients on maintenance therapy, concomitant drug abuse is a serious problem. Dextromethorphan, an over-the-counter antitussive agent that can be purchased without prescription, is a drug with a high potential for misuse, especially when consumed in high doses.The objective of this study was to investigate possible abuse of dextromethorphan among substituted opioid-dependent patients and comparison of subjective and objective findings.Due to its ability to increase serotonin levels, opioid-dependent patients may be particularly susceptible to dextromethorphan misuse. Dextromethorphan misuse may have side effects, including psychiatric symptoms and serotonin syndrome, and may induce assault, suicide, or homicide.

METHODS

A total of 104 opioid-dependent patients in maintenance treatment were included in this cross-sectional study conducted in the outpatient department of the Psychiatric Hospital, University of Zurich. Study participants were divided into 2 groups based on laboratory results: dextromethorphan abusers (n = 12) and nonabusers (n = 92). The objective use and concentrations of dextromethorphan was detected using 3-month hair toxicology analysis.Statistical analysis was performed by using χ test, Student t test, Mann-Whitney U test, and Barnard exact test.

RESULTS

Dextromethorphan was abused by 12 (11.5%) patients, 11 (91.7%) of whom did not report concomitant abuse of dextromethorphan but were identified through hair analysis. In general, there were significant differences among patients abusing dextromethorphan compared with nondextromethorphan consumers in terms of trauma due to sexual maltreatment/violence, multiple traumas, or harmful use of hallucinogenic drugs.

CONCLUSIONS

Further studies are necessary to examine dextromethorphan and its impact on patients with psychiatric comorbidities and psychiatric medication. According to literature, there is a significant drug interaction risk due to the impact of dextromethorphan misuse on serotonin syndrome and psychiatric symptoms.1-3 We recommend active inquiry into and testing for concomitant drug abuse among substituted opioid-dependent patients to reduce the risk of drug interactions and side effects in this especially vulnerable group of patients.

[Pregabalin abuse and dependence in various European countries: Association with substitution policies]

INTRODUCTION

Pregabalin was first approved in 2004 for the treatment of peripheral neuropathic pain and focal epileptic seizures, with or without secondary generalization. Prescription frequency has increased significantly since approval. In the early days, little attention was paid to the problem of misuse and dependence on pregabalin; in recent years, there has been a significant increase in the number of publications focusing on this problem. This review deals with these risk factors and risk groups of pregabalin abuse and dependence in different European countries and their drug policies.

RESULTS

Pregabalin abuse and dependence has increased significantly since its introduction to the market. It was shown that solo abuse of pregabalin is rare. In most cases, pregabalin was combined with other substances, which is also a predictor of pregabalin abuse. There were different reasons for the non-prescription use of pregabalin; it was used to increase the psychotropic effect, on the one hand, and to alleviate withdrawal symptoms, on the other hand. Furthermore, in Sweden, pregabalin was found in 28% of fatal intoxications among drug addicts. Young people were particularly affected. Abuse of pregabalin was detected in countries with restrictive substitution programmes, while in countries with liberal drug policies, no abuse was detected. However, the data situation in Switzerland with a liberal substitution programme is based on only one study, which is why pregabalin use in liberal substitution programmes cannot be conclusively clarified.

CONCLUSIONS

There seems to be a connection between a country's drug policy and the illegal use of pregabalin among persons in a substitution programme in that country. There are also risk factors and risk groups for pregabalin dependence and abuse.

[Problematic Online Gambling: Review of the Situation in Switzerland]

Problem gambling is a DSM-5-recognized behavioural addiction of growing concern through the emergence of the Internet with better availability and accessibility of gambling and a wider range of game offers. Thus, a new target group is approached through Online Gambling, which is leading to new issues in the prevention on problem gambling. In this study we discuss the differences in characteristics between Online and Offline Gamblers, the risk factors to develop a gambling problem as well as prevention methods and therapies. This review focuses on the situation in Switzerland with regard to the actual political occurrences and the new law on Online Gambling.

Concomitant Heroin and Cocaine Use among Opioid-Dependent Patients during Methadone, Buprenorphine or Morphine Opioid Agonist Therapy

BACKGROUND

Among all the treatment methods developed so far, opioid agonist treatment (OAT) is the most effective therapy for opioid dependence. While methadone (MTD) is the most commonly used, fewer data are available on alternative opioid agonist. The aim of this study was to assess the efficacy of buprenorphine (BUP) and slow-released morphine compared to MTD with regard to the reduction of concomitant heroin and cocaine use.

METHODS

This cross-sectional study included 105 patients receiving MTD, BUP, or slow-release morphine as opioid agonist therapy at the Psychiatric Hospital of Zurich. Illicit drug use was assessed using a retrospective 3-month hair toxicology analysis to quantify concentrations of heroin degradation products and metabolites, as well as cocaine and cocaine metabolites. We have also collected self-reports, but in the data of the study, only the results of the hair analysis were considered.

RESULTS

BUP-treated patients showed lower rates of illicit opiate consumption in comparison to the group treated with MTD or slow-released morphine (p < 0.05). The proportion of heroin-positive hair samples associated with slow-release morphine treatment was similar to the proportion associated with MTD treatment. Neither the MTD vs. slow-released morphine groups nor the BUP vs. MTD groups showed significant differences in the number of patients consuming cocaine although patients in the BUP group had significantly lower concentrations of cocaine in hair testing compared to the patients in the MTD group. Prevalence of cocaine consumption was also significantly lower in the BUP group compared to patients in the slow-release morphine group (p < 0.05).

CONCLUSION

This study suggests that BUP OAT is associated with reduced additional opiate co-use.

Stigma as a Barrier to Mental Health Service Use Among Female Sex Workers in Switzerland

Background: Many sex workers suffer from mental health problems, but do not seek help. Aim: To examine stigma-related and non stigma-related barriers to care and perceived need for treatment among female sex workers in Switzerland. Methods: Mental health service use, barriers to care, perceived need and presence of illness, symptoms, and psychiatric diagnoses were assessed among 60 female sex workers in Zürich, Switzerland. Outcomes: Mental health service use was defined as use of psychiatric medication, psychotherapy, or substance use services for at least 1 month during the past 6 months. Results: Adjusting for symptom levels, mental health service use was predicted by lower stigma-related, not by structural, barriers as well as by more perceived need for treatment and higher age. Clinical Implications: Sex workers with mental health problems would benefit from non-stigmatizing mental health care as well as from interventions to reduce public and self-stigma associated with mental illness and sex work. Strengths and Limitations: Limitations are the cross-sectional data, limited sample size, and recruitment from an information center for sex workers. Conclusion: Interventions that aim to increase mental health service use among sex workers should take stigma variables into account.

Myeloablative radioimmunotherapy with 188Re-CD66mAb before stem cell transplantation

Aim: Tumour necrosis factor-α (TNF-α) serum levels may increase due to intensive conditioning regimes with highdose- chemotherapy and total body irradiation (TBI) before stem cell transplantation. This increases the risk for developing acute graft versus host disease (aGvHD) after stem cell transplantation. In this prospective study we investigated the influence of radioimmunotherapy with 188Re- CD-66-mAb on changes on TNF-α serum levels. Patients, methods: In 18 patients we measured TNF-α before and up to 96 hours after radioimmunotherapy, in 2 patients in addition following TBI, in 9 patients also following chemotherapy. For measuring TNF-α we used an automated immunochemiluminescence assay (Immulite 1000 DPC Biermann, Bad Nauheim). The mean follow up period to record incidence of aGVHD was 100 days after stem cell transplantation. Results: Compared to the basal levels before, the levels of TNF-α after conditioning with 188Re-CD-66-mAb did not increase significantly and remained in the physiological range. In contrast, these initial physiological cytokine levels increased and became pathological following 48 h after total body irradiation (13.2 ± 6.6 pg/ml) and chemotherapy (10.8 ± 15.7 pg/ml). In our study we found a low incidence of aGvHD (22.2%, n = 4/18). Conclusion: These results demonstrate that additional conditioning therapy with 188Re-CD-66-mAb does not increase proinflammatory cytokine levels of TNF-α. This finding may indicate that additive radioimmunotherapy may not be a significant factor for increasing the rate of conditioning- associated aGvHD.

Guidelines for biological treatment of substance use and related disorders, part 1: Alcoholism, first revision

These practice guidelines for the biological treatment of alcohol use disorders are an update of the first edition, published in 2008, which was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). For this 2016 revision, we performed a systematic review (MEDLINE/PUBMED database, Cochrane Library) of all available publications pertaining to the biological treatment of alcoholism and extracted data from national guidelines. The Task Force evaluated the identified literature with respect to the strength of evidence for the efficacy of each medication and subsequently categorised it into six levels of evidence (A-F) and five levels of recommendation (1-5). Thus, the current guidelines provide a clinically and scientifically relevant, evidence-based update of our earlier recommendations. These guidelines are intended for use by clinicians and practitioners who evaluate and treat people with alcohol use disorders and are primarily concerned with the biological treatment of adults with such disorders.

Telecommunications Network Measurements of Online Gambling Behavior in Switzerland: A Feasibility Study

BACKGROUND

Methodological shortcomings of gambling studies relying on self-report or on data sets derived from gambling operators tend to result in biased conclusions. The aim of this study was to analyze online gambling behavior using a novel network database approach.

METHODS

From October 13 to October 26, 2014, telecommunications network data from a major telecommunications provider in Switzerland were analyzed. Netflows between mobile devices and a poker operator were quantified to measure the gambling duration and session number.

RESULTS

Time spent gambling during night and working hours was compared between devices with longest (red group), intermediate (orange group), and shortest gambling time (green group). Online gambling behavior differed depending on overall gambling time, F (2, 3,143). Night and working hours gambling was the highest in the red group (53%), compared to the orange (50.1%) and the green groups (41.5%). Post hoc analyses indicated significant differences between the orange and green groups (p < 0.05). No differences were observed between the red and orange groups (p = 0.850), and the red and green groups (p = 0.053).

CONCLUSIONS

On mobile devices, distinct gambling patterns were observed depending on the overall gambling time. This methodology could also be used to investigate online gaming, social media use, and online pornography.

Treatment-refractory substance use disorder: Focus on alcohol, opioids, and cocaine

Substance use disorders are common, but only a small minority of patients receive adequate treatment. Although psychosocial therapies are effective, relapse is common. This review focusses on novel pharmacological and other treatments for patients with alcohol, opioid, or cocaine use disorders who do not respond to conventional treatments. Disulfiram, acamprosate, and the opioid antagonist naltrexone have been approved for the treatment of alcoholism. A novel, "as needed" approach is the use of the mu-opioid antagonist and partial kappa agonist nalmefene to reduce alcohol consumption. Other novel pharmacological approaches include the GABA-B receptor agonist baclofen, anticonvulsants such as topiramate and gabapentin, the partial nicotine receptor agonist varenicline, and other drugs. For opioid dependence, opioid agonist therapy with methadone or buprenorphine is the first-line treatment option. Other options include oral or depot naltrexone, morphine sulfate, depot or implant formulations, and heroin (diacetylmorphine) in treatment-refractory patients. To date, no pharmacological treatment has been approved for cocaine addiction; however, 3 potential pharmacological treatments are being studied, disulfiram, methylphenidate, and modafinil. Pharmacogenetic approaches may help to optimize treatment response in otherwise treatment-refractory patients and to identify which patients are more likely to respond to treatment, and neuromodulation techniques such as repeated transcranial magnetic stimulation and deep brain stimulation also may play a role in the treatment of substance use disorders. Although no magic bullet is in sight for treatment-refractory patients, some novel medications and brain stimulation techniques have the potential to enrich treatment options at least for some patients.

The association of pineal gland volume and body mass in obese and normal weight individuals: a pilot study

BACKGROUND

In obese individuals impaired sleep and neuroendocrine alterations such as melatonin deficits are associated with circadian rhythm disruption, altered circadian clock gene expression, and bright light at night. While the relation of pineal gland volume (PGV) and melatonin levels has recently been documented in humans, surprisingly little is known about the possible interference of the PGV and the pathophysiology of obesity in humans.

SUBJECTS AND METHODS

We therefore compared the PGV of obese with non-obese individuals; both groups were matched by age and gender. Volumetric analyses were performed on the basis of 3 Tesla high resolution Magnetic Resonance Imaging (MRI).

RESULTS

We found, that the PGV was significantly smaller in obese individuals than in lean controls (P=0.036). Moreover, PGV and waist-hip ratio showed a significant negative association in controls (P=0.018, r^s=-0.602) whereas no association of both variables was found in obese individuals (P=0.856, r^s=-0.051).

CONCLUSIONS

Thus, the current pilot investigation suggests that pineal gland function, reflected by PGV might be involved in the energy homeostasis and pathophysiological mechanisms that contribute to the development and the maintenance of obesity in humans. Moreover, our data supports the notion that the replacement of melatonin deficits might be a novel strategy in the treatment of obesity.

["Food addiction" as a possible risk factor for obesity]

The prevalence rates of overweight and obesity are, internationally as well as in Switzerland, increasing in recent years. The neurobiology tries to explore an improved understanding of the central nervous causes of obesity. Findings from addiction research seem very useful because there are certain similarities between addiction and obesity in terms of neurobiological causes. An improved understanding of the disease of obesity could help to develop more effective therapies for obese patients in the future. Further research, e. g. in the field of stress regulation, is thus urgently needed.

Current Findings and Mechanisms of Action of Disulfiram in the Treatment of Alcohol Dependence

As an alcohol-aversive agent, disulfiram occupies an exceptional position in the pharmacological relapse prevention of alcohol dependence. In contrast to anti-craving drugs, disulfiram does not modulate neurobiological mechanisms of addiction, but rather works by producing an aversive reaction when combined with alcohol. Therapeutic and adverse effects are therefore closely related: On the one hand, the aversiveness of the disulfiram ethanol reaction has the potential to support abstinence in a subgroup of alcohol-dependent patients, while on the other hand it becomes a health threat if the patient fails to maintain complete abstinence. The exceptional position of disulfiram is also related to the role that expectations play in the mediation of therapeutic effects. These are not determined by the pharmacological effects or the actual occurrence of a disulfiram-ethanol reaction, but are attributable to patient awareness that the drug was consumed and the corresponding anticipation of an aversive reaction if combined with alcohol. This is in line with the findings of a recent meta-analysis that only showed significant effects for disulfiram in open-label trials. The authors of the meta-analysis conclude that due to expectations induced in both the treatment and placebo groups, blinded studies are incapable of distinguishing a difference between groups. The mediation of therapeutic effects through expectation has a number of consequences for clinical practice and future research on disulfiram.

Clinical potential of methylphenidate in the treatment of cocaine addiction: a review of the current evidence

Background

Cocaine use continues to be a public health problem, yet there is no proven effective pharmacotherapy for cocaine dependence. A promising approach to treating cocaine dependence may be agonist-replacement therapy, which is already used effectively in the treatment of opioid and tobacco dependence. The replacement approach for cocaine dependence posits that administration of a long-acting stimulant medication should normalize the neurochemical and behavioral perturbations resulting from chronic cocaine use. One potential medication to be substituted for cocaine is methylphenidate (MPH), as this stimulant possesses pharmacobehavioral properties similar to those of cocaine.

Aim

To provide a qualitative review addressing the rationale for the use of MPH as a cocaine substitute and its clinical potential in the treatment of cocaine dependence.

Methods

We searched MEDLINE for clinical studies using MPH in patients with cocaine abuse/dependence and screened the bibliographies of the articles found for pertinent literature.

Results

MPH, like cocaine, increases synaptic dopamine by inhibiting dopamine reuptake. The discriminative properties, reinforcing potential, and subjective effects of MPH and cocaine are almost identical and, importantly, MPH has been found to substitute for cocaine in animals and human volunteers under laboratory conditions. When taken orally in therapeutic doses, its abuse liability, however, appears low, which is especially true for extended-release MPH preparations. Though there are promising data in the literature, mainly from case reports and open-label studies, the results of randomized controlled trials have been disappointing so far and do not corroborate the use of MPH as a substitute for cocaine dependence in patients without attention deficit hyperactivity disorder.

Conclusion

Clinical studies evaluating MPH substitution for cocaine dependence have provided inconsistent findings. However, the negative findings may be explained by specific study characteristics, among them dosing, duration of treatment, or sample size. This needs to be considered when discussing the potential of MPH as replacement therapy for cocaine dependence. Finally, based on the results, we suggest possible directions for future research.

[Substance abuse in older adults]

In respect of demographic change, the number of older patients with substance abuse and addiction is on the raise. In this review we present important clinical and therapeutic aspects of substance abuse and addiction in the elderly and focus on alcohol, benzodiazepines and opioids. Daily and risky alcohol consumption is common among older people. They also have an increased risk getting alcohol-related complications. For early detection, laboratory parameters and questionnaires such as the AUDIT-C are suitable. Therapeutically brief interventions have been proved successful. Also, abuse of benzodiazepines, especially low-dose addiction, is widespread among older persons, although often overlooked, and patients often do not recognize their addiction. The physician has to know the correct indication, adequate dosage and pharmacological interactions. A slow-dose reduction is recommended in case of addiction. Thanks to opioid substitution therapy, patients with an opioidaddiction can reach a higher age. Age influences the effects of the substitute, which may require an adjustment of the dosage. Treatment of elderly patients should be based on their needs and resources and is usually very effective.

[Mechanism of action of disulfiram and treatment optimization in prevention of recurrent alcoholism]

The current frequent use of disulfiram in alcohol relapse prevention, and the possible extension of the indication (cocaine addiction, pathological gambling) make in-depth knowledge about therapeutic effects, interactions, contraindications, and side effects of disulfiram in alcohol relapse prevention the psychological-psychotherapeutic and supportive effects are perhaps more important than the pharmacological effects. The efficacy and safety of supervised disulfiram treatment is verified in a number of studies (also in co-morbid psychiatric patients). In addition, in this review options were presented, which can improve the safety of the treatment with disulfiram (e.g. Ethylglucuoronide and pharmacogenetics). Given the high prevalence of alcohol dependence in our view disulfiram is used very little, although the use of disulfiram in the context of structured, multi-modal outpatient treatment programs are considered to be safe.

Lack of association of a functional catechol-O-methyltransferase gene polymorphism with risk of tobacco smoking: results from a multicenter case-control study

BACKGROUND

The catechol-O-methyltransferase (COMT) modulates dopaminergic neurotransmission in the prefrontal cortex as well as in the mesolimbic reward system. Since the reward system mediates addictive behavior, the COMT gene is a strong candidate gene regarding the pathophysiology of tobacco dependence and smoking behavior. Because of rather conflicting results in previous studies, the purpose of the present study was to test for association between a functional genetic variant in the COMT gene (single nucleotide polymorphism [SNP] rs4680) and tobacco smoking behavior.

METHODS

In a population-based case-control multicenter study designed for tobacco addiction research, a total of 551 current smokers of European ancestry and 548 age-matched healthy volunteers (never-smokers) were genotyped for SNP rs4680 and extensively characterized concerning their smoking behavior.

RESULTS

We found no association between smoking status and SNP rs4680 genotype nor did we find a significant association to the degree of tobacco dependence.

CONCLUSIONS

Although prefrontal cortical and ventral striatal activity are highly relevant for addictive behavior, and under partial control of COMT rs4680 genotype, no association between COMT and smoking behavior was observed. Other genetic variants may account for the high heritability of behavioral smoking phenotypes.

Insula-specific H magnetic resonance spectroscopy reactions in heavy smokers under acute nicotine withdrawal and after oral nicotine substitution

The aim of this study was to clarify whether addiction-specific neurometabolic reaction patterns occur in the insular cortex during acute nicotine withdrawal in tobacco smokers in comparison to nonsmokers. Fourteen male smokers and 10 male nonsmokers were included. Neurometabolites of the right and the left insular cortices were quantified by magnetic resonance spectroscopy (MRS) on a 3-Tesla scanner. Three separate MRS measurements were performed in each subject: among the smokers, the first measurement was done during normal smoking behavior, the second measurement during acute withdrawal (after 24 h of smoking abstinence), and the third shortly after administration of an oral nicotine substitute. Simultaneously, craving, withdrawal symptoms, and CO levels in exhaled air were determined during the three phases. The participants in the control group underwent the same MR protocol. In the smokers, during withdrawal, the insular cortex showed a significant increase in glutamine (Gln; p = 0.023) as well as a slight increase not reaching significance for glutamine/glutamate (Glx; p = 0.085) and a nonsignificant drop in myoinositol (mI; p = 0.381). These values tended to normalize after oral nicotine substitution treatment, even though differences were not significant: Gln (p = 0.225), Glx (p = 0.107) and mI (p = 0.810). Overall, the nonsmokers (control group) did not show any metabolic changes over all three phases (p > 0.05). In smokers, acute nicotine withdrawal produces a neurometabolic reaction pattern that is partly reversed by the administration of an oral nicotine substitute. The results are consistent with the expression of an addiction-specific neurometabolic shift in the brain and confirm the fact that the insular cortex seems to play a possible role in nicotine dependence.

Application of electronic diaries in patients with schizophrenia and bipolar disorders

BACKGROUND

Despite the dissemination of second generation antipsychotics for schizophrenia and bipolar disorder, outcomes remain suboptimal, largely due to poor treatment and drug adherence. The primary aim of the current study was to assess the tolerability, validity and feasibility of the pocket-sized electronic diary Medicus®.

SUBJECTS AND METHODS

Our case observations attempted to evaluate eighteen patients suffering from schizophrenia and bipolar disorder. All of the patients were treated with the second generation antipsychotic quetiapine. We followed them up in two German medical centers over two years.

RESULTS

The present results display an improvement of mood-stability in all patients treated with quetiapine. All patients were in regular contact to their psychiatrist over a period of 24 months. A complete description of the coherences between the symptoms was essential for estimation, which was conducted by Medicus®. Moreover, Medicus® seem to be useful for improving compliance within a medication regimen.

CONCLUSIONS

Although uncontrolled case observations can only be interpreted with caution, Medicus® seems to deserve further investigation and may hold the potential to optimize treatment and drug adherence in patients suffering from schizophrenia and bipolar disorders.

Agomelatine for Depression in Schizophrenia: A Case-Series

OBJECTIVES

Agomelatine, a melatonin (MT1/MT2) receptor agonist and 5-HT2C receptor antagonist, is a new antidepressant and a potential therapeutic option for major depressive episodes and negative symptoms in persons with schizophrenia. We investigated such treatment outcomes with respect to antidepressant efficacy, safety, and tolerability.

METHODS

We report a consecutive case series of seven patients with schizophrenia and comorbid major depressive symptoms who received agomelatine for a period of at least six weeks in addition to stable doses of antipsychotic agents. General psychopathology, positive, negative and depressive symptoms were assessed with standardized interviews. Relevant blood parameters were assessed.

RESULTS

Depressive symptoms improved significantly. Positive symptoms remained stable, while negative symptoms and global psychopathology improved significantly. Agomelatine was well tolerated in most patients.

CONCLUSIONS

Our findings provide initial evidence that agomelatine is safe and efficacious in treating depressive symptoms in patients with schizophrenia. Furthermore, agomelatine seems to be effective for the treatment of negative symptoms. Randomized controlled trials are necessary to confirm these first observations.

Genetic variation in the neuropeptide Y gene promoter is associated with increased risk of tobacco smoking

BACKGROUND

Neuropeptide Y (NPY) is a strong candidate gene regarding the pathophysiology of tobacco dependence. It has been associated with various addictive and psychiatric disorders, and closely interacts with the brain reward system. The aim of the present study was to test for association between a functional genetic variant in the NP-Y promoter gene (SNP rs16147) and tobacco smoking.

METHODS

In a population-based case-control multicenter study designed for tobacco addiction research, a total of 550 Caucasian current smokers, and 544 never-smokers were genotyped for SNP rs16147 and behaviorally characterized with the State-Trait Anxiety Inventory (STAI).

RESULTS

Subjects with TT genotype of the SNP rs16147 were significantly more frequently smokers than never-smokers (p = 0.046). In addition, TT genotype exhibited increased state anxiety scores compared to carriers of the C allele (p = 0.037).

CONCLUSIONS

Our results provide evidence for an involvement of the functionally relevant SNP rs16147 in the pathophysiology of tobacco dependence. Further studies are needed to confirm our findings.

Dextromethorphan withdrawal and dependence syndrome

BACKGROUND

The N-methyl-D-aspartate (NMDA) antagonist dextromethorphan has been available in pharmacies without a prescription since 1954 as an antitussive agent. There is an alarming increase in reports of its abuse. Dextromethorphan is avidly taken, mainly by young people, as a psychoactive drug. The currently available data yield incomplete information about the extent of the problem and its significance for addiction medicine in Germany.

CASE PRESENTATION AND COURSE

We report the case of a 44-year-old man who became dependent on dextromethorphan through years of abuse, buying the substance for himself without a prescription in German pharmacies. He told us he had taken it regularly for six years. He had become dependent on dextromethorphan, ultimately taking it in a dose of 1800 mg daily. This led him to overt neglect of his work and leisure activities. A urine sample taken on admission to the hospital was found to contain dextromethorphan. During inpatient detoxification, he developed an vegetative withdrawal syndrome consisting of craving, diaphoresis, nausea, hypertension, and tachycardia. He was treated on our ward for three weeks, and a stay in a residential detoxification facility was planned thereafter.

CONCLUSION

Dextromethorphan is a psychotropic substance that carries a potential for abuse and dependence. On the basis of the currently available data, its reclassification as a prescription drug should be considered.

Why is disulfiram superior to acamprosate in the routine clinical setting? A retrospective long-term study in 353 alcohol-dependent patients

AIMS

To compare the long-term effectiveness of acamprosate (ACP) and disulfiram (DSF) in the treatment of alcohol dependence and their effectiveness in regard to patient characteristics, within a naturalistic outpatient treatment setting.

METHOD

Retrospective data from 2002 to 2007 were analysed on 353 alcohol-dependent subjects in outpatient treatment, who, according to the patient's and the clinician's mutual decision, received either supervised DSF (with thrice-weekly appointments) or ACP (once-weekly appointments) following an inpatient alcohol detoxification treatment. Abstinence was assessed by alcohol breathalyzer, patients' self-report, urine and serum analyses, and overall physicians' rating.

RESULTS

Baseline data in terms of current addictive behaviour and course of disease differed between groups to the disadvantage of the DSF group; compared to the ACP group, subjects treated with DSF showed a longer duration of alcohol dependence, higher amounts of daily alcohol consumption and more alcohol detoxification treatments in their history. In follow-up, Kaplan-Meier survival analysis revealed significant differences between groups in the primary and secondary measures of outcome (P always <0.01). Time elapsed before the first alcohol relapse as well as attendance to outpatient treatment and cumulative alcohol abstinence achieved within outpatient treatment was explicitly longer in the DSF group. A longer duration of alcohol dependence predicted a favourable treatment outcome in the DSF group, while for the ACP group the chances for a successful treatment increased with shorter duration of alcohol dependence.

CONCLUSIONS

This study supports the thesis that supervised DSF is an important component of alcoholism treatment, and it appears to be more effective than the treatment with ACP particularly in patients with a long duration of alcohol dependence.

Supervised disulfiram in relapse prevention in alcohol-dependent patients suffering from comorbid borderline personality disorder--a case series

AIMS

Disulfiram is widely used to prevent alcoholic relapse. However, due to the intended adverse reaction with ethanol, some believe that its use is dangerous for patients with personality disorders or psychiatric comorbidities because of their increased risk of impulsivity or suicidal behaviour. We examined the safety and efficacy in relapse prevention of a series of alcoholics with borderline personality disorder (BPD).

METHODS

Case history study of patients diagnosed with BPD, prescribed disulfiram in a dose of 1.5-2.5 g/week, supervised by a physician in up to three brief contacts per week.

RESULTS

Two out of eight patients remained completely abstinent during the supervised disulfiram therapy over a mean period of 9.25 months. Adherence to treatment was 18.44 +/- 21.78 months. The first relapse occurred after 1.38 +/- 1.41 months. The cumulated time of abstinence was 16.88 +/- 20.48 months. The overall tolerability was considered to be high; dizziness and fatigue appeared in all patients at the beginning of the therapy but did not persist. No serious adverse events or ethanol-disulfiram interactions were observed. No suicidal behaviour was reported.

CONCLUSIONS

Although case observations should be interpreted with caution, supervised disulfiram seems to deserve further investigation in patients with comorbid BPD, for whom it appears to help prevent alcoholic relapse.

Disulfiram, an option for the treatment of pathological gambling?

AIM

Pathological gambling and comorbid alcohol dependence often occur in combination. Disulfiram is one of the proven drugs for alcohol dependence. In addition to its inhibiting acetaldehyde dehydrogenase, disulfiram inhibits dopamine beta-hydroxylase and may thereby increase dopamine and decrease norepinephrine cerebral concentrations. Because there may be common neurochemical substrates and neuronal circuits for pathological gambling and addiction, we wished to explore the effect of disulfiram in gambling.

METHOD

We describe the outcome of a patient with alcohol dependence and pathological gambling treated with disulfiram D.

RESULTS

During treatment with disulfiram, the patient reported that his desire to gamble disappeared entirely. Follow-up indicated that he has not gambled for >12 months.

CONCLUSIONS

Although uncontrolled case observations should be interpreted with caution, disulfiram deserves further investigation in pathological gambling.

[Impact of functional social support for abstinence after inpatient detoxification]

OBJECTIVE

Several studies discovered an association between social support and therapy outcomes in patients suffering from alcoholism. However, less is known about the influence of functional social support (fss) on these outcomes. In this prospective study, we examined the impact of fss on different alcohol-dependence related variables in 132 alcohol-dependent patients.

METHODS

The fss was measured with the Medical Outcome Study (MOS) Social Support Survey at baseline and at the end of the study.

RESULTS

We found significantly higher fss levels in patients with a current partnership. However, there was no association between fss or its sub-dimensions (emotional, cognitive and practical social support) with days until relapse. Fss was stable in the 12 week interval, despite ongoing weekly therapy. However, controlling for the variables "partnership" and "time of first withdrawal symptoms", we found a negative correlation between perceived practical social support and number of previous inpatient detoxifications.

CONCLUSIONS

Increased empirical understanding of the impact of social relationships in alcohol-dependent patients would help to improve treatment prognosis, in addition, optimizing the currently available therapeutic options.