Andreas Conca

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

ObjectiveThe aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions.MethodsCombined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas.ResultsThere are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries.ConclusionsDatabases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

No benefit derived from repetitive transcranial magnetic stimulation in depression: a prospective, single centre, randomised, double blind, sham controlled “add on” trial

Repetitive transcranial magnetic stimulation (rTMS) has been reported to demonstrate slight effects in the treatment of depression. Hence, a novel bilateral versus unilateral and sham stimulation design was applied to further assess rTMS’ antidepressant effects. Forty one medication free patients with major depression, admitted to a psychiatric unit specialising in affective disorders, were consecutively randomised into 3 groups. Group A1 (n = 12) received unilateral active stimulation consisting of high frequency (hf) rTMS over the left dorsolateral prefrontal cortex (LDLPC) and subsequent sham low frequency (lf) rTMS over the right dorsolateral prefrontal cortex (RDLPC). Group A2 (n = 13) received simultaneous bilateral active stimulation consisting of hf-rTMS over the LDLPC and lf-rTMS over the RDLPC. Group C (n = 13) received bilateral sham stimulation. Stimulation was performed on 10 consecutive workdays. All patients received antidepressant medication on the first day of stimulation, which was continued during and after the stimulation period. As no significant difference in antidepressant outcome between group A1 and A2 was found, the two groups were pooled. The time course of the outcome variables Hamilton depression rating scale (HDRS21) and Beck depression inventory (days 0, 7, 14, 28) by repeated measures analysis of variance revealed no significant group differences (in terms of a group by time interaction), whereas there was a significant effect of time on all three outcome variables in all groups. The results suggest that rTMS as an “add on” strategy, applied in a unilateral and a bilateral stimulation paradigm, does not exert an additional antidepressant effect.

Transcranial magnetic stimulation : A novel antidepressive strategy ?

Transcranial magnetic stimulation (TMS) is a well-established diagnostic probe in neurological practice. The increasing knowledge of biological mechanisms in electroconvulsive therapy presents a clear case for studying the applicability of TMS as a therapeutic tool in psychiatry. Based on the results of our pilot study showing a possible antidepressive effect of TMS, we conducted a controlled clinical trial on patients affected by major depression (DSM-III-R). Group 1 (n = 12) underwent TMS as add-on therapy to standard antidepressive medication, while group 2 (n = 12) was treated only with antidepressive medication. Already after the third add-on TMS session, a statistically significantly greater remission of depressive symptoms occurred in the patients of group 1 (p = 0.003). This statistically significant difference between the groups became even more marked on the last day of the study (p = 0.001, Wilcoxon). The results and further implications of TMS in psychiatric disorders are discussed.

Maintenance electroconvulsive therapy in affective and schizoaffective disorder

Twenty-one patients (13 depressives and 8 schizoaffectives) who underwent maintenance electroconvulsive therapy (M-ECT) were compared with controls who received maintenance pharmacotherapy alone. Measures of effectiveness and safety of maintenance treatment were prospectively obtained during a 1-year follow-up. Survival analysis demonstrated a significantly better outcome defined by time to rehospitalization for all patients of the M-ECT group. Regarding the subgroups, depressives of the M-ECT group had markedly decreased rehospitalization rates cmpared to depressive controls. Furthermore, M-ECT in depressives resulted in a significant reduction in hospitalization rates and duration during follow-up. In schizoaffective patients, a significant difference in survival time was found in favor of the M-ECT group. In both groups, schizoaffectives had a markedly poorer outcome compared to depressive subjects. Our results indicate that in selected patients M-ECT, at least in combination with supporting medication, may be an efficient and safe alternative to pharmacological continuation or maintenance therapy alone.

Effect of Chronic Repetitive Transcranial Magnetic Stimulation on Regional Cerebral Blood Flow and Regional Cerebral Glucose Uptake in Drug Treatment-Resistant Depressives

Brain imaging studies have shown that repetitive transcranial magnetic stimulation (rTMS) is biologically active. The aim of the present study was to investigate the patterns of the regional cerebral glucose uptake rate (rCMRGlu) and regional 99mTc HMPAO uptake rate (regional cerebral blood flow; rCBF) during a series of therapeutic rTMS sessions at low frequency. Four drug-resistant depressed patients underwent 10 rTMS sessions as an add-on measure over 14 days. One day before and 1 day after the TMS series, 511-keV SPECT with simultaneous 18F-fluorodeoxyglucose and 99mTc HMPAO measurements were carried out. All patients showed a good clinical outcome. Statistically significant common changes in rCBF and rCMRGlu patterns were found in the upper frontal regions bilaterally in terms of increased uptake rates and in the left orbitofrontal cortex in terms of decreased uptake rates of both isotopes compared to controls. However, the lateralization patterns of rCBF and rCMRGlu after rTMS treatment revealed marked differences. Thus, although no relevant changes in lateralization of the glucose uptake were observed, a clear right-sided preponderance of rCBF also in areas remote from the stimulation site was described. Therapeutic rTMS seems to influence distinct cortical regions, affecting rCBF and rCMRGlu in a homogeneous manner as well as in different ways, which are probably region dependent and illness related. The role of the stimulation coil placement site should be taken into account.

Sexual Dysfunction Related to Psychotropic Drugs: A Critical Review – Part I: Antidepressants

Sexual dysfunction is a potential side effect of antidepressant drugs: this article presents a critical review of the current literature. Although many studies have been published on this subject, only some have used a validated sexual function rating scale and most lacked either a baseline or placebo control or both. In addition, many of the studies on sexual dysfunction associated with antidepressants are limited by other methodological flaws. However, there is consistent evidence to suggest that antidepressant medication adversely affects one or more of the 3 phases of sexual response (desire, arousal and orgasm). Antidepressants with strong serotonergic properties have the highest rate of sexual side effects. Clinicians must be aware of drug-induced sexual dysfunction, since its presence can have important consequences on clinical management and compliance.

Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a single-centre, randomised, double-blind, sham-controlled trial in female outpatients.

Background: Bulimia nervosa (BN) is often associated with depressive symptoms and treatment with antidepressants has shown positive effects. A shared deficient serotonergic transmission was postulated for both syndromes. The left dorsolateral prefrontal cortex was argued to regulate eating behaviour and to be dysfunctional in eating disorders. Methods: Fourteen women meeting DSM-IV criteria for BN were included in a randomised placebo-controlled double-blind trial. In order to exclude patients highly responsive to placebo, all patients were first submitted to a one-week sham treatment. Randomisation was followed by 3 weeks of active treatment or sham stimulation. As the main outcome criterion we defined the change in binges and purges. Secondary outcome variables were the decrease of the Hamilton Depression Rating Scale (HDRS), the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Scale (YBOCS) over time. Results: The average number of binges per day declined significantly between baseline and the end of treatment in the two groups. There was no significant difference between sham and active stimulation in terms of purge behaviour, BDI, HDRS and YBOCS over time. Conclusion: These preliminary results indicate that repetitive transcranial magnetic stimulation (rTMS) in the treatment of BN does not exert additional benefit over placebo. A larger number of patients might clarify a further role of rTMS in the treatment of BN.

Transcranial magnetic stimulation induces 'pseudoabsence seizure'.

Objective: Several studies support the hypothesis of an antidepressive or mood‐enhancing effect of repetitive transcranial magnetic stimulation (rTMS) on depressive patients. The most acute concern regarding rTMS is possible seizure induction; therefore reports on seizure during rTMS are of special significance.

Clinical impacts of single transcranial magnetic stimulation (sTMS) as an add‐on therapy in severely depressed patients under SSRI treatment

Research on single and rapid transcranial magnetic stimulation (sTMS/rTMS) indicates an antidepressive efficacy of these methods. In our 4 week study of sTMS, 12 patients affected by severe non‐psychotic major depression (DSM‐III‐R) were enrolled and put on standardized combined antidepressant medication with the serotonin re‐uptake inhibitor citalopram, and the serotonin modulating drug, trazodone. They underwent sTMS in a specific method as an add‐on therapy. Age, gender, illness and episode duration, episode number, Hamilton Rating Depression Scale‐24 (HRDS), Mini‐Mental State (MMS), drug levels assessed by HPLC, magnesium and thyroid stimulating hormone (TSH) were recorded. For each patient functional brain imaging was performed by 18FDG and 99mTc HMPAO SPECT at the beginning of the study, as were EEG tracings which also were recorded at the end. Lorazepam was allowed as co‐medication. Of the patients, 66·7 per cent (N=8) could be identified as sTMS responders. Possible predictors for sTMS response as add‐on therapy may be duration, pattern of improvement in global and in specific single items of the HRDS, lorazepam dosage, functional involvement of basal ganglia and cortical temporal lobe and the initially lower mean frequency and lability of the alpha‐activity of EEG. These variables possibly predict the clinical outcome of depressed patients treated by sTMS as an add‐on therapy. Copyright

Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017

Authors C. Hiemke1, 2, N. Bergemann3, H. W. Clement4, A. Conca5, J. Deckert6, K. Domschke7, G. Eckermann8, K. Egberts9, M. Gerlach9, C. Greiner10, G. Gründer11, E. Haen12, U. Havemann-Reinecke13, G. Hefner14, R. Helmer15, G. Janssen16, E. Jaquenoud17, G. Laux18, T. Messer19, R. Mössner20, M. J. Müller21, M. Paulzen11, B. Pfuhlmann22, P. Riederer6, A. Saria23, B. Schoppek24, G. Schoretsanitis25, M. Schwarz26, M. Silva Gracia12, B. Stegmann12, W. Steimer27, J. C. Stingl10, M. Uhr28, S. Ulrich29, S. Unterecker6, R. Waschgler30, G. Zernig23, 31, G. Zurek32, P. Baumann33