Effects of hypnotics on sleep quality and daytime well-being. Data from a comparative multicentre study in outpatients with insomnia

The effect of treatment (28 days) with zopiclone, triazolam, flunitrazepam and placebo on sleep quality and daytime well-being was proven in a randomised, double-blind, parallel group, multicentre study in private practice. Results of an exploratory statistic of treatment efficacy in a subgroup of 1,291 patients suffering from insomnia are presented. Patients met the following criteria: insomnia lasting at least four weeks and the presence of at least two of the following: 1) sleep latency ≥ 45 minutes, 2) total sleep time ≤ 6 hours, and 3) nocturnal awakening ≥3 times. Treatment efficacy was assessed according to the following factors: either a shortening of sleep latency by at least 15 minutes, or prolongation of total sleep time by at least 20%, or reduction of the number of nocturnal awakenings to three or less and a refreshed feeling in the morning as well as no impairment in daytime well-being due to tiredness or anxiety. The total response rate was markedly higher with zopiclone (42.3%; p = 0.0003) than with placebo (29.0%). Triazolam (36.6%; p = 0.0905) and flunitrazepam (33.1%; p = 0.3401) were also more effective than the placebo, but they both tended to have a lower response rate than with zopiclone (p = 0.1199 and 0.0151, respectively). Total response was found to be essentially a reflection of the response of the socially important parameter of daytime well-being. These results suggest that zopiclone is more effective in the treatment of insomnia than either triazolam or flunitrazepam. Since the response of daytime well-being to therapy was generally poor, this parameter embodies the next main therapeutic challenge in the treatment of patients with insomnia.

Repetitive Transkranielle Magnetstimulation

Die repetitive Transkranielle Magnetstimulation (rTMS) ist eine innovative Technologie, mit der nicht-invasiv neurobiologische, physiologische und psychologische Funktionen des Gehirns moduliert werden können. In Konferenzen deutscher TMS-Experten wurde, einem formalen Konsensusprozess folgend, das Nutzen/Risiko-Verhältnis der rTMS als therapeutische Technik für die Psychiatrie beurteilt. Die rTMS wurde als viel versprechendes und innovatives Verfahren beurteilt, dessen weitere Erforschung wünschenswert ist. Zurzeit erscheinen depressive Störungen unter der Vielzahl untersuchter Diagnosen als mögliche Hauptindikation einer rTMS-Behandlung. Die überwiegend medikamentös vorbehandelten und zum Teil therapieresistenten depressiven Patienten zeigten in den existierenden Studien ein positives Nutzen/Risiko-Profil im Sinne einer moderaten klinischen Verbesserung bei zugleich niedriger Nebenwirkungsrate. Die rTMS sollte grundsätzlich von in der Methode erfahrenen oder speziell ausgebildeten Ärzten durchgeführt werden. Die aktuellen Sicherheitsempfehlungen sind dabei zu berücksichtigen und ein engmaschiges Therapiemonitoring sollte erfolgen. Obwohl der wissenschaftliche Datenbestand zur rTMS stetig wächst, ist die Methode gegenwärtig noch als experimentelles Therapieverfahren einzuschätzen, das bislang noch weniger gut untersucht ist als vor einer Zulassung stehende Psychopharmaka.

TMS: Neue Einsatzmöglichkeiten in der neurophysiologischen Charakterisierung von Psychopharmaka und der biologischen Phänotypisierung psychischer Erkrankungen

Zwei Aspekte der transkraniellen Magnetstimulation (TMS) finden zunehmend Einzug in die Psychiatrie. Zum einen die repetitive transkranielle Magnetstimulation (rTMS) zur Behandlung psychischer Erkrankungen, zum anderen die diagnostische Variante des Verfahrens. Methodische Erweiterungen dieser diagnostisch ausgerichteten TMS eröffnen die Möglichkeit, schmerzfrei und nichtinvasiv die kortikale Exzitabilität des motorischen Systems zu messen. Damit lassen sich neue Erkenntnisse zur Wirkungsweise von Psychopharmaka gewinnen. Besonders interessant erscheint zudem die Möglichkeit der biologischen Phänotypisierung mittels dieses Verfahrens. Hierbei lassen sich so genannte neurophysiologische Endophänotypen definieren, die zum Teil genetisch determiniert sind.

Structural brain changes are associated with response of negative symptoms to prefrontal repetitive transcranial magnetic stimulation in patients with schizophrenia

Impaired neural plasticity may be a core pathophysiological process underlying the symptomatology of schizophrenia. Plasticity-enhancing interventions, including repetitive transcranial magnetic stimulation (rTMS), may improve difficult-to-treat symptoms; however, efficacy in large clinical trials appears limited. The high variability of rTMS-related treatment response may be related to a comparably large variation in the ability to generate plastic neural changes. The aim of the present study was to determine whether negative symptom improvement in schizophrenia patients receiving rTMS to the left dorsolateral prefrontal cortex (DLPFC) was related to rTMS-related brain volume changes. A total of 73 schizophrenia patients with predominant negative symptoms were randomized to an active (n=34) or sham (n=39) 10-Hz rTMS intervention applied 5 days per week for 3 weeks to the left DLPFC. Local brain volume changes measured by deformation-based morphometry were correlated with changes in negative symptom severity using a repeated-measures analysis of covariance design. Volume gains in the left hippocampal, parahippocampal and precuneal cortices predicted negative symptom improvement in the active rTMS group (all r⩽-0.441, all P⩽0.009), but not the sham rTMS group (all r⩽0.211, all P⩾0.198). Further analyses comparing negative symptom responders (⩾20% improvement) and non-responders supported the primary analysis, again only in the active rTMS group (F_{(9, 207)}=2.72, P=0.005, partial η ²=0.106). Heterogeneity in clinical response of negative symptoms in schizophrenia to prefrontal high-frequency rTMS may be related to variability in capacity for structural plasticity, particularly in the left hippocampal region and the precuneus.

Efficacy of different protocols of transcranial magnetic stimulation for the treatment of tinnitus: Pooled analysis of two randomized controlled studies

OBJECTIVES

Tinnitus is related to alterations in neuronal activity of auditory and nonauditory brain areas. Targeted modulation of these areas by repetitive transcranial magnetic stimulation (rTMS) has been proposed as a new therapeutic approach for chronic tinnitus.

METHODS

Two randomized, double-blind, parallel-group, controlled clinical trials were performed subsequently and pooled for analysis. A total of 192 tinnitus patients were randomly allocated to receive 10 stimulation sessions of either sham rTMS, PET-based neuronavigated 1 Hz rTMS, 1Hz r TMS over the left auditory cortex, or combined 20 Hz rTMS over the left frontal cortex, followed by 1 Hz rTMS over the left auditory cortex.

RESULTS

rTMS treatment was well tolerated and no severe side effects were observed. All active rTMS treatments resulted in significant reduction of the TQ as compared to baseline. The comparison between treatment groups failed to reach significant differences. The number of treatment responders was higher for temporal rTMS(38%) and combined frontal and temporal rTMS (43%), as compared to sham (6%).

CONCLUSIONS

This large study demonstrates the safety and tolerability of rTMS treatment in patients with chronic tinnitus. While the overall effect did not prove superior to placebo, secondary outcome parameters argue in favour of the active stimulation groups, and specifically the combined frontal and temporal rTMS protocol.

[Hypothermia under olanzapine treatment: clinical case series and review of current literature]

BACKGROUND

Antipsychotic drugs may lead to hypothermia as well as hyperthermia. Although known for decades and clinically highly relevant, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are still far from being fully understood. In clinical practice, much attention is paid to antipsychotic drug-induced elevation of body core temperature as observed in the neuroleptic malignant syndrome (NMS). But also hypothermia is a clinically highly relevant adverse reaction to antipsychotic drugs.

MATERIAL AND METHODS

Here we report a case series of three patients who developed severe hypothermia after administration of olanzapine. A review of the current literature is given with a focus on risk factors for the development of antipsychotic drug-induced hypothermia and its pathophysiologic mechanisms.

RESULTS

A 51-year-old female patient suffering from catatonic schizophrenia, cachectic nutritional condition and hypothyroidism developed severe hypothermia of 30.0°C body core temperature after administration of 30 mg olanzapine per day under comedication with lorazepam and L-thyroxine. A 48-year-old female patient with catatonic schizophrenia showed hypothermia of 31.0°C (rectal measurement) after single-dose administration of olanzapine 10 mg orally and a total of 3 mg lorazepam (1-1-1 mg). The third case report describes a 69-year-old male patient with acute delusional disorder exhibiting hypothermia of 33.0°C (rectal measurement) in combination with a reversible atrioventricular block grade III without any further comedication.

CONCLUSION

A review of the current literature reveals that thermoregulatory disturbances as sequelae of antipsychotic drug administration depend on individual disposition as well as various independent risk factors such as environmental temperature, somatic comorbidities, endocrinological abnormalities (e.g. hypothyroidism) and structural damage of the brain. A complex interaction of dopaminergic regulatory mechanisms in the ventral hypothalamus and peripheral vaso- and sudomotor adjustments seems to be causative. Hypothermia following antipsychotic drug administration represents a serious adverse drug reaction and a potentially life-threatening event.

Orexin receptor antagonism, a new sleep-enabling paradigm: a proof-of-concept clinical trial

The orexin system is a key regulator of sleep and wakefulness. In a multicenter, double-blind, randomized, placebo-controlled, two-way crossover study, 161 primary insomnia patients received either the dual orexin receptor antagonist almorexant, at 400, 200, 100, or 50 mg in consecutive stages, or placebo on treatment nights at 1-week intervals. The primary end point was sleep efficiency (SE) measured by polysomnography; secondary end points were objective latency to persistent sleep (LPS), wake after sleep onset (WASO), safety, and tolerability. Dose-dependent almorexant effects were observed on SE, LPS, and WASO. SE improved significantly after almorexant 400 mg vs. placebo (mean treatment effect 14.4%; P < 0.001). LPS (–18 min (P = 0.02)) and WASO (–54 min (P < 0.001)) decreased significantly at 400 mg vs. placebo. Adverse-event incidence was dose-related. Almorexant consistently and dose-dependently improved sleep variables. The orexin system may offer a new treatment approach for primary insomnia.

Effects of acupuncture needle penetration on motor system excitability

OBJECTIVES

Transcranial magnetic stimulation (TMS) studies reported changes in motor evoked potential amplitude after acupuncture needling both at traditional acupoints and non-acupoints. However, the effects of needle penetration per se have not yet been investigated with TMS. The present study aimed at exploring effects of deep manual acupuncture needling compared to a state-of-the-art, non-penetrating control condition on several standard TMS measures of motor system excitability.

METHODS

Twenty healthy volunteers received both verum and sham acupuncture applied at the acupoint GB 34 near the right knee, using a crossover design. A needle with a retractable tip ("Streitberger needle") was used as sham condition to minimize non-specific effects. TMS parameters (resting motor threshold, active motor threshold, cortical silent period, short intracortical inhibition, and intracortical facilitation) were calculated from the abductor digiti minimi (ADM) of both hands 15 min before and after needling by a researcher blind to the treatment condition.

RESULTS

Verum compared to sham acupuncture significantly increased resting motor threshold. No significant treatment effect was found for any other measure, though cortical silent period and intracortical facilitation showed trends to increase in the hemisphere contralateral to the needling site after verum acupuncture.

CONCLUSIONS

These results suggest a subtle but specific inhibitory effect of acupuncture needle penetration at acupoint GB 34 on motor system excitability. Further investigations should be performed with a particular emphasis on the measurements of resting motor threshold, cortical silent periods and intracortical facilitation.

CS03-02 - Sleep and chronic pain

Recent nation-wide epidemiological data confirm the well-known clinical observation of a strong relationship between pain syndromes and disordered sleep.

In experimental settings of pain patients as well as healthy subjects, pain perception shows a strong circadian pattern exhibiting significant variation over the 24-hour sleep-wake period. Several lines of scientific evidence indicate that homoeostatic components of sleep may mask circadian pain perception, which results in a two-process model of pain regulation depending on the circadian sleep-wake status.

Since pain may worsen sleep, sleep deprivation increases pain, and quality of sleep not only affects nocturnal pain but influences pain during daytime hours, models of interactive pathomechanisms of pain and sleep are widely accepted.

Clinical consequences include various treatment methods that consider both, pain and sleep. E.g., intake of pain medication should follow circadian aspects which assure sufficient pain reduction at early morning hours; ideal pain medication at night should have hypnotic properties, including the promotion of deep sleep; pain medication during daytime hours should activate patients to support good sleep during the following night. Psychotherapy needs to support both, the management of pain and of sleep.

Chronobiological issues of sleep and circadian rhythms

Progress in unravelling the cellular and molecular basis of mammalian circadian regulation over the past decade has provided us with data that deteriorations in measurable circadian output parameters, such as sleep/wake deficits and dysregulation of circulating hormone levels, are common features of most central nervous system disorders.

At the core of the mammalian circadian system is a complex of molecular oscillations within the hypothalamic suprachiasmatic nucleus. These oscillations are modifiable by afferent signals from the environment, and integrated signals are subsequently conveyed to remote central neural circuits where specific output rhythms are regulated. Usually our sleep/wake cycle, temperature and melatonin rhythms are internally synchronized with a stable phase relationship. When there is a desynchrony between the sleep/wake cycle and circadian rhythm, sleep disorders such as advanced and delayed sleep phase syndrome can arise as well as transient chronobiologic disturbances, for example from jet lag and shift work.

Increasing evidence suggests that disrupted temporal organization of biological functions impairs behaviour, cognition, affect, and emotion. Furthermore, disruption of circadian clock genes impairs the sleep-wake cycle and social rhythms, which may be implicated in particular in mental disorders. An increasing number of journal publications point to a crucial role of circadian rhythm dysregulations in particular for affective disorders, which should e addressed specifically in modern psychiatry.

SS05-02 - Management of depression with agomelatine: A different perception

Agomelatine is a completely new approach to the treatment of depression thanks to its innovative mode of action. Acting as melatonergic agonist and 5-HT2C antagonist, it provides depressed patients with a distinctive antidepressant efficacy that perfectly suits patients’ needs and addresses all symptoms at each step of depression. Two years after the first launch in Europe, now is the time for an update from doctors and patients alike.

The patient/doctor relation is key when initiating depression treatment, because patients are reluctant to start, fearing withdrawal symptoms, serious unwanted side effects, and “addiction”. It is important therefore that they understand that agomelatine has none of these effects.

The benefits perceived by patients right from the first days of treatment are influential, because patients are reluctant to continue with classic antidepressants (delayed onset of perceived benefit, early side effects). The early improvement reported by patients on agomelatine supplements data on clinical benefits seen in clinical trials from the first week versus venlafaxine (CGI-I, rate of response, daytime alertness, feeling good) and after two weeks versus sertraline (twice as many HAM-D responders to agomelatine as to sertraline).

Finally, patients are reluctant to maintain antidepressant treatment because of later side effects (weight gain, sexual dysfunction, emotional blunting). Patients on agomelatine confirm the absence of the classic side effects of antidepressants and are more likely to continue treatment than they are with other drugs. Both the antidepressant efficacy and the tolerability were confirmed in a large non-interventional study in a real-life setting in daily practice.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders

Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners. These British Association for Psychopharmacology guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. Those invited to attend included BAP members, representative clinicians with a strong interest in sleep disorders and recognized experts and advocates in the field, including a representative from mainland Europe and the USA. Presenters were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomized controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aimed to reach consensus where the evidence and/or clinical experience was considered adequate or otherwise to flag the area as a direction for future research. A draft of the proceedings was then circulated to all participants for comment. Key subsequent publications were added by the writer and speakers at draft stage. All comments were incorporated as far as possible in the final document, which represents the views of all participants although the authors take final responsibility for the document.

Berry anthocyanins and anthocyanidins exhibit distinct affinities for the efflux transporters BCRP and MDR1

BACKGROUND AND PURPOSE

Dietary anthocyanins hold great promise in the prevention of chronic disease but factors affecting their bioavailability remain poorly defined. Specifically, the role played by transport mechanisms at the intestinal and blood-brain barriers (BBB) is currently unknown.

EXPERIMENTAL APPROACH

In the present study, 16 anthocyanins and anthocyanidins were exposed to the human efflux transporters multidrug resistance protein 1 (MDR1) and breast cancer resistance protein (BCRP), using dye efflux, ATPase and, for BCRP, vesicular transport assays.

KEY RESULTS

All test compounds interacted with the BCRP transporter in vitro. Of these, seven emerged as potential BCRP substrates (malvidin, petunidin, malvidin-3-galactoside, malvidin-3,5-diglucoside, cyanidin-3-galactoside, peonidin-3-glucoside, cyanidin-3-glucoside) and 12 as potential inhibitors of BCRP (cyanidin, peonidin, cyanidin-3,5-diglucoside, malvidin, pelargonidin, delphinidin, petunidin, delphinidin-3-glucoside, cyanidin-3-rutinoside, malvidin-3-glucoside, pelargonidin-3,5-diglucoside, malvidin-3-galactoside). Malvidin, malvidin-3-galactoside and petunidin exhibited bimodal activities serving as BCRP substrates at low concentrations and, at higher concentrations, as BCRP inhibitors. Effects on MDR1, in contrast, were weak. Only aglycones exerted mild inhibitory activity.

CONCLUSIONS AND IMPLICATIONS

Although the anthocyanidins under study may alter pharmacokinetics of drugs that are BCRP substrates, they are less likely to interfere with activities of MDR1 substrates. The present data suggest that several anthocyanins and anthocyanidins may be actively transported out of intestinal tissues and endothelia, limiting their bioavailability in plasma and brain.

Repetitive transcranial magnetic stimulation for the treatment of negative symptoms in residual schizophrenia: rationale and design of a sham-controlled, randomized multicenter study

Current meta-analysis revealed small, but significant effects of repetitive transcranial magnetic stimulation (rTMS) on negative symptoms in patients with schizophrenia. There is a need for further controlled, multicenter trials to assess the clinical efficacy of rTMS on negative symptoms in schizophrenia in a larger sample of patients. The objective of this multicenter, randomized, sham-controlled, rater- and patient-blind clinical trial is to investigate the efficacy of 3-week 10-Hz high frequency rTMS add on to antipsychotic therapy, 15 sessions per 3 weeks, 1,000 stimuli per session, stimulation intensity 110% of the individual motor threshold) of the left dorsolateral prefrontal cortex for treating negative symptoms in schizophrenia, and to evaluate the effect during a 12 weeks of follow-up. The primary efficacy endpoint is a reduction of negative symptoms as assessed by the negative sum score of the positive and negative symptom score (PANSS). A sample size of 63 in each group will have 80% power to detect an effect size of 0.50. Data analysis will be based on the intention to treat population. The study will be conducted at three university hospitals in Germany. This study will provide information about the efficacy of rTMS in the treatment of negative symptoms. In addition to psychopathology, other outcome measures such as neurocognition, social functioning, quality of life and neurobiological parameters will be assessed to investigate basic mechanisms of rTMS in schizophrenia. Main limitations of the trial are the potential influence of antipsychotic dosage changes and the difficulty to ensure adequate blinding.

Cognitive and neurobiological alterations in electromagnetic hypersensitive patients: results of a case-control study

BACKGROUND

Hypersensitivity to electromagnetic fields (EMF) is frequently claimed to be linked to a variety of non-specific somatic and neuropsychological complaints. Whereas provocation studies often failed to demonstrate a causal relationship between EMF exposure and symptom formation, recent studies point to a complex interplay of neurophysiological and cognitive alterations contributing to symptom manifestation in electromagnetic hypersensitive patients (EHS). However, these studies have examined only small sample sizes or have focused on selected aspects. Therefore this study examined in the largest sample of EHS EMF-specific cognitive correlates, discrimination ability and neurobiological parameters in order to get further insight into the pathophysiology of electromagnetic hypersensitivity.

METHOD

In a case-control design 89 EHS and 107 age- and gender-matched controls were included in the study. Health status and EMF-specific cognitions were evaluated using standardized questionnaires. Perception thresholds following single transcranial magnetic stimulation (TMS) pulses to the dorsolateral prefrontal cortex were determined using a standardized blinded measurement protocol. Cortical excitability parameters were measured by TMS.

RESULTS

Discrimination ability was significantly reduced in EHS (only 40% of the EHS but 60% of the controls felt no sensation under sham stimulation during the complete series), whereas the perception thresholds for real magnetic pulses were comparable in both groups (median 21% versus 24% of maximum pulse intensity). Intra-cortical facilitation was decreased in younger and increased in older EHS. In addition, typical EMF-related cognitions (aspects of rumination, symptom intolerance, vulnerability and stabilizing self-esteem) specifically differentiated EHS from their controls.

CONCLUSIONS

These results demonstrate significant cognitive and neurobiological alterations pointing to a higher genuine individual vulnerability of electromagnetic hypersensitive patients.

[Documentation in psychiatry and psychotherapy: prerequisites and clinical practice]

BACKGROUND

As a result of changes to the legal and economic framework over the past years, medical documentation has changed substantially.

METHODS

Based on a literature search of important medicolegal studies and appeal decisions, an overview is given of legal principles and their practical consequences, especially for the fields of psychiatry and psychotherapy.

RESULTS

Documentation is a contractual and crime-related duty arising from the professional code for doctors and the legal obligation to provide documentation. In addition to being a memory aide for the doctor, its purposes are to safeguard and justify the treatment and to provide legal evidence. The documentation should be provided in a format that is sufficiently clear for specialist staff, using keywords, possibly handwritten, and use contemporary terminology. All important diagnostic and therapeutic measures must be documented. This is particularly important when the treatment deviates from standard treatment and in medical procedures aiming to protect the patient.

CONCLUSIONS

The legal requirements for documentation are becoming more stringent. The time spent on such activities has so far not been reimbursed by the financing bodies.

Positron emission tomography findings in obstructive sleep apnea patients with residual sleepiness treated with continuous positive airway pressure

Despite sufficient continuous positive airway pressure (CPAP) therapy, some patients with the obstructive sleep apnea syndrome (OSAS) still suffer from excessive daytime sleepiness (EDS). In some of them, no cause of the persistence of EDS can be found. Brain damage due to nocturnal hypoxemia is a potential cause for this unclear persistent sleepiness (UPS). This study was done to evaluate this hypothesis. Patients with UPS were identified among the OSAS patients, who came for a CPAP therapy checkup to our sleep laboratory. UPS was recognized when no explanation for persistent EDS could be yielded by standard diagnostic procedures. Out of 167 patients under CPAP therapy 13 had UPS. To investigate the brain morphology, positron emission tomography (PET) scanning with the tracer fluorine-18 fluorodeoxyglucose (FDG), called FDG-PET, were performed in 7 of the UPS patients. Abnormal PET findings were concentrated in frontal area (found in 4 patients). The frontal abnormality seems to distinguish the OSAS patients with UPS from the whole OSAS population, examined in previous studies.

Antidepressant effects of augmentative transcranial magnetic stimulation: randomised multicentre trial

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a new treatment option for depression. Previous studies were performed with low sample sizes in single centres and reported heterogeneous results.

AIMS

To investigate the efficacy of rTMS as augmentative treatment in depression.

METHOD

In a randomised, double-blind, sham-controlled multicentre trial 127 patients with moderate to severe depressive episodes were randomly assigned to real or sham stimulation for 3 weeks in addition to simultaneously initiated antidepressant medication.

RESULTS

We found no difference in the responder rates of the real and the sham treatment groups (31% in each) or in the decrease of the scores on the depression rating scales.

CONCLUSIONS

The data do not support previous reports from smaller samples indicating an augmenting or accelerating antidepressant effect of rTMS. Further exploration of the possible efficacy of other stimulation protocols or within selected sub-populations of patients is necessary.