Pramipexol bei der Parkinson-Krankheit Ergebnisse einer Anwendungsbeobachtung

Pramipexole is a novel, internationally available selective nonergot D2 dopamine agonist. The effectiveness, tolerability, and safety of pramipexole have been extensively proven in controlled trials in patients in the early and advanced stage of Parkinson's disease as monotherapy and in combination with L dopa. These trials indicated specific activity against tremor, anhedonia, and depression. Therefore, the present prospective, multicenter postmarketing surveillance study evaluated for the first time to what extent the results from the controlled pramipexole trials could be replicated under routine conditions in neurological practice and clinics. Modern scales were applied for the assessment of tremor and mood, i.e., the Short Parkinson's Evaluation Scale (SPES), the Tremor Impact Scale (TIS), and the German version of the Snaith-Hamilton Pleasure Scale (SHAPS-D). In 298 German Centers, 657 Parkinson's patients (365 men, 292 women) in advanced disease stages were treated with pramipexole in combination with levodopa. The average ages (+/- SD) were 67 (+/- 8.9) years for men and 69 (+/- 9.4) years for females. Motor functioning, especially tremor, motor complications, depression, and activities of daily living improved highly significantly (P < 0.0005), including self-rating by the patients. The dosage of levodopa could be reduced on average by 8% (P < 0.0001). This might contribute to a slowing of the disease progression in the long run. Dropouts due to side effects were observed only in 3.5% of the patients. Using new assessment scales suitable for routine application allowed confirmation of the results from controlled clinical trials with regard to tremor, anhedonia, and depression. The average daily dosage of pramipexole prescribed was 1.05 mg and thus was definitely lower than the average daily dosages of 2.35-2.66 mg used in controlled trials. This signifies that the option to adjust dosage according to effectiveness and tolerability under routine conditions yields a considerably lower incidence of adverse effects.

Insight in schizophrenia-course and predictors during the acute treatment phase of patients suffering from a schizophrenia spectrum disorder

BACKGROUND

To analyse insight of illness during the course of inpatient treatment, and to identify influencing factors and predictors of insight.

METHODS

Insight into illness was examined in 399 patients using the item G12 of the Positive and Negative Syndrome Scale ("lack of insight and judgement"). Ratings of the PANSS, HAMD, UKU, GAF, SOFAS, SWN-K and Kemp's compliance scale were performed and examined regarding their potential association with insight. The item G12 was kept as an ordinal variable to compare insight between subgroups of patients.

RESULTS

Almost 70% of patients had deficits in their insight into illness at admission. A significant improvement of impairments of insight during the treatment (p<0.0001) was observed. At admission more severe positive and negative symptoms, worse functioning and worse adherence were significantly associated with poorer insight. Less depressive symptoms (p=0.0004), less suicidality (p=0.0218), suffering from multiple illness-episodes (p<0.0001) and worse adherence (p=0.0012) at admission were identified to be significant predictors of poor insight at discharge.

CONCLUSION

The revealed predictors might function as treatment targets in order to improve insight and with it outcome of schizophrenia.

Evaluating depressive symptoms and their impact on outcome in schizophrenia applying the Calgary Depression Scale

OBJECTIVE

To examine depressive symptoms, their course during treatment, and influence on outcome.

METHOD

Weekly Calgary Depression Scale for Schizophrenia ratings were performed in 249 inpatients with schizophrenia. Early response was defined as a 20% reduction in the total score of the Positive and Negative Syndrome Scale for Schizophrenia from admission to week 2, response as a 50% reduction in the total score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) from admission to discharge and remission according to the consensus criteria.

RESULTS

Thirty six per cent of the patients were depressed at admission, with 23% of them still being depressed at discharge. Depressed patients scored significantly higher on the PANSS negative and general psychopathology subscore, featured more impairments in subjective well-being (P < 0.0001) and functioning (P < 0.0001). They suffered from more suicidality (P = 0.0021), and had greater insight into their illness (P = 0.0105). No significant differences were found regarding early response, response, and remission.

CONCLUSION

Patients with depressive symptoms should be monitored closely, given the burden of negative symptoms, their impairments in well-being and functioning and the threat of suicidality.

A critical analysis and discussion of the appropriateness of the schizophrenia consensus remission criteria in clinical pharmaceutical trials

BACKGROUND

The aim of this paper is to apply the proposed consensus remission criteria to an acutely ill inpatient sample at admission and evaluate their adaptability in this patient population and pharmaceutical trials.

METHODS

The Remission in Schizophrenia Working Group's consensus criteria were applied to 272 acutely ill schizophrenia patients. Patients were examined using the PANSS, HAMD, UKU and SWN-K total scales at admission as well as the GAF, SOFAS and the Strauss-Carpenter Prognostic Scale. Sociodemographic and clinical baseline variables were assessed using a standardized documentation system.

RESULTS

33 patients (12%) fulfilled the symptom severity component of the proposed remission criteria already at baseline. Almost no significant differences were found when comparing patients with achieved and failed symptom severity component that would explain the hospitalization of the patients with achieved criteria despite their apparently mild psychopathological symptoms. The only explainable difference was that patients with an achieved symptom severity component had received significantly more antipsychotics and had suffered from significantly more life events before admission.

CONCLUSION

The present results raise the question whether the symptom severity threshold is adequate to identify patients in remission when applied in clinical trials.

Outcome of suicidal patients with schizophrenia: results from a naturalistic study

OBJECTIVE

Purpose was to assess suicidality before and at the time of admission in patients with schizophrenia and compare outcome differences.

METHOD

Biweekly PANSS (Positive and Negative Syndrome Scale), HAMD (Hamilton Depression Rating Scale) and UKU (Udvalg for Klinske Undersogelser Side Effect Rating Scale) ratings were evaluated in 339 in-patients with schizophrenic spectrum disorders. Response was defined as an initial 20% PANSS total score reduction at discharge, remission was defined according to the proposed consensus criteria by the Remission in Schizophrenia Working Group.

RESULTS

Suicidal patients (22%) scored significantly higher on the PANSS negative subscore, PANSS insight item and HAMD total score at admission and at discharge. They developed significantly more side effects. No differences were found concerning response and remission between the two patient subgroups.

CONCLUSION

Despite receiving significantly more antidepressants the suicidal patients suffered from significantly more depressive symptoms up to discharge, yet without differing regarding response and remission.

Time course of antipsychotic treatment response in schizophrenia: results from a naturalistic study in 280 patients

OBJECTIVE

To describe the course of positive and negative symptoms during inpatient treatment and examine remission and response rates under routine clinical care conditions.

METHODS

Two hundred and eighty inpatients with schizophrenia (DSM-IV criteria) were assessed with the Positive and Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the symptom-severity component of the consensus criteria (Remission in Schizophrenia Working Group) as a rating of three or less in the relevant PANSS items at discharge, and response as a reduction of at least 20% in the PANSS total score from admission to discharge.

RESULTS

The mean duration of inpatient treatment was 54.8 days. Of the total sample, 78.5% achieved the criteria for response and 44.6% those for remission. Mean PANSS total scores decreased from 72.4 at admission to 52.5 at discharge (p<0.001). A reduction in PANSS total scores was found from visit to visit, up to week 8. The most pronounced decline was observed within the first two weeks of treatment.

CONCLUSION

Response rates were comparable to those found in efficacy studies, and remission rates were slightly higher. This may be explained by differences in the selection and the treatment of patients. Nevertheless, the findings might indicate that a complex naturalistic treatment approach is beneficial in terms of effectiveness.

Standardized remission criteria in schizophrenia: descriptive validity and comparability with previously used outcome measures

INTRODUCTION

Standardized consensus criteria for remission in schizophrenia were recently proposed. As yet, the validity of these criteria and their comparability with previously used outcome measures are unclear.

METHODS

The symptom-severity component of the proposed remission criteria was applied to 288 inpatients who fulfilled the ICD-10 criteria for schizophrenia. Global functioning and psychopathological symptoms were assessed using GAF, PANSS, SANS, HAM-D and CDSS.

RESULTS

When patients with symptom remission at discharge from hospitalization (n=158, 54.9%) were compared to those without symptom remission, significant differences were found with respect to the global functioning (GAF) and all observed psychopathological symptom dimensions. The percentage agreement with previously used outcome measures ranged between 52.6 and 80.0%, the kappa values between 0.120 and 0.594. A moderate accordance (kappa value: 0.495) was found with a Clinical Global Impression (CGI) severity score of three or less.

DISCUSSION

The results indicate a high descriptive validity of the symptom-severity component of the proposed remission definition. However, the new criteria differ partially from previously used outcome measures. This aspect should be considered in the interpretation of clinical trials.

Dopaminagonisten als Antidepressiva

Results of preclinical and clinical studies implicate that, in addition to serotonin and norepinephrin, dopaminergic mechanisms play a role in the pathogenesis and treatment of depression. Newer antidepressants such as bupropion, sertraline, and venlafaxine act as partial inhibitors of presynaptic dopamine reuptake. Experimental studies show that dopaminergic effects contribute to the development of anxiety, depression, and anhedonia. These studies revealed, among the new nonergot dopamine agonists, anxiolytic properties for ropinirole and anxiolytic, antidepressive, and antianhedonic effects of pramipexole which seem to relate to its specific action on D(2) and D(3) receptors in the mesolimbic system and prefrontal cortex. In addition, affective disorders may be associated with impairments of neuronal plasticity, and pramipexole seems to exert neurotrophic properties. Controlled and open studies in depressed patients with Parkinson's disease show therapeutic effects of dopamine agonists on motor deficits, anhedonia, and depression. Various dopamine agonists have been tested in open studies in patients with depression and may add to the spectrum of treatment options in mood disorders. Recently published placebo-controlled trials in small patient groups implicate that pramipexole is effective as additional treatment to mood stabilizers in I and II bipolar depression.

Kinetic tremor in Parkinson's disease--an underrated symptom

Since the first description of the disorder which we now call "Parkinson's Disease" (PD) much has changed not only because of new therapeutic possibilities. Initially only the rest tremor was described. Today it is generally accepted that PD can be accompanied by different forms of tremor. Nevertheless the kinetic tremor is hardly examined and no attention is paid to it in clinical rating scales although it can already be found in old published drawings of PD-patients. To date instrumented investigations do not capture the most common kinetic tremor of PD that seems to be frequent under everyday life conditions. In order to assess the significance of kinetic tremor in PD, tremor during a spiral drawing task was investigated in an open study involving 870 patients. The results indicate that a combination of rest, postural and kinetic tremors constitute the most frequent tremor constellation in PD.

Langfristige Auswirkungen traumatischer Ereignisse auf somatische und psychische Beschwerden

The effects of expulsion from German territories following World War Two have not been studied systematically, and little is known about long-term effects of this potentially traumatic experience. Via mail, 600 refugees from former German territories due to World War Two were asked to complete questionnaires about biographic data, somatic and psychic health (SCL-90-R questionnaire), and specific aspects related to traumatic experiences (post-traumatic stress disorder questionnaire). Of those contacted, 25% participated in the investigation. Of them, 9.8% fulfilled diagnostic criteria of post-traumatic stress disorder according to DSM IV. Only 1.8% of an age-matched control group met these criteria. Analysis of the SCL-90-R questionnaire showed higher scores for former refugees in somatic and psychic complaints than the control group. We show that expulsion following war may lead to symptoms of post-traumatic stress disorder and somatic and psychic complaints after more than 50 years. Our investigation supports the necessity of adequate care for subjects expelled from their home countries and the psychologically traumatised.

[Locomotion and depression. Clinical and physiological aspects of gait alterations in Parkinson's disease and major depression]

BACKGROUND

Behavioral disturbances of patients with major depression manifest in various motor domains and are relevant for differential diagnosis, therapeutic interventions, as residual symptoms and possibly early manifestation of Parkinson's disease. Alterations of gait as the main component of locomotion are a clinically well-known motor phenomenon of depressed patients. Therefore, pathophysiology of gait disturbances, different methods to analyze gait and empirical findings in patients with major depression are summarized.

METHODS

The current literature was examined including information of manufacturers, Medline, PubMed, PsychLIT and Excerpta Medica. Findings in healthy subjects, in Parkinson's disease, and in major depression are discussed in detail regarding specificity and clinical relevance.

RESULTS

Kinematic analysis of gait regulation by videography, ultrasound, opto-electronic measures reveals information about disturbances in central nervous motor programming. Only few studies exist about quantitative data of gait alterations in patients with major depression. Results indicate disturbances in functions of the basal ganglia.

CONCLUSIONS

Analysis of gait using modern technology yields information about cortical and subcortical dysfunctions. Empirical findings in major depression need further investigation regarding their relevance as residual symptoms, as response predictors, and as risk factors for manifestation of Parkinson's disease.

[Motor behavior in depression: applications and limitations of actigraphic analyses]

OBJECTIVE

Alterations of motor behavior in depression play a key role in psychosocial activities and interpersonal communication and are relevant for differential diagnosis and treatment. Functions and application of actigraphy and empirical findings in depression will be summarised and discussed.

METHODS

The current knowledge retrieved from information of manufacturers, Medline, PsycLIT, and PSYNDEX regarding features of actigraphic equipment and clinical aspects of gross motor analysis in depression was examined.

RESULTS

Actigraphy is a practical method to monitor and quantify gross motor activity, but setting variables including sensitivity or epoch length vary among commercially available instruments. Measures of motor activity in depressed patients are used for diagnosis, evaluation of sleep, and prediction of treatment response.

CONCLUSIONS

Measurements of motor behavior by actigraphy can be used in depression for diagnostic procedures and treatment evaluation. The role of actigraphic setting variables needs further clarification. Actigraphy may be used for behavioral analysis including individual regulation of motor activity as an objective parameter for evaluation of depression and other psychiatric disorders.

Comorbid anxiety and affective disorder in alcohol-dependent patients seeking treatment: the first Multicentre Study in Germany

The goals of this study were to describe demographic variables, drinking history, and the 6-month prevalence of Axis I comorbidity among alcohol-dependent subjects in GERMANY: The variables: amount of alcohol consumption, age at onset of the first alcohol consumed, age at onset of daily alcohol consumption, age at onset of withdrawal symptoms and number of detoxifications were related to the different comorbid disorders and gender. In this study, 556 patients from 25 alcohol treatment centres were enrolled between 1 January 1999 and 30 April 1999. After a minimum of 10 days of sobriety patients who fulfilled ICD-10 and DSM-IV criteria of alcohol dependence were interviewed for data collection using the Mini-DIPS (German version of the Anxiety Disorders Interview Schedule) and a standardized psychosocial interview. The 6-month prevalence of comorbid Axis I disorders was 53.1%. Among the patients with comorbidity, affective and anxiety disorders were most frequent. Comorbid stress disorder was associated with an early start of drinking, an early beginning of withdrawal symptoms, highest number of detoxifications, and the highest amount of alcohol consumed. Female patients with anxiety disorder consumed more alcohol and started earlier than females without this comorbid disorder. The data do not answer the question of the pathogenesis of comorbid disorders and alcoholism, but indicate that stress disorders in alcoholic patients and anxiety disorders in female alcoholics influence the course and severity of alcoholism.

[Disordered behavioral control in psychiatric illnesses. Neurophysiological aspects of impulsive behavior]

OBJECTIVE

Dysfunction of behavioral control represents a central component of many psychiatric disorders and may be connected with self-mutilating and antisocial behavior. However, only a few studies have investigated objective assessment and quantification of impulsive behavior, which is relevant for psychiatric practice and research. Because new techniques enable objective assessment of behavior generation and execution, the current knowledge about neurophysiological aspects of behavioral control is summarized.

METHOD

The contemporary literature on neuronal mechanisms of initiation and execution of behavior and movements and new neurophysiological methods and findings are discussed in respect to their application in psychiatry.

RESULTS

Behavior, defined as movements of a body in time and space, is the result of cortical and subcortical processes. These consist of two general components: (1) perception and selection of a stimulus and (2) execution of a movement, including decision and planning phases. Planning and execution, modulated by cognition and emotions, are dependent on the balance of inhibitory and excitatory aspects of behavior control. Combined detection of electrical brain activity and kinematic analysis of peripheral movements enables the analysis of control mechanisms.

CONCLUSION

Impulsiveness and inhibition of behavior depend on neuronal control mechanisms which can be analyzed by neurophysiological methods. Objective assessment of impulsive behavior related to psychiatric disturbances including eating disorders, substance abuse, and personality disorders may clarify underlying neurobiological mechanisms and enable rational pharmaco- and psychotherapeutic interventions.

Amitriptyline enhances the central component of physiological tremor

OBJECTIVES

Postural tremor is a regularly encountered side effect of amitriptyline which can be strong enough to cause discontinuation of therapy. The aim was to characterise amitriptyline induced tremor and to assess if the central or reflex component of physiological tremor was modulated by this drug.

METHODS

The postural hand tremor was measured in 15 patients on a clinical rating scale, by power spectral analysis of accelerometer, forearm flexor, and extensor EMG before and after the beginning of amitriptyline treatment for major depression or chronic pain syndrome. A coherence analysis between flexor and extensor muscles on the same side was performed.

RESULTS

There was a clinically visible increase in postural tremor in a third of these patients. The tremor amplitude measured by accelerometer total power increased in every patient under amitriptyline. The EMG synchronisation as reflected by significant peaks in the flexor or extensor spectrum generally occurring at higher frequencies (8-18 Hz) than the accelerometric tremor frequencies (6-11 Hz) did not change. The number of patients with a significant flexor-extensor coherence in the 7-15 Hz range increased significantly under amitriptyline, the frequency bands of significant coherence corresponded with the EMG frequencies, and both were independent of changes to the hand's resonant frequency by added inertia.

CONCLUSIONS

An enhancement of postural tremor under amitriptyline is a common phenomenon although not always clinically apparent. The increase in EMG-EMG coherence indicates an increased common central drive to the motor units as its frequency is not influenced by peripheral resonance or reflex mechanisms. This is the first account of a drug induced enhancement of the central component of physiological tremor.

Spatiotemporal gait patterns during over ground locomotion in major depression compared with healthy controls

Alterations of locomotion are frequent, observable features of patients suffering from depression and have been investigated in these patients by actigraphy, cinematography and ground reaction forces. However, spatiotemporal parameters and neurophysiological mechanisms of gait have not yet been studied in depth in depression. The relationship between spatial and temporal parameters may yield insight into the pathophysiology of altered movements in depression. Therefore, gait patterns were quantitatively assessed and analysed in depressed subjects (n=16) and compared to matched healthy controls. Spatiotemporal gait parameters were measured during over ground walking at self-selected walking speed on a walkway previously validated in healthy subjects and used for orthopaedic and neurological patients. Compared to controls, depressed patients showed significantly lower gait velocity (p<0.001), reduced stride length (p<0.005), double limb support (p<0.005) and cycle duration (p<0.005). There was a significant correlation between cadence and gait velocity in depressed patients (r=0.51, p<0.05), but not in healthy controls (r=0.11, p>0.05). In patients with major depression, reduced gait velocity was associated with stride hypometria and increased cycle duration. Velocity was associated with cadence in depressed patients but not in healthy controls. The results may indicate possible deficiencies in the motor control system in depression. These first results about alterations of spatiotemporal gait patterns in depression warrant further longitudinal and experimental studies.

Segmentation of behavior and time structure of movements in depressed patients

Psychomotor alterations are fundamental psychopathological features of major depression and observable components of behavior. Human behavior is segmented into action units with a duration of a few seconds. Cognitive and emotional dysfunctions in depression may affect the time structure of movements. Therefore, upper limb movements (total n = 707) of depressed patients and matched healtyh controls were studied using videotaped interviews and frame-by-frame analysis with an accuracy of 40 ms. Both groups displayed a similar temporal distribution, but nonrepetitive action units were significantly shorter (median = 1.16 s) and repetitive units longer (median = 4.92 s) in depressed patients compared to controls (median = 1.93 and 3.01, respectively). Movement alterations were related to anhedonia and subjective severity of depression. Altered time structure of movements represents an observable psychopathological sign and may be relevant for pathophysiological and behavioral aspects in depression.

Timing of movements in depressed patients and healthy controls

BACKGROUND

Psychomotor disturbances are fundamental psychopathological features of major depression and observable components of behaviour. Human behaviour is segmented into action units with duration of a few seconds due to central nervous motor processing. Timing may depend on cognitive and emotional functions which are affected in depression. Therefore, time structure of action units in depressed patients was compared to healthy controls.

METHODS

Included were patients with major depression and melancholic features. Upper limb movements (total n = 566) of depressed patients and matched controls were evaluated using videotaped interviews and frame-by-frame analysis with a temporal resolution of 40 ms.

RESULTS

Behaviour of depressed patients in interview sessions was organised in action units with a narrow time span of only a few seconds. Single, non-repetitive action units were significantly shorter (median = 1.20 s) and repetitive units longer (median = 4.92 s) in patients compared to controls (median = 2.08 and 2.96, respectively).

LIMITATIONS

Behaviour in interview sessions might differ from activities of daily living.

DISCUSSION

Altered temporal segmentation of movements appears to be an observable, measurable sign of melancholic depression and may allow further insights in pathophysiological dysfunctions of the disease. Clinical implications of these motor changes for differential diagnosis, course and treatment of depression are discussed and need further evaluation.

[Motor signs of depression]

OBJECTIVE

Alterations of motor phenomena are observable clinical phenomena of depressed patients. In addition to cognitive and emotional disturbances, motor dysfunctions are frequent psychopathological features which relate to neurobiological mechanisms of depression. Specific functions of various motor domains, pathophysiological concepts, and relevance of motor functions for diagnosis and prognosis of depression are summarized.

METHODS

The contemporary literature regarding clinical and research aspects of differential diagnosis, treatment response and pathophysiology as well as the current knowledge regarding objective measures of motor signs in depression are reviewed.

RESULTS

Alterations in motility (gross motor activity), locomotion, gestures, mimic, speech characteristics, and tremor are relevant for diagnosis, therapy and prognosis of depression. A large body of literature exists regarding qualitative, indirect measures of motor phenomena and quantitative analysis of motility. Only few unidimensional studies exist in respect to locomotion, gait and tremor in depression. The low correlation between physiological and clinical features may be due to methodological issues. Whereas most publications investigate motor functions indirectly using different functional coding and classification systems, only few studies report direct, physical, characteristics (kinematics) of motor phenomena in depression.

CONCLUSIONS

Existing concepts do not clarify the relation of psychological and somatic components of motor signs. Agitation and retardation should be analyzed as multidimensional and independent variables. New psychometric instruments for documentation of motor phenomena in depression need further evaluation. Application of current technology and quantitative movement analysis may yield further insights in pathophysiological mechanisms and therapeutic strategies and represent important aspects of neurobiological research of depression.

Temporal segmentation of human short-term behavior in everyday activities and interview sessions

Human behavior is structured by serial order and timing of functionally related groups of movements with a duration of a few seconds. These elementary action units have been described in ethological studies during unstaged everyday behavior, but not during interview sessions. Psychomotor alterations are relevant for differential diagnosis and treatment, and psychiatric patients are generally evaluated during interview sessions. Therefore the time structure of upper limb movements (n = 764) of healthy subjects (n = 22) were studied using videotaped interviews and frame-by-frame analysis and compared to movements (n = 530) of unstaged human everyday behavior (n = 154). The number of action units, but not their duration, was correlated inversely with self-reported impairment of mood and pleasure experience in healthy persons. The temporal distribution of movements in interview sessions did not differ from the time patterns of everyday behavior. This method could be a promising tool to investigate time patterns of movements and psychomotor alterations in psychiatric patients during interview sessions.

Motor activity and perception of sleep in depressed patients

Subjectively experienced sleep patterns often differ from observed sleeping behavior in insomniacs. Sleep patterns have been evaluated by measurements of motor activity in healthy subjects and insomniacs, but results may depend on the insomnia subtype. Sleep disturbances are frequent complaints in depression, but the influence of psychopathology on activity measurements remains elusive. Therefore, the relationship between reported sleep complaints and motor activity was studied in patients with major depression. Severity of depression was documented in depressed inpatients by observer-(HAMD) and self-rated scales (DACL, SHAPS-D). Self-reports of sleep were obtained by Pittsburgh Sleep Quality Index (PSQI) and daily sleep logs (DSL). Motor activity was continuously recorded over 72 h by actigraphy. 'Good' sleepers showed less motor activity during the night compared to 'poor' sleepers (p<0.01). Patients with high HAMD scores (> or = 18) showed greater nocturnal motor activity and less sleep quality compared to patients with low HAMD scores (p<0.01). When controlling for age and severity of depression, partial correlation was found to be significant between perceived daily sleep quality and nocturnal motor activity (r = -0.63, p<0.01). There was a significant effect of nocturnal motor activity as a covariate on disturbances of subjective sleep quality and severity of depression as the main effect (p<0.01). In depressed patients, nocturnal motor activity seems to be an indicator of experienced sleep disturbances. The results warrant further controlled studies to evaluate the role of psychological factors for objective measurements and subjective perception of sleep patterns.

Psychomotor retardation and anhedonia in depression

Anhedonia, the inability to experience pleasure, and observed changes in psychomotor performance are frequent psychopathological phenomena in major depression with possible common neurobiological mechanisms. Interest, pleasure and reactivity to pleasurable stimuli contribute to movement generation and observable behaviour. Therefore the relationship between anhedonia and psychomotor retardation was studied in 48 depressed patients. Subjectively experienced anhedonia correlated with self-rated but not with observer-rated global severity of depression. There was a significant correlation between anhedonia and psychomotor retardation assessed with the Widöcher Retardation Scale. The results suggest the existence of an empirical relationship between reduced ability to experience pleasure and observable psychomotor retardation in depression. Specific measures of psychomotor phenomena may provide further insights into the relationship between observable behaviour and self-experienced symptoms in depression.

Antimicroglia antibodies in sera of Alzheimer's disease patients

BACKGROUND

Immune mechanisms seem to contribute to the degenerative process in Alzheimer's disease. Antibodies directed against animal brain tissue were found in sera of Alzheimer's patients.

METHODS

Antibodies were measured in sera of 25 Alzheimer's patients and a comparison group of 25 age- and sex-matched controls. Sera were tested for their immunological response to various brain structures of postmortem human brain tissue.

RESULTS

In 8 patients with Alzheimer's disease perinuclear antibodies directed against microglia were found in amygdala and frontal cortex. In the control group 1 subject showed antibody binding to microglia.

CONCLUSIONS

Perinuclear antibodies to microglia may play a role in tissue destruction of Alzheimer's disease. These data add to the evidence that immune mechanisms play a role in the pathophysiology of Alzheimer's disease.

[German version of the Snaith-Hamilton-Pleasure Scale (SHAPS-D). Anhedonia in schizophrenic and depressive patients]

The Snaith-Hamilton-Pleasure-Scale (SHAPS), introduced in English in 1995, assesses self-reported anhedonia in psychiatric patients. It has proven psychometric properties and advantages in applicability compared to other instruments assessing anhedonia. This study presents results of a systematic transcultural protocol translating the SHAPS into German (SHAPS-D). Quality of translation was confirmed on the one hand by bilingual reviewers with regard to equivalence in content and tone. On the other hand stable results were found in a test-retest-design crossing the English and German version with bilingual persons. SHAPS-D was obtained from schizophrenic (n = 50) and depressive (n = 33) patients and from healthy controls (n = 67). Results on applicability, internal consistency and relationship to depression, subjective quality of life, well-being as well as psychopathology indicate that the SHAPS-D is a useful and promising instrument in assessing anhedonia.

[Motor activity and subjective findings in depressive patients]

Intensity of symptoms including mood and psychomotor activity has been shown to vary according to the time of the day in a group of depressed patients. This pattern represents one diagnostic criterion for the melancholic type of depression. The variation of intensity is experienced by the patient and can be observed as a behavioral symptom. However, the relation of circadian alterations in psychomotor activity and depressed mood remains unclear. Therefore, spontaneous motor activity and experienced intensity of symptoms were measured in 21 depressed patients who showed daily variations of subjective symptoms. Patients felt significantly less active, awake, and more depressed in the morning compared to the evening. However, corresponding activity levels, which were measured by actigraphy, appeared significantly higher in the morning compared to the evening. Increased motor activity could represent the observable behavioral equivalent of self-experienced psychomotor retardation and depressed mood.

Motor activity and daily variation of symptom intensity in depressed patients

Spontaneous motor activity measured by actigraphy and subjectively experienced intensity of symptoms were investigated in 16 unipolar depressed inpatients with melancholic features. Patients felt significantly less active, awake, and more depressed in the morning compared to the evening. However, morning activity levels appeared significantly higher compared to evening levels. Diurnal variations of symptoms were reflected by actigraphically measured motor activity, which was negatively correlated with subjectively experienced symptom intensity. Increased motor activity may represent an observable, psychobiological, behavioral equivalent of self-experienced depressive symptoms in major depression with melancholic features.

[Chronic fatigue syndrome--psychiatric aspects]

Diagnosis of the chronic fatigue syndrome depends on various somatic and psychopathological symptoms. Somatic symptoms of the syndrome have been subject of an extensive body of literature. In comparison, psychiatric aspects have caught relatively less attention. Psychiatric aspects of etiological, diagnostic, and therapeutic concepts are essential for evaluation of the syndrome. Application of CDC-criteria to a well known disease does not solve the nosological problem, but may define the syndrome more accurately. In this respect, issues including psychiatric comorbidity and specificity of neuropathological symptoms are discussed. Psychological variables seem to have a high predictor value for time course and outcome of the symptoms. Etiological concepts emphasize on biological or psychosocial factors. Alterations of biological parameters including immune functions, sleep regulation, and hypothalamic-pituary-adrenocortical function have been reported. The role of cultural factors has been discussed extensively. Somatic and psychological stress may result in the same clinical syndrome via psychoimmunological mechanisms. An integrated, interdisciplinary approach to further refine diagnostic criteria, understanding of etiology and development of adequate therapeutic measures seems necessary.

Effect of carbamazepine on agitation in Alzheimer's inpatients refractory to neuroleptics

BACKGROUND

Agitation in Alzheimer's disease remains a principal problem in the clinical management of elderly patients. Neuroleptic medication appears to have modest efficacy in controlling behavioral symptoms in dementia patients. Carbamazepine has been reported to decrease agitation associated with various psychiatric disorders and to reduce neuroleptic side effects.

METHOD

In an open prospective study, the effects of carbamazepine on agitation, hostility, and uncooperativeness were investigated in 15 severely demented Alzheimer's inpatients who had failed to respond to prior treatment with neuroleptics. Depending on clinical efficacy and tolerability of carbamazepine treatment, concomitant medication with haloperidol was initiated. Severity of psychopathologic symptoms was assessed by the Brief Psychiatric Rating Scale during the study period of 4 weeks.

RESULTS

In 2 subjects, carbamazepine treatment was discontinued because of leukopenia and allergic reactions. A significant improvement in factor scores activation and hostility was observed after 4 weeks. Ten patients received concomitant medication with haloperidol.

CONCLUSION

Carbamazepine may be effective in treating agitation in severely demented Alzheimer's inpatients refractory to neuroleptic medication alone. The combination of carbamazepine and haloperidol seems to be promising in clinical management of elderly Alzheimer's patients.

[Therapeutic use of carbamazepine for treatment of agitation and affective disorders in geriatric psychiatry patients]

Symptomatic behavioral disturbances including agitation, motor restlessness, outbursts and hostility remain a major problem in clinical management of gerontopsychiatric patients. Termination of home care and subsequent hospitalisation is caused largely by behavior disturbances and not cognitive deficits. Clinical efficacy of neuroleptic treatment seems to be modest and is limited by unwanted side effects. Carbamazepine shows psychotropic effects and seems to improve limbic pathology including aggression and poor impulse control in various psychiatric disorders. Treatment with carbamazepine was evaluated in an open study design in 29 gerontopsychiatric inpatients. Carbamazepine was efficient in treating agitated behavior disturbances in dementia and other disorders. Adverse effects of the drug showed up only in a small percentage of the patients and were reversible after discontinuation of the drug. The results suggest that carbamazepine may be effective in treating agitated behavior in gerontopsychiatric patients with different disorders. It may represent a sensible alternative or complementation to other therapeutic interventions.

[Anti-cyclic manifestation of asthma bronchiale and schizophrenic psychosis]

The interaction between the central nervous system and the immune system has been focus of recent research. Whereas cyclic AMP has been described as a link between atopic and affective disorders, a possible link between atopic disorders and schizophrenia has not yet been investigated. A 33-year-old patient showed episodes of allergic-asthmatic and paranoid-catatonic symptoms which appeared in an anticyclic pattern. Biological, clinical and therapeutic aspects are discussed in respect to the interaction between immunological and psychiatric disorders. Cyclic-AMP as a second-messenger is not specific for a certain cell species and might represent a possible link for integrated communication between the nervous and the immune system.