Kneginja Richter

Adjunctive lithium treatment in the prevention of suicidal behaviour in depressive disorders: a randomised, placebo-controlled, 1-year trial

Objective:  Evidence based on controlled studies is still limited for treatment strategies that prevent recurrence of suicide attempts. Findings from observational as well as meta‐analytic studies strongly suggest that lithium may have suicide‐protective properties.

Vascular depression consensus report – a critical update

BackgroundVascular depression is regarded as a subtype of late-life depression characterized by a distinct clinical presentation and an association with cerebrovascular damage. Although the term is commonly used in research settings, widely accepted diagnostic criteria are lacking and vascular depression is absent from formal psychiatric manuals such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition – a fact that limits its use in clinical settings. Magnetic resonance imaging (MRI) techniques, showing a variety of cerebrovascular lesions, including extensive white matter hyperintensities, subcortical microvascular lesions, lacunes, and microinfarcts, in patients with late life depression, led to the introduction of the term “MRI-defined vascular depression”.DiscussionThis diagnosis, based on clinical and MRI findings, suggests that vascular lesions lead to depression by disruption of frontal–subcortical–limbic networks involved in mood regulation. However, despite multiple MRI approaches to shed light on the spatiotemporal structural changes associated with late life depression, the causal relationship between brain changes, related lesions, and late life depression remains controversial. While postmortem studies of elderly persons who died from suicide revealed lacunes, small vessel, and Alzheimer-related pathologies, recent autopsy data challenged the role of these lesions in the pathogenesis of vascular depression. Current data propose that the vascular depression connotation should be reserved for depressed older patients with vascular pathology and evident cerebral involvement. Based on current knowledge, the correlations between intra vitam neuroimaging findings and their postmortem validity as well as the role of peripheral markers of vascular disease in late life depression are discussed.ConclusionThe multifold pathogenesis of vascular depression as a possible subtype of late life depression needs further elucidation. There is a need for correlative clinical, intra vitam structural and functional MRI as well as postmortem MRI and neuropathological studies in order to confirm the relationship between clinical symptomatology and changes in specific brain regions related to depression. To elucidate the causal relationship between regional vascular brain changes and vascular depression, animal models could be helpful. Current treatment options include a combination of vasoactive drugs and antidepressants, but the outcomes are still unsatisfying.

Health promotion and work: prevention of shift work disorders in companies

Workplace health promotion is a strategy to improve the health and well-being of people at work. The measures aim at the personal, organisational and work environment. Shift work is one of many reasons provoking increased job stress. According to worldwide epidemiological data, up to 30% of the working population are employed in shifts. Taking into consideration that shift work causes a large number of somatic and psychiatric diseases which bear considerable negative consequences for the health status and the quality of life, it seems to be important to initiate health promotion strategies for shift workers in the companies. The results of recent studies indicate that well-scheduled und targeted health programmes can change the lifestyle of shift working employees and have an impact on the risk factors involved. One problem, though, is a considerable time lag till effects become apparent; therefore, the long-term economic effects of workplace health promotion have not been evaluated sufficiently to date. These definitely positive effects highlight the demand for trainings and workshops for people in shift work. We urgently suggest a speedy implementation of the recommended strategies by companies with shift work systems. In our view, this poses a challenge to the “infant” interdisciplinary field of sleep medicine that should be solved.

Recommendations for the prevention of breast cancer in shift workers

The functioning of the human body is regulated by the rhythmical change between rest and activity. The SCN (suprachiasmatic nucleus) is responsible for the central control of the biorhythm and the genetic prediction of the individual chronotype, whereas peripheral time cues such as light, social contacts and times of meals modulate the rhythmical activity of the body. Shift workers suffer from a disruption of the sleep-wake rhythm, insomnia and a lack of melatonin. These factors might trigger the development of breast cancer in female shift workers. The growing amount of data which indicate the high risk of breast cancer in female shift workers demonstrates the need for the implementation of prevention strategies against insomnia in shift workers. These strategies include regular sleep education courses on the prevention of sleep disorders in companies. The individual chronotype could be an important predictor for the adaptability to shift work.

Suicide prevention by lithium SUPLI--challenges of a multi-center prospective study.

Abstract Several studies have shown that there is a significantly increased risk of suicide related mortality in patients with a positive history of suicide attempts. The SUPLI-Study is the first prospective, randomized, double blind, placebo controlled multi-center trial focusing on the proposed suicide preventive effects of lithium in patients with suicidal behavior but not suffering from bipolar disorder or recurrent major depressive disorder. Patients with a recent history of a suicide attempt are treated with lithium versus placebo during a 12 month period. The hypothesis is that lithium treatment will lead to a 50% reduction of suicidal behavior. The protocol of the study and preliminary results are presented.

Adjunctive lithium treatment in the prevention of suicidal behavior in patients with depression and comorbid personality disorders.

Abstract Objective. Patients with both major depression and personality disorders have a high risk of suicidal behavior. Lithium is meant to have anti-suicidal properties in patients with affective disorders. The anti-suicidal effect of lithium in patients with affective disorders and comorbid personality disorders has not been investigated yet. Methods. A post-hoc analysis of a subsample of patients with depression and comorbid personality disorder (PD) and a recent suicide attempt (n = 19) from the prospective, placebo-controlled lithium intervention study (N = 167), was conducted. Results. Three patients in the lithium group (n = 8) and two patients in the placebo group (n = 11) presented a suicide attempt throughout the course of the study. No differences related to suicidal behavior could be detected between the placebo group and the group with lithium intervention. Conclusions. On the basis of the small sample size, among patients with comorbid PD, lithium does not seem to have an effect on suicidal behavior in contrast to patients with affective disorders without comorbid PD.

Two in a bed: The influence of couple sleeping and chronotypes on relationship and sleep. An overview

ABSTRACT Objective: To summarize research on couple sleeping with respect to gender-specific differences and chronotype. Methods: Systematic review of the literature. Results: Millions of adults around the world share their beds with a partner. This may be an expression of intimacy and attachment and tends to intensify romantic relationships. Yet, couple sleeping still has underestimated implications for the quality of the relationship, quality of sleep and for physical and psychological health which are not consistently positive. Implications for research and therapy are discussed. Conclusions: Despite the people involved perhaps not even being aware of their nocturnal interactions, it is important that sleeping together becomes a subject of discussion. Abbreviations: REM: rapid eye movement; QOL: quality of life; OSA: obstructive sleep apnea; CPAP: continuous positive airway pressure

Schlafmedizinische Differenzialdiagnostik in Psychiatrie und Psychotherapie

ZusammenfassungKlagen über einen gestörten Schlaf oder erhöhte Tagesmüdigkeit gehören zu den häufigsten Beschwerden, die Patienten gegenüber ihrem Psychiater und Psychotherapeuten beklagen. Solche Beschwerden können Symptom einer psychiatrischen Störung sein, aber auch hinweisend auf andere oder zusätzliche Erkrankungen. Deshalb sind Grundkenntnisse in der schlafmedizinischen Differenzialdiagnostik von erheblicher klinischer Bedeutung für Psychiater und Psychotherapeuten. In der vorliegenden Übersicht wird nach einer Darstellung der diagnostischen Methoden das differenzialdiagnostische Vorgehen orientiert an den klassischen Leitsymptomen, nämlich Ein- und Durchschlafstörungen, gestörte nächtliche Motorik und erhöhte Tagesmüdigkeit, dargestellt.SummaryComplaints about disturbed sleep or increased daytime sleepiness are among the most frequent symptoms reported to psychiatrists by patients. Such complaints can be symptoms of an underlying psychiatric disorder or indicative of a separate or comorbid sleep disorder. Hence, basic knowledge in the differential diagnosis of sleep medicine pathologies is pivotal for psychiatrists and psychotherapists. In the present overview following a description of the diagnostic methods, the diagnostic work-up according to the major symptomatic clusters, namely disturbances in initiating and maintaining sleep, abnormal nocturnal movements and excessive daytime sleepiness will be presented.

Near-death experiences, attacks by family members, and absence of health care in their home countries affect the quality of life of refugee women in Germany: a multi-region, cross-sectional, gender-sensitive study

BackgroundThe year 2016 has marked the highest number of displaced people worldwide on record. A large number of these refugees are women, yet little is known about their specific situation and the hurdles they have to face during their journey. Herein, we investigated whether sociodemographic characteristics and traumatic experiences in the home country and during the flight affected the quality of life of refugee women arriving in Germany in 2015–2016.MethodsSix hundred sixty-three women from six countries (Afghanistan, Syria, Iran, Iraq, Somalia, and Eritrea) living in shared reception facilities in five distinct German regions were interviewed by native speakers using a structured questionnaire. Sociodemographic data and information about reasons for fleeing, traumatic experiences, symptoms, quality of life, and expectations towards their future were elicited. All information was stored in a central database in Berlin. Descriptive analyses, correlations, and multivariate analyses were performed.ResultsThe most frequent reasons cited for fleeing were war, terror, and threat to one’s life or the life of a family member. Eighty-seven percent of women resorted to smugglers to make the journey to Europe, and this significantly correlated to residence in a war zone (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.4–4.6, p = 0.003) and homelessness prior to fleeing (OR = 2.1, 95% CI = 1–4.3, p = 0.04). Overall the described quality of life by the women was moderate (overall mean = 3.23, range of 1–5) and slightly worse than that of European populations (overall mean = 3.68, p < 0.0001). The main reasons correlating with lower quality of life were older age, having had a near-death experience, having been attacked by a family member, and absence of health care in case of illness.ConclusionsRefugee women experience multiple traumatic experiences before and/or during their journey, some of which are gender-specific. These experiences affect the quality of life in their current country of residence and might impact their integration. We encourage the early investigation of these traumatic experiences to rapidly identify women at higher risk and to improve health care for somatic and mental illness.

Management of Chronic Tinnitus and Insomnia with Repetitive Transcranial Magnetic Stimulation and Cognitive Behavioral Therapy – a Combined Approach

It has been estimated that up to 80% of people will experience symptoms of tinnitus over the courses of their lives, with rates of comorbid sleeping problems ranging from 50 to 77%. Because of a potential connection between tinnitus and sleep disorders as well as high rates of comorbid psychiatric disorders, interdisciplinary approaches to treatment seem to be the most efficient option. In this study, we present the case of a 53-year-old male patient, who started to experience symptoms of tinnitus at the age of 49, most likely caused by work-related stress. Over the course of his illness, the patient developed comorbid insomnia. He consulted us for treatment of both conditions and we developed a treatment plan with ten sessions of repetitive transcranial magnetic stimulation (rTMS) followed by 10 sessions of cognitive behavioral therapy (CBT). We used the Tinnitus Fragebogen (TF) to assess the severity of the tinnitus, the Beck Depression Inventory (BDI-II) for depressive symptoms, and the WHO Well-being Index (WHO-5) for subjective well-being. Improvements could be achieved with regard to both diagnoses and the patient went from severe (48) to clinically negligible (12) TF scores, from minimal (BDI-II score 10) to no (0) depressive symptoms, and from just above critical (WHO-5 percentile 52) to above average (84) well-being. The combination of technological and psychological approaches to treat tinnitus and insomnia thus proved successful in this case. One may therefore conclude that rTMS may be considered an effective first therapeutic step for tinnitus treatment prior to CBT. To our knowledge this is the first published case in which rTMS and CBT were combined for tinnitus therapy. The approach proved successful since it led to a considerable increase in well-being and everyday functioning. To gauge the effect on a more general level, large-scale studies are still needed to cancel out potential placebo effects. Likewise, the importance of the order of the two treatments, and the possibility of using other therapies in combination with CBT to address certain tinnitus subtypes and different etiologies must be studied in greater detail.