[ECMO Therapy in a Case of Severe ARDS Related to COVID-19]

We report the case of a 60-year old female patient with advanced severe lung injury as a consequence of COVID-19-pneumonia. The patient was initially treated with highflow oxygen via nasal cannula (HFNC) and CPAP for two days but had to be intubated and mechanically ventilated. After failure of mechanical ventilation because of persistant severe hypoxemia treatment was switched to ECMO which was applicated for 24 days. Prognostic parameters indicated a favourable trend after day 14. After discontinuation of ECMO and 11 days of intermittent assisted ventilation via tracheostoma and low dose oxygen (1 l/min), the patient could be transferred to rehabilitation. The last chest radiograph prior to transferral revealed a nearly complete resolution of bilateral pulmonary infiltrates. Our case demonstrates that severe COVID-19-associated lung injury can be reversible even after prolonged ECMO.

What are depressive symptoms in acutely ill patients with schizophrenia spectrum disorder?

Background:

Aim was to examine depressive symptoms in acutely ill schizophrenia patients on a single symptom basis and to evaluate their relationship with positive, negative and general psychopathological symptoms.

Methods:

Two hundred and seventy-eight patients suffering from a schizophrenia spectrum disorder were analysed within a naturalistic study by the German Research Network on Schizophrenia. Using the Calgary Depression Scale for Schizophrenia (CDSS) depressive symptoms were examined and the Positive and Negative Syndrome Scale (PANSS) was applied to assess positive, negative and general symptoms. Correlation and factor analyses were calculated to detect the underlying structure and relationship of the patient’s symptoms.

Results:

The most prevalent depressive symptoms identified were depressed mood (80%), observed depression (62%) and hopelessness (54%). Thirty-nine percent of the patients suffered from depressive symptoms when applying the recommended cut-off of a CDSS total score of > 6 points at admission. Negligible correlations were found between depressive and positive symptoms as well as most PANSS negative and global symptoms despite items on depression, guilt and social withdrawal. The factor analysis revealed that the factor loading with the PANSS negative items accounted for most of the data variance followed by a factor with positive symptoms and three depression-associated factors.

Limitations:

The naturalistic study design does not allow a sufficient control of study results for the effect of different pharmacological treatments possibly influencing the appearance of depressive symptoms.

Conclusion:

Results suggest that depressive symptoms measured with the CDSS are a discrete symptom domain with only partial overlap with positive or negative symptoms.

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.

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.

Long-term treatment with flupentixol results of a post-marketing surveillance study

Schizophrenia is one of the most expensive illnesses. Antipsychotics are an essential component of the acute and preventative treatment of this illness, and long-term treatment is necessary to decrease the risk of psychotic relapse. The efficacy and tolerability of flupentixol was evaluated in a post-marketing surveillance study (PMS) in schizophrenic patients receiving long-term treatment in routine clinical practice. Psychiatrists in office practice treated patients for approximately 10 weeks, with a subsequent follow-up period of up to 18 months. We here report on the follow-up period in 128 patients. The benefit for schizophrenic patients increased with the treatment duration of flupentixol as documented by the Clinical Global Impression (CGI). Subjective quality of life improved during the first study period, and this remained stable in the follow-up period. No increase in body weight was observed during the study. The relapse rate was much lower than in other studies. Anticholinergic medication was necessary for 22.7% of the patients at any time. More than 70% of the psychiatrists involved evaluated the treatment as very good or good. The results of this study suggest that flupentixol is a potent and safe antipsychotic for the long-term treatment of schizophrenia in routine clinical practice.

Safety, Tolerability and Treatment Response of Flexible Doses of Paliperidone ER in Acutely Exacerbated Patients with Schizophrenia

Objective:

To explore tolerability, safety and treatment response of flexible doses of oral paliperidone ER in patients with schizophrenia suffering from an acute episode.

Methods:

Interim analysis of a 6-week prospective, open-label, international study. Endpoints were the rate of responders defined as a ≥30% improvement in the Positive and Negative Syndrome Scale (PANSS) from baseline to endpoint, the Clinical Global Impression-Severity Scale (CGI-S), weight change and adverse events (AEs).

Results:

100 patients were analyzed (51% male, mean age 39.0±11.6 years). 82% of patients completed the study. Most frequent reasons for early discontinuation were subject choice (10%) and lack of efficacy (7%). the mean dose of paliperidone ER was 5.9 mg/day at baseline and 7.9 mg/day at endpoint. an improvement of ≥30% in total PANSS was observed in 68% of patients (95% confidence interval [CI]58%;77%], with a decrease in mean total PANSS scores from 98.2±16.2 at baseline to 71.1±20.3 at endpoint (mean change -27.1±19.9; 95%CI -31.1;-23.2, p< 0.0001) and onset of efficacy as of day 2. the percentage of patients rated as at least markedly ill in CGI-S decreased from 69% to 20.3%. AEs reported in ≥5% were insomnia (14%), tachycardia (10%), akathisia (6%), extrapyramidal disorder (6%), headache (5%) and schizophrenia (5%). Median weight gain was 0.7 kg (95% CI 0.19;1.96) from baseline to endpoint.

Conclusion:

This analysis supports data from recent controlled studies that flexibly dosed paliperidone ER is safe, well tolerated and associated with a clinically meaningful treatment response in patients with an acute schizophrenic episode.

Escitalopram in Clinical Practice: Results of an Open-Label Trial in Outpatients with Depression in a Naturalistic Setting in Germany

INTRODUCTION

An open, multi-center, study was designed to address the efficacy and tolerability profile of treatment with escitalopram under naturalistic conditions in outpatients with depression.

METHODS

A total of 11,760 patients were treated with escitalopram and followed for 8 weeks. Rating scales included the Clinical Global Impression-Severity (CGI-S), the Clinical Global Impression-Improvement (CGI-I), and a short version of the Montgomery-Asberg Depression Rating Scale (svMADRS) for assessment of various clinical parameters.

RESULTS

During the course of the study, patients showed a clear pattern of improvement in their general state of health (CGI-S) and a decrease in the severity of their depression. The majority (82.8%) of patients initially received 10 mg/day escitalopram. By the end of the trial period, 32.5% of the patients were treated with 20 mg/day escitalopram compared to 64.0% receiving 10 mg/day escitalopram. After 2 weeks, 40.7% of patients were much or very much improved (CGI-I < or =2), increasing to 82.5% at the last assessment. There were no significant differences in response to treatment between women and men, with regard to treatment by specialists versus GPs, or with regard to age (< or =65 versus >65 years of age). Adverse reactions were similar to those found in controlled trials, and no new reactions were noted. The most common adverse reactions were nausea, anxiety, and vertigo.

CONCLUSIONS

This observational study corroborates the high therapeutic efficacy of escitalopram treatment, while confirming the tolerability profile, in a naturalistic treatment setting.

Initial Treatment of Severe Acute Psychosis with Fast Orally Disintegrating Risperidone Tablets

INTRODUCTION

Although the use of atypical antipsychotics is the standard of care in the maintenance treatment of psychosis, most clinicians still rely on conventional neuroleptics to treat acutely agitated psychotic patients. The objective of this study was to evaluate the effectiveness and safety of a fast orally disintegrating tablet formulation of risperidone in the initial treatment of a large sample of very acutely ill psychotic patients.

METHODS

In this multi-center, prospective, open-label observational trial, 191 schizophrenic patients were treated upon admission to hospital with fast orally disintegrating risperidone tablets for up to seven days. Co-medication was per usual clinical practice and at physician's discretion. Psychopathology was rated at baseline, 2, 24 and 48 hours and 4 and 7 days after initiation of therapy.

RESULTS

A mean PANSS total score of 114.3+/-23.4 at baseline reflected a severely exacerbated patient population. The PANSS total score was significantly reduced to 83.6+/-26.8 (p<0.0001) and the CGI from 5.6+/-0.7 to 4.5+/-1.1 (p<0.0001) after 7 days. The median time to calmness was 70 min and the associated PANSS item 4 (excitation) dropped two hours after the first intake of the study medication from 4.3+/-1.5 to 3.1+/-1.5 (p<0.0001). A total of 172 patients (90.1%) out of 191 completed the study. The median risperidone dose was 2 mg/d at the initiation of therapy and 4 mg/d after one week.

CONCLUSION

Oral treatment of acutely exacerbated schizophrenic patients with fast orally disintegrating risperidone tablets, alone or in combination with benzodiazepines, was associated with a rapid onset of action and a significant and clinically relevant improvement of acute symptoms.

[Polypharmacy in the treatment of schizophrenia]

Current standards for the pharmacological treatment of schizophrenia favour antipsychotic monotherapy. Most atypical antipsychotics developed in recent years meet the statutory requirement of being at least as effective as Haloperidol. Nevertheless, pharmacoepidemiological data show an increase in polypharmacy. The importance of the studies is underlined by the fact that 40 - 50 % of schizophrenic inpatients and up to 90 % schizophrenic outpatients receive antipsychotic combination therapies. Treatment resistance, reduction of dose-related side effects caused by antipsychotic monotherapy or the effect on concomitant symptoms of schizophrenia, such as comorbid depression, might justify combination therapy or augmentation strategies. Apart from the high costs, polypharmacy is associated with reduced patient compliance and an increased risk of undesired pharmacological effects. Since polypharmacy is increasingly common further educational measures in psychopharmacology should be getting more attention. Due to the very small number of controlled studies that exist at present this report will focus on case reports of the most frequent as well as some of the lesser prescribed combination therapies. Finally, conclusions will be discussed in relation to therapy recommendations.

[The work of medical doctors on psychiatric wards: an analysis of everyday activities]

In Germany, the economic situation of psychiatric hospitals has markedly changed during the last years. Whilst the number of patients has steadily increased, many clinics considerably reduced the number of therapeutic staff due to an increasing lack of financial support. The German psychiatry personnel regulations act defines the number of therapeutic staff required for an adequate psychiatric treatment, but the requirements of this regulations act nowadays are widely missed in most of the German psychiatric hospitals. This severely affects the therapeutic work on psychiatric wards. This study analyses tasks and activities of medical doctors on psychiatric wards and compares the hours spent with various types of activities with the amount of time that should be spent according to the personnel regulations act. Results show that doctors spend much more time with documentation and administrative work than originally intended by the personnel regulations act. They compensate this mainly by a reduction of time spent in direct contact with the patients. In this context, the number of psychotherapy sessions as well as sessions with the patients' relatives has been considerably reduced, whereas the time spent for emergency intervention and basic treatment still corresponds to the calculations according to the personnel regulations act. All in all, the results show that a reduction of therapeutic staff in psychiatric hospitals directly leads to a change in treatment settings with a focus on less individual treatment options.

[Valproic acid in prophylaxis of bipolar disorder. A case of valproate-induced encephalopathy]

A 28-year-old patient with a 5-year history of bipolar disorder developed signs of encephalopathy 2 weeks after the addition of valproic acid to his treatment regimen of doxepine, risperidone, and biperidene. The clinical signs were drowsiness, ataxic gait, asterixis, and a generalized epileptic seizure. Discontinuation of valproic acid gradually resulted in complete remission of these symptoms. Valproate encephalopathy has been described mainly in patients receiving anticonvulsant polytherapy. This complication might become more prevalent in psychiatric pharmacotherapy due to the increasing use of valproic acid.

[Combination therapies in antidepressive drug refractory depression--an overview]

Despite the availability of a wide range of effective antidepressant drugs, nearly 30% of depressed patients fail to respond to antidepressant treatment. Various pharmacological strategies have been developed to treat such refractory depression, of which augmentation therapies are one of the most important. This article reviews both benefits and risks of all known augmentation therapies. Among these treatment strategies the efficacy of lithium augmentation is very well documented by a large number of controlled studies - lithium augmentation can therefore be recommended in depression refractory to antidepressant treatment. The efficacy of triiodothyronine (T3) augmentation and the combination of different antidepressants - like a TCA-MAOI combination - is described in a large number of case reports and uncontrolled studies; the number of placebo controlled double blind studies, confirming the efficacy of these treatment strategies, is however relatively small. T3 augmentation and combined antidepressant treatment may therefore be considered in the treatment of refractory depression; in contrast to lithium augmentation these combination therapies are however only second-line strategies. Other augmentation therapies (TCA + stimulants, TCA + reserpine, TCA + yohimbine, TCA + fenfluramine, SSRI + buspirone) are very interesting clinical research strategies, but don't have too much importance in clinical practice at the moment.

[High dosage tranylcypromine treatment of "therapy refractory" depressions]

Refractory depression is a significant problem in hospital medicine especially under in-patient treatment conditions. On the basis of a case report, the importance of treatment with high-dose tranylcypromine as a useful therapeutic strategy in refractory depression is discussed.

[Perspectives on the therapy of neuropsychiatric diseases with adenosinergic substances]

The function of the neuromodulator, adenosine, has been thoroughly examined during the last two decades. Adenosine inhibits the release of several neurotransmitters and endogenous adenosine is supposed to have sedative and anticonvulsive properties. Lately, it has been discussed whether neuropsychiatric disorders could be treated with adenosynergic drugs. In patients with anxiety disorder a first clinical trial with the reuptake inhibitor dipyridamole was not successful. Disorders of the basal ganglia and schizophrenia might be positively influenced by newly developed A2-receptor ligands. A1-receptor agonists might prove to be neuroprotective; they also could be of importance in the treatment of epilepsy. Selective A1-receptor antagonists might be used in the treatment of depressive disorders and of neurodegenerative disorders such as Alzheimer's disease. The adenosine receptor antagonist, caffeine, is widely used in the treatment of migraine; more selective antagonists would provide a more powerful treatment.

[Predicting antidepressive treatment success--critical review and perspectives]

Although antidepressants have been available for over 35 years, it is not possible to accurately predict the response to this kind of treatment. This article reviews both clinical and biological predictors of treatment response. Among the clinical predictors chronicity of depression, high neuroticism and psychotic features are associated with poor response. Tricyclic antidepressants remain the drugs of choice in "endogenous" depression, whereas monoamine oxidase inhibitors play an important role in the treatment of atypical depression. Biological predictors of response, despite a lot of interesting findings that may be important for the future, are not yet sufficiently established for clinical practicability.

[Group psychotherapy in patients with panic disorder and agoraphobia]

The one-year supportive group-psychotherapy (3 groups with 8-9 patients) was carried out once-weekly by two therapists in 26 patients who met the DSM-III-R criteria for panic disorder and agoraphobia. Patients filled in various ratings at the beginning and at the end of the therapy and a visual analog scale before as well as after each session. Twelve months after the end of the group-therapy the Longitudinal Interval Follow-up Evaluation (LIFE) was carried out. During the group-psychotherapy panic sensations, anxiety, nervousness and fears as well as psychosocial disability decreased. Duration of illness affected the reduction of panic sensations, anxiety, nervousness and fears during the first 6 months of the group-psychotherapy. Phobic fears and avoidance behavior mostly improved in patients with a duration of illness of more than 5 years and an additional depressive disorder. At the one-year follow-up 80% of panic patients without depressive disorder were symptom-free and reported better partner-relationships, more satisfaction, and a better social adjustment compared with panic patients with concomitant depressive disorders.

[Monoamine oxidase inhibitors in the treatment of obsessive disorders. Two case reports and review of the literature]

Two patients who were admitted to hospital with severe obsessive compulsive disorders (OCD) improved dramatically after treatment with the MAO-Inhibitor tranylcypromine. The possibility of treating obsessive-compulsive disorders with MAO-Inhibitors and serotonergic drugs is discussed.

[Adenosine and methylxanthines in the central nervous system--on their significance for psychiatry and neurology]

In the last 15 years the central effects of adenosine and its importance for neurology and psychiatry have increasingly become an object of investigation. Physiology and metabolism of adenosine have been examined by different research groups. The effects of adenosine in the central nervous system and the various mechanisms of these effects have been described by electrophysiologic methods. The inhibition of the release of several neurotransmitters through adenosine has already been described 10 years ago. In this review studies on binding sites for adenosine receptor ligands are discussed thoroughly. The properties and the highly specific distribution of the distinct receptor subtypes are described. For the functioning of the adenosinergic system the different interactions with other centrally active substances such as benzodiazepines, barbiturates, neuroleptics, anti-depressants, opiates, alcohol and carbamazepine have turned out to be of interest. The results of neuropsychiatric investigations on methylxanthines, which are antagonists at the adenosine receptor, are widely considered. Finally the discussion on the importance of the adenosinergic system in different neurological and psychiatric diseases is summed up. The particular significance of adenosine in the modulation of dopaminergic functions is emphasised.

[Indications for therapy using MAO inhibitors]

The MAOIs have been an underutilized and overly feared class of medical compounds potentially useful for a wide spectrum of disorders. At one end of the spectrum they have been found effective for several anxiety disorders, especially when phobic or panic reactions are part of the symptoms. At the other end of the spectrum, they are effective in patients with melancholic depressions, especially outpatients who have lack of energy, a history of bipolar disorder, or a nonresponse to conventional treatment with TCAs. However, their major role for psychiatric patients appears to be in the large heterogeneous group of ambulatory depressives who have symptoms of both anxiety and depression. The danger of side effects or toxicity associated with MAOIs has been exaggerated. Most side effects are relatively mild and are controllable by dose reduction or other supportive measures. The adverse reaction of most concern, hypertensive crisis, is great extent preventable with appropriate dietary restrictions. Selective and reversible MAOI's may have a better safety profile compared to classical MAOI's.

[Therapy refractory depression--causes and treatment possibilities]

Despite the advances in the treatment of depression, 10 to 30% of all depressions remain--depending on the definition of the term--refractory to treatment. Having clarified possible causes such as wrong diagnosis, poor compliance, inadequate treatment, drug interactions and psychological factors, various treatment methods can be applied. However it is necessary to know not only the efficacy but also the side effects and contraindications of these methods.