Artemios Pehlivanidis

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD

BackgroundAttention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.MethodsThe European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.ResultsBesides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?ConclusionsADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Using the Autism Diagnostic Interview-Revised and the Autism Diagnostic Observation Schedule-Generic for the Diagnosis of Autism Spectrum Disorders in a Greek Sample with a Wide Range of Intellectual Abilities

We studied the interrelationship between the Autism Diagnostic Observation Schedule-Generic (ADOS-G), the Autism Diagnostic Interview-Revised (ADI-R) and DSM-IV clinical diagnosis, in a Greek sample of 77 children and adolescents, referred for the assessment of a possible pervasive developmental disorder (PDD) and presenting a wide range of cognitive abilities. The agreement of the ADOS-G and the ADI-R with the clinical diagnosis was estimated as satisfactory and moderate, respectively, while both instruments presented with excellent sensitivity for the diagnosis of autistic disorder along with satisfactory specificity. ADOS-G/ADI-R agreement was estimated as fair. Our results confirm the discriminant validity of ADI-R and ADOS-G in diagnosing pervasive developmental disorders in children and adolescents with a wide range of intellectual abilities.

Schema therapy for patients with chronic depression: a single case series study

BACKGROUND AND OBJECTIVES This study tested the effectiveness of schema therapy (ST) for patients with chronic depression. METHODS Twelve patients with a diagnosis of chronic depression participated. The treatment protocol consisted of 60 sessions, with the first 55 sessions offered weekly and the last five sessions on a biweekly basis. A single case series A-B-C design, with 6 months follow-up was used. Baseline (A) was a wait period of 8 weeks. Baseline was followed by introduction to ST and bonding to therapist (phase B) with individually tailored length of 12-16 sessions, after which further ST was provided (phase C) up to 60 sessions (included the sessions given as introduction). Patients were assessed with Hamilton Rating Scale for Depression three times during baseline, at the end of phase B, then every 12 weeks until the end of treatment and at 6 months follow-up. Secondary outcome measures were the Hamilton Rating Scale for Anxiety and the Young Schema Questionnaire. RESULTS At the end of treatment 7 patients (approximately 60%) remitted or satisfactorily responded. The mean HRSD dropped from 21.07 during baseline to 9.40 at post-treatment and 10.75 at follow-up. The effects were large and the gains of treatment were maintained at 6-month follow-up. Only one patient dropped out for reasons not related to treatment. LIMITATIONS The lack of control group, the small sample and the lack of a multiple baseline case series. CONCLUSIONS This preliminary study supports the use of ST as an effective treatment for chronic depression.

Efficacy of antidepressants in child and adolescent depression: a meta-analytic study

Summary.Objectives: To examine whether antidepressant drugs are superior to placebo in the treatment of juvenile depression. Method: Extensive literature search was done to retrieve all randomised controlled and all uncontrolled trials describing children and adolescents with a diagnosis of depression who underwent any antidepressant drug treatment. In order to combine results, separate analyses using random effect models were conducted first for controlled and then for both controlled and open studies. Results: 18 controlled and 23 open trials were submitted to meta-analysis. Tricyclics showed no significant benefit over placebo. Odds ratios for SSRIs were 1.84 (95% CI 1.35–2.50) for controlled and 1.83 (95% CI 1.40–2.40) for controlled and uncontrolled studies suggesting a significant benefit over placebo. Combining all antidepressants also gave confidence interval excluding the value one. Conclusions: Despite some promising data concerning the use of SSRIs in the treatment of adolescent depression, caution is warranted until the long-term safety of these agents can be demonstrated. Insufficient data are available to judge even the short term merits of these agents in prepubertal children. There is no evidence to support the use of tricyclics in this population.

A survey of the attitudes of Greek medical students toward electroconvulsive therapy

Data on attitudes toward electroconvulsive therapy have been reported from various countries; no information, however, is available from Greece. In this survey, we report the results of a questionnaire reflecting the general attitude of Greek medical students toward ECT. A total of 161 sixth (final)-year medical students who had no previous exposure to a formal didactic experience on ECT, were asked to complete a questionnaire before attending a scheduled 90-minute lecture on ECT, as part of their regular curriculum. Questions in the questionnaire could be grouped to indicate a positive, a reserved, or a negative attitude toward ECT. Overall, before the lecture, 50.3% held a positive attitude toward ECT, 43.5% were reserved, and 6.2% held a negative attitude. A subgroup of these students (n = 137) were asked again to score the same questionnaire immediately following the lecture to rate the impact of the didactic seminar. The proportion of students with a positive attitude after the lecture was increased to 78.1%, (P < 0.001), while the proportion of students with reserved and negative attitudes were reduced to 20.4% (P < 0.001) and 1.5%, respectively. These encouraging findings reflect, however, only the immediate effects of the lecture and do not guarantee persistence of this change in attitudes over time.

Effects of TRH administration on orientation time and recall after ECT

Summary We investigated the effect of thyrotropin-releasing hormone (TRH) on orientation time and recall, in nine depressed female inpatients undergoing electroconvulsive therapy (ECT). In a balanced order crossover design, an intravenous bolus of 0.4 mg TRH or placebo was administered 20 min before ECT in the first two sessions. Orientation time and retrograde and anterograde components of the memory dysfunction, immediately and 24 h later, were assessed. Administration of TRH did not influence orientation time, word recall, or immediate short story recall compared with placebo. We did find, however, an improvement in the number of short story items recalled after 24 h when patients were given TRH compared with placebo. This indicates that TRH may have a protective role against the specific negative effect of ECT on delayed recall.

Amisulpride monotherapy in a patient with clozapine-resistant schizophrenia.

To the Editor: C lozapine is most often the drug of choice for patients with treatmentresistant schizophrenia. In clozapineresistant patients, polypharmacy is widely used, although no firm evidence exists for any effective augmentation strategy. In the following case, we describe the satisfactory response to amisulpride monotherapy of a patientwith long-lasting clozapine-resistant schizophrenia. Mr A, a 34-year-old patient, has had disorganized schizophrenia since the age of 14 years, and he has been hospitalized 15 times. Because of his history of unresponsiveness to various antipsychotics (both typical and atypical) and to the combination with antidepressants and antiepileptics, he was administered clozapine. Clozapine was administered at an adequate dose (500 mg/d) and with good compliance, for a period of 4 years. Clozapine has been efficacious for the positive schizophrenia symptoms, but negative symptoms were intensified, and the patient’s overall functioning deteriorated. During his last hospitalization, the patient experienced a monthlong exacerbation of psychotic symptoms, characterized by extremely disorganized behavior, psychomotor agitation, delusions of persecution, auditory hallucinations, and thoughts of self-harming. Cytochrome P450 (CYP) pharmacogenetic testing indicated that the patient was a CYP 3A5 poor metabolizer and a CYP 2D6 intermediate metabolizer. Taken into consideration, the poor pharmacological history and to avoid first-pass metabolism, amisulprideVan antipsychotic whose clearance is largely due to urinary excretionV was initiated. Clozapine was gradually discontinued, and the patient was set on 1200 mg of amisulpride monotherapy. Therapeutic response to amisulpride was clinically evaluated as excellent and was further confirmed by Positive and Negative Syndrome Scale ratings that dropped from an initial measurement of 125 to 42 at discharge, a total of 3 months since admission. This significant improvement persisted during the 2-month outpatient follow-up. To our knowledge, this report is unique in the sense that clozapine in this treatment-resistant case of schizophrenia was totally replaced by amisulpride. The most acknowledged clinical practice for treating clozapine-resistant patients with schizophrenia is the enhancement of clozapine by the addition of other antipsychotics (typical, atypical, and amisulpride). The good response of this case to monotherapy with amisulpride against the background of previous unsuccessful antipsychotic treatments could be partially related to its preponderant renal metabolic route and the Batypical[ atypical properties of amisulpride. Amisulpride’s high and selective affinity for dopamine D2/D3 receptors, lack of affinity for serotonin receptors, activity against phencyclidine, and a mesolimbic preference may give amisulpride its unique properties possibly related to the excellent response that was shown in our case.