Adelheid Czernik

Lithium versus carbamazepine in the maintenance treatment of bipolar disorders - a randomised study

In a randomised multicentre study, the prophylactic efficacy of lithium and carbamazepine was compared in 144 patients with bipolar disorder (74 vs. 70 patients; observation period: 2.5 years; lithium serum level: 0.63 +/- 0.12 mmol/l, carbamazepine dose: 621 +/- 186 mg/day). Hospitalisations, recurrences, need of psychotropic comedication and adverse effects prompting discontinuation were defined as treatment failures. Survival analyses regarding hospitalisations and recurrences showed no statistically significant differences between both drugs. Results were distinctly in favour of lithium, considering recurrences combined with comedication (P = 0.041) and/or adverse effects (P = 0.007). Whereas adverse effects prompting discontinuation were more frequent under carbamazepine (9 vs. 4, ns), lithium patients reported more often slight/moderate side effects (61% vs. 21% after 2.5 years; P = 0.0006). In completers, recurrences occurred in 28% (lithium) vs. 47% (carbamazepine) of the patients (P = 0.06). Lithium seems to be superior to carbamazepine in maintenance treatment of bipolar disorder, in particular when applying broader outcome criteria including psychotropic comedication and severe side effects.

Reliability and validity of Quality of Life assessed by the Short-Form 36 and the Modular System for Quality of Life in patients with schizophrenia and patients with depression

Reliability and validity of the Quality of Life (QoL) construct were investigated in healthy controls (N=346), patients with depression (N=114) and patients with schizophrenia (N=91) using two different QoL instruments: the Short-Form 36 (SF-36), a well-established generic instrument measuring eight dimensions; and the Modular System for Quality of Life (MSQoL), a recently developed instrument measuring seven core dimensions and four specific modules (objective data, partnership, family, occupation). The MSQoL and the SF-36 were administered at three intervals (hospital admission, discharge and 4-month follow-up). Reliability, group profiles (clinical specificity), responsiveness, discriminant validity (with regard to sociodemographic, psychopathological, clinical and state variables) and convergent validity were tested. At admission, patients with depression had the lowest QoL level, patients with schizophrenia had an intermediate level, and controls had the highest QoL level. At discharge and follow-up, the two patient groups did not differ from each other, but still had lower levels than controls. Both patient groups improved significantly in QoL from admission to discharge. This improvement was confounded by improvement in depressive symptoms, but not in positive or negative symptoms. Current mood state influenced QoL assessments in all three samples substantially. In conclusion, QoL can be measured reliably and with sufficient responsiveness by the MSQoL and the SF-36 in psychiatric and non-clinical populations, although discriminant validity with regard to depression and current mood is questionable.

Lithium vs carbamazepine in the maintenance treatment of schizoaffective disorder: a randomised study

In a randomised multicentre study, the prophylactic efficacy of lithium and carbamazepine was compared in schizoaffective disorder. A total of 90 ICD-9 schizoaffective patients were included in the maintenance phase (2.5 years). They were also diagnosed according to RDC and DSM-III-R and classified into subgroups. Mean serum levels were 0.58±0.12 mmol/l for lithium and 6.4±1.5 μg/ml for carbamazepine (mean dose 643±179 mg/d). Outcome criteria were hospitalisation, recurrence, concomitant psychotropic medication and adverse effects leading to discontinuation. There were more non-completers under carbamazepine than under lithium (p=0.02). Survival analyses demonstrated no significant differences between lithium and carbamazepine in treatment outcome. Patient’s ratings of side effects (p=0.003) and treatment satisfaction (p=0.02) favoured carbamazepine. Following the RDC criteria, patients of the schizodepressive and non-classifiable type did better under carbamazepine (p=0.055 for recurrence), whereas in the schizomanic patients equipotency of both drugs was found. Applying DSM-III-R, carbamazepine demonstrated a superiority in the patient group with more schizophrenia-like or depressive disorders (p=0.040 for recurrence), but not in patients fulfilling the DSM-III-R criteria of bipolar disorder. Lithium and carbamazepine seem to be equipotent alternatives in the maintenance treatment of broadly defined schizoaffective disorders. However, in subgroups with depressive or schizophrenia-like features and regarding its long-term tolerability carbamazepine seems to be superior.

The recruitment process for a multicenter study on the long-term prophylactic treatment of affective disorders '

The paper reports on the process of patient recruitment for a controlled clinical multicenter study on the treatment of affective disorders. Two thirds of the patients screened did not participate because prophylactic treatment was either unnecessary or not justified for medical reasons. Further, a number of patients equal to that eventually allocated to the trial refused to participate for personal, idiosyncratic reasons. In spite of this, the patients in the trial were very similar to those not participating with respect to relevant variables such as age, sex, number of and intervals between previous episodes or severity of the present episode.

DAS KONSTRUKT LEBENSQUALITAT : METAANALYTISCHE VALIDIERUNG UND DIE ENTWICKLUNG EINES MODULAREN ERHEBUNGSSYSTEMS

ZusammenfassungIn einer von der Arbeitsgruppe „Lebensqualität (LQ)” der „Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie” (AMDP) unterstützten multizentrischen Studie wird das Konstrukt Lebensqualität (LQ) anhand von acht (inter)national validierten Erhebungsinstrumenten sowie einer gesunden (n=479), einer depressiven (n=171) und einer schizophrenen (n=139) Stichprobe metaanalytisch untersucht. Neben herkömmlichen psychometrischen Kriterien liegt der methodische Schwerpunkt dabei auf einem facettenanalytischen Vorgehen. Der resultierende Fragebogen „Modulares System zur Lebensqualität” (MSLQ) besteht aus einem für alle 3 Stichproben hinreichend validen Kernmodul mit 47 Items (ein „G-Faktor” und 6 Subdimensionen) sowie 4 spezifischen Modulen (Demographie, Familie, Partnerschaft, Beruf). Für die psychopathologischen Subgruppen lassen sich keine spezifischen Module etablieren. Die validierte Struktur der subjektiv eingeschätzten Lebensqualität (in Form einer facettenanalytischen Radexkonstellation) bietet die Möglichkeit zu einer kumulativ angelegten Forschung und einer untersuchungsspezifischen Anpassung des MSLQ.SummaryThe construct Quality of Life (QoL) is investigated by metaanalysis of eight (inter)nationally validated questionnaires in a multicenter study. Data have been collected in a mentally healthy (n=479), a depressed (n=171) and a schizophrenic (n=139) sample. Conventional psychometric criteria and a facet analytical methodology have been applied. The resulting questionnaire „Modular System for Quality of Life” (MSQoL) consists of a core module with 47 items (one „G-factor” and six subdimensions), which is sufficiently valid for all three samples. Additionally, there are four specific modules (demography, family, partnership, profession). No specific modules can be identified for the psychopathological subgroups. The validated radex structure for subjective QoL offers the opportunity for a cumulative research design and for adaptations to the actual setting.

Persönlichkeit, akzentuierte Wesenszüge und Persönlichkeitsstörungen: Ein Beitrag zur dimensionalen Diagnostik von Persönlichkeitsstörungen

ZusammenfassungIm Rahmen dimensionaler Diagnostik von Persönlichkeitsstörungen (PS) werden sowohl kontinuierliche Übergänge von normalen zu pathologischen Persönlichkeitsmerkmalen (Kontinuitätshypothese) als auch eine universelle Gültigkeit basaler Persönlichkeitsdimensionen (Universalitätshypothese) angenommen. In der vorliegenden Studie wurde die Validität der von Leonhard konzipierten akzentuierten Wesenszüge (WZ) als vermittelndes Konstrukt zwischen normalen Persönlichkeitsmerkmalen (Big-Five-Faktoren) und PS anhand einer gesunden (n=166) und einer klinischen Stichprobe (n=78) untersucht. Neun empirisch und theoretisch abgeleitete Kontinua über die 3 Konstruktebenen hinweg (Big Five, WZ, PS) wurden mit Hilfe von Fragebogendaten geprüft. Obwohl sich die beiden Stichproben hoch signifikant in fast allen untersuchten Variablen unterschieden, zeigte sich eine weitgehende Ähnlichkeit hinsichtlich der (In)validität einzelner Kontinua als auch der komplexen Ähnlichkeitsstruktur aller untersuchten Variablen in ihren wechselseitigen Abhängigkeiten, die mit Hilfe multidimensionaler Skalierung analysiert wurden. Das Konzept der WZ kann in 6 von 9 getesteten Kontinua als sinnvolle Ergänzung für ein universell gültiges dimensionales Modell der Persönlichkeit(sstörungen) angesehen werden.SummaryA dimensional diagnostic system for personality disorders (PD) postulates continuous transition from normal to disordered personalities (continuity hypothesis) and universal validity of basic personality dimensions (universal hypothesis). The present study investigates the validity of Leonhards concept of attenuated personalities that define a conceptual link between normal personality dimensions and PD. Nine possible continuous transitions between three conceptual levels (Big Five personality factors, nine attenuated personality traits, nine PD) were tested by questionnaire data obtained from a mentally healthy (n=166) and a clinical sample (n=78). Both samples differed significantly in nearly all variables. However, they showed substantial similarity concerning the (in)validity of single continua and the complex structure of all variables as analyzed by multidimensional scaling. The concept of attenuated personalities could be validated for six out of nine tested continua and can be recommended for application in dimensional models of personality and personality disorders.

5-HT brain function in affective disorder: d,l-fenfluramine-induced hormone release and clinical outcome in long-term lithium/carbamazepine prophylaxis

Prolactin (PRL) and Cortisol (CORT) responses to d,l-fenfluramine (FEN) challenge (60 mg) were examined in patients with affective disorders on two occasions under euthymic conditions: drug-free before admission to prophylactic treatment and after about 9 months of medication with lithium or carbamazepine. Response to treatment was assessed by a complex algorithm using continuous ratings in outpatient clinic over a period of 2 years. In general, treatment resulted in a delayed and diminished CORT release (n.s.); subgroup analysis revealed an attenuated CORT response (P < 0.05) in responders, whereas nonresponders showed no change in CORT secretion pattern except an enhanced CORT baseline value (P < 0.05). Cross-sectional comparison of responders with nonresponders under medication yielded a trend for greater CORT stimulation in nonresponders. This result was not affected by FEN/NorFEN or lithium/carbamazepine serum levels, baseline CORT values, age, sex, diagnostic distribution, number of appointments to the outpatient clinic or duration of medication at the time of FEN test session. Before onset of prophylactic medication responders and nonresponders could not be discriminated significantly regarding stimulated hormone release, probably due to the small sample size (n = 17). CORT response to FEN was increased in drugfree unipolar patients compared to bipolar (P < 0.05) and to schizoaffective patients (P < 0.1). In accordance with its well-documented presynaptic 5-HT-agonistic action lithium medication resulted in a significantly greater increase in CORT release than carbamazepine (P < 0.05). Evaluation of PRL stimulation showed patterns of secretion quite similar to those of CORT, without reaching statistical significance in most cases. Perhaps due to methodological differences in assessing treatment response, these data do not confirm former results, which supposed an enhanced 5-HT net activity in long-term prophylactic lithium treatment. Because of high interindividual variances of hormone parameters, the FEN-test procedure is not a useful tool for the prediction of therapeutical outcome in terms of clinical routine use. Relations of stimulated hormone response as a marker of central serotoninergic activity and clinical outcome are discussed.

EEG-Veränderungen unter langjähriger Lithiumbehandlung

The effect of longstanding therapy using lithium salts compared to other psychotropic drugs in combination with lithium salts or other psychotropic drugs alone, on the human EEG is examined and compared with the literature. We found in our sample of 56 patients under lithium therapy: (1) that lithium salts – like other psychotropic drugs – evoke a significant increase in paroxysmal dysrhythmic activity and EEG abnormalities collectively; (2) that lithium salts cause an increase in rhythmical patterns and abnormalities in vigilance; and that (3) the combination of lithium salts with other psychotropic drugs leads to a significant augmentation of focal abnormalities of the left brain area and epileptic potentials, while EEG recordings without abnormalities are significantly diminished under this therapy. It results from this investigation that the risk for central decompensation in relation to the individual disposition seems to be especially high for the combination therapy.

Zur Frage des Einsamkeitserlebens Gesunder und Neurotiker

SummaryOne purpose of this study was to formulate definitions of “lone-liness”, “being alone”, and “isolation” as philosophical and sociological concepts; we made use of the relevant literature, devoting particular attention to work with an evaluative bias. The polarity profile was used to measure attitudes to loneliness. We found substantial differences in attitude between our sample of normal subjects and the sample of German subjects examined by Hofstätter in 1957: the attitudes of our normal subjects were more similar to those of the American subjects also examined by Hofstätter in 1957. This result is interpreted as an indication of adaptation to the times.The subjective experience of loneliness was also examined in 112 healthy and 56 neurotic subjects. It appeared to be possible to make a clear distinction between normal and neurotic subjects on the basis of the problems seen as inherent to loneliness in each group. Neurotic subjects suffer more deeply from loneliness and feel lonelier than normals, and this difference is highly significant; however they are less communicative and less willing to attempt new contacts.We concluded that the loneliness variables allowed the diagnosis of neurosis with 78% accuracy, which indicates that the problem of loneliness is relevant to neurosis.ZusammenfassungEine definitorische Abgrenzung der Begriffe „Einsamkeit“, „Alleinsein“ und „Vereinsamung“ unter philosophischem und soziologischem Aspekt wird anhand entsprechender Aussagen der Literatur — vor allem auch im Hinblick auf eine wertende Einstellung — versucht. In der mit dem Polaritätenprofil gemessenen wertenden Einstellung zur Einsamkeit ergeben sich bei unserem Normal-Personenkollektiv deutliche Unterschiede im Vergleich zur Einstellungsattitüdenposition des deutschen Hofstätterschen Kollektivs von 1957 einerseits bzw. eine Angleichung an die von ihm zum gleichen Zeitpunkt gemessene amerikanische Einstellung andererseits. Dieses Ergebnis wird auf dem zeitgeschichtlichen Hintergrund als Hinweis einer Anpassung an den Zeitgeist interpretiert.Des weiteren wurde nicht nur die Einstellung gegenüber der Einsamkeit, sondern auch das Einsamkeitserleben sowohl bei gesunden (112) Versuchspersonen als auch bei neurotischen (56) Versuchspersonen untersucht. Anhand der Klassifizierung der Einsamkeitsproblematik schien eine eindeutige Abgrenzung zwischen Gesunden und Neurotikem möglich. Es zeigt sich, daß Neurotiker höchst signifikant stärker unter Einsamkeit leiden und sich einsamer fühlen, jedoch weniger kommunikationswillig und kontaktfreudig sind als Gesunde.Hinsichtlich der nosologischen Zuordnung ergab sich anhand der Einsamkeitsvariablen eine diagnostische Trefferwahrscheinlichkeit von 78%, was dafür spricht, daß sich die Einsamkeitsproblematik als ein für das Ereignis Neurose relevanter Aspekt erweist.

Facettentheoretische Validierung des Konstrukts Lebensqualität bei depressiv Erkrankten

Die gesundheitsbezogene Lebensqualitatsforschung, die sich insbesondere aus dem Bedurfnis nach einem „weichen“ Therapieeffizienzkriterium motiviert, ist zur Zeit durch einen Zustand begrifflicher und empirischer Unklarheit charakterisiert, fur den das Motto der anarchistischen Erkenntnistheorie „anything goes“ (Feyerabend, 1983) eine adaquate Beschreibung liefert: Bereits nach Durchsicht weniger Standardwerke (Bowling, 1991; Walker und Rosser, 1988; Wenger et al., 1984) sowie des Programmes zum letzten „Quality of life “-Kongres in Wien (Association of European Psychiatrists, 1994) stost man auf nicht weniger als 104 Mesinstrumente, die alle in irgendeiner Weise vorgeben, Lebensqualitat (LQ) erheben zu konnen. Daruberhinaus scheint die Konzeptualisierung des Konstruktes LQ weitgehend der definitorischen Willkur eines jeden Autors uberlassen mit der Folge eines vorwiegend atheoretischen Aktivismus mit ebenso vielen in- und expliziten Modellierungen wie Operationalisierungen.