Marc Ziegenbein

Comorbidity of alcohol and substance dependence with attention-deficit/hyperactivity disorder (ADHD).

AIMS Attention-deficit/hyperactivity disorder (ADHD) is of great clinical importance not only because of its high prevalence but also due to the frequent comorbid illnesses that are connected with this disorder. Several studies were able to demonstrate that ADHD constitutes a significant risk factor for the exacerbation of habit-forming illnesses, i.e. addictions. METHODS We conducted a study on 152 adult patients with alcohol dependence (n = 91) or multiple substance addiction (n = 61) to determine whether or not these patients were affected by ADHD. For retrospective assessment of childhood ADHD, the WURS-k was used as well as the DSM-IV symptom checklist for ADHD. The CAARS was used to assess the persisting symptoms of ADHD in adults. RESULTS 20.9% (WURS-k) or 23.1% (DSM-IV diagnostic criteria) of the alcohol-dependent patients showed evidence of retrospective ADHD affliction in childhood. With the help of CAARS, ADHD was proved to be persistent in 33.3% of the adult patients. In the group of substance-addicted patients 50.8% (WURS-k) and 54.1% (DSM-IV) presented with diagnostic criteria for ADHD in childhood and 65.5% (CAARS) showed evidence of ADHD persisting in adulthood. CONCLUSIONS These results reveal that habit-forming illnesses can be associated with a high comorbidity with ADHD, expressed in the form of alcohol abuse and also in consumption of illegal drugs. The results underline the great importance of early and adequate diagnostics and therapy of ADHD for the prevention of habit-forming illnesses.

Treating dopamimetic psychosis in Parkinson's disease : Structured review and meta-analysis

Psychosis due to dopamimetic treatment is a difficult problem in patients with Parkinsons disease (PD). The aim of this structured review with meta-analysis was to evaluate which neuroleptic drugs can efficiently be used to treat drug-induced psychosis (DIP) in Parkinsons disease. Electronic databases were screened for the key words Parkinsons disease and psychosis. Only 7 trials with a satisfactory allocation concealment and data reporting were included into the study. Two trials compared low-dose clozapine versus placebo with a significantly better outcome for clozapine regarding efficacy and motor functioning. In one trial clozapine was compared against quetiapine showing equivalent efficacy and tolerability. However, in two placebo controlled trials quetiapine failed to show efficacy. In two further placebo controlled trials olanzapine did not improve psychotic symptoms and significantly caused more extrapyramidal side effects. Based on randomized trial-derived evidence which is currently available, only clozapine can be fully recommended for the treatment of DIP in PD. Olanzapine should not be used in this indication.

Aripiprazole augmentation of clozapine in treatment-resistant schizophrenia : A clinical observation

AbstractBackground: Therapeutic options for patients with treatment-resistant schizophrenia are limited, and combination treatment with atypical antipsychotic drugs is an often used strategy. We tested the hypothesis that the combination of aripiprazole and clozapine would lead to an improvement in this patient group. Methods: Eleven patients with treatment-resistant schizophrenia participated in this clinical trial and received a combination of aripiprazole and clozapine. Patients had to have remained on a stable dose of clozapine for at least 6 months in order to ensure a reasonable opportunity to respond to clozapine monotherapy. Clinical status was evaluated at baseline and at 3 months’ follow-up using the Brief Psychiatric Rating Scale (BPRS). Results: All patients completed 3 months’ combination treatment. There was a significant reduction in the mean BPRS score in seven patients (63.6%) over the 3 months of combination treatment. Augmentation with aripiprazole in clozapine-treated patients did not result in a corresponding increase in adverse effects. Use of the combination allowed a significant reduction in the daily dose of clozapine. Conclusions: Combined application of clozapine and aripiprazole is in accordance with a neurobiological rationale and appears to be safe and well tolerated without increased risk of adverse effects.

Possible criteria for inpatient psychiatric admissions: which patients are transferred from emergency services to inpatient psychiatric treatment?

BackgroundPatients with psychiatric problems often seek help and assistance in hospital emergency departments. An important task of emergency room staff is to decide whether such patients need to be admitted or whether they can be treated on an outpatient basis.MethodsPsychiatric treatments given in the Central Interdisciplinary Emergency Department (CED) at the Medical University of Hannover (MHH) in 2002 were analysed.ResultsOf a total of 2632 patients seeking psychiatric help, 51.4% were admitted for inpatient treatment. Patients with dementia syndromes were admitted more frequently than patients with other psychiatric diseases. Suicidality was often the reason for admission. Accompanied patients were less likely to be hospitalised, unless a care-order was in force. Restraining measures and acute medication also had an impact on the rate of admissions.ConclusionThe results may help psychiatrists in the emergency department to make a more effective decision regarding inpatient admission in the interest of the individual patient.

Depressive symptoms in first-and second-generation migrants: A cross-sectional study of a multi-ethnic working population

Background: Migrants in Europe may suffer from depression more often than the native-born population of the particular host country. Reports about the prevalence of depression in migrants are, however, heterogeneous and the possible causes are the subject of controversial discussion. Aims: The aims of this study are to determine the incidence of depressiveness in a large multi-ethnic working population with and without a history of migration, and to investigate possible connections with migration status and acculturation criteria. Methods: The cross-sectional study asked 7062 employees of a university hospital to complete a self-rating questionnaire concerning socio-demographic data, migration status and indicators of acculturation. Depressiveness was assessed by means of the German version of the Center of Epidemiological Studies Depression Scale (CES-D). Results: The response rate was 41.7% (N = 2932); 14.9% of the participants (n = 419) reported a history of migration, 275 (65.8%) of whom were first-generation (M1) and 143 (34.2%) second-generation (M2) migrants. According to the CES-D scores, 8.7% of non-migrants (n = 207) suffered from clinically relevant depressive symptoms, compared to 16% (n = 44) of the M1 group (OR = 2.10, 95% CI: 1.44–3.04, p < .001) and 14% (n = 20) in M2 (OR = 1.68, 95% CI: 1.01–2.79, p = .048). Taking gender into consideration revealed that only the female migrants showed a statistically significant increased rate of depressiveness (χ 2 = 16.68, p < .001). Conclusions: Our results suggest that first- and second-generation female migrants are more likely to suffer from depressiveness than non-migrant females. In this model a history of migration is shown to be an independent risk factor for depressiveness.

Psychiatric Expert Opinions on Asylum Seekers in Germany

OBJECTIVE To investigate the frequency of traumatisation, suicidality and given diagnoses in expert opinions on asylum seekers and to describe the sociodemographic characteristics of this population. METHODS The psychiatric expert opinions on asylum seekers, furnished in an 8-year-period at Hannover Medical School, were analysed retrospectively for qualitative and quantitative characteristics. RESULTS 62 psychiatric expert opinions on asylum seekers were included in this study. The asylum seekers originated from 18 different countries, mainly from Turkey and former Yugoslavia. Most expert opinions were given in secondary asylum procedures, i. e. after the initial asylum request had been rejected. The asylum seekers reported on traumatisation in 82.3 %. The most frequently reported forms of traumatisation were rape in female, and torture in male persons. According to ICD-10 or DSM-IV-R criteria posttraumatic stress disorder (PTSD) was the most frequent diagnosis (74.1 %) in this study. The second most common diagnoses were depressive disorders (ICD-10: F32.x in 33.9 % and ICD-10: F33.x in 25.9 %). Suicidal tendency was found in 56.5 % of the asylum seekers. CONCLUSIONS Cultural differences, language barriers, a heavy burden by psychological symptoms, and clinical severity are difficulties in the process of psychiatric assessment of refugees in legal asylum procedures.

Effects of methylphenidate in ADHD adults on target evaluation processing reflected by event-related potentials

Attention deficit/hyperactivity disorder (ADHD) is a widely examined disease in childhood. There is evidence that the disease responds well to medication with methylphenidate (MPH). The effect of MPH in adults with ADHD is a question that is often raised, because many adults request such therapy today. As yet, there is a lack of studies on event-related potentials (ERPs) and MPH in ADHD adults. In the present study we examined 10 adults diagnosed with ADHD, with and without MPH medication (30 mg daily), by means of ERP in a visual Go/NoGo experiment to gain information about target evaluation processing in these patients and about the effects on these attentional processes during medication with MPH. Visually, there seem to be differences in the frontal electrodes for the N2 and in the parietal electrodes for the P300. But these differences do not achieve statistical significance. There are also no statistically relevant differences for the N1 or the slow wave. MPH does not seem to have an effect on target evaluation processing, when comparing the ERPs of non-medicated and medicated ADHD adults. Especially the P3 does not appear to be modulated by medication with MPH in these ADHD adults, in contrast to findings in ADHD children.

Personality Disorders in a Cross-Cultural Perspective: Impact of Culture and Migration on Diagnosis and Etiological Aspects

The diagnosis of personality disorders is highly dependent on how a society views certain behavior. Self concept, adaptation and social context are important aspects of the cultural dimensions of personality disorders. However, the relevance and implications of the influence of sociocultural factors are seen differently. Accordingly, there are very distinct conceptional, nosological and diagnostic approaches for classifying personality dispositions and personality disorders in a cross-cultural perspective. The present paper describes the social and cultural context of migration from an European perspective. A review of the literature on mental health risk in immigrants is given, and special focus is placed on the impact of culture on the development of personality in general and on the emergence and manifestation versus prevention of personality disorders in specific. Due to globalization and migration processes clinicians and therapists are increasingly called upon to assess the level of personality functioning, not only in patients from different ethnic backgrounds, but also in traumatized refugees and migrants. Multiple social and cultural factors have an influence on each level of the diagnostic and therapeutic process. In addition to thorough background knowledge concerning trauma, migration and culture specific issues, cultural sensitivity and cultural competence are requisite for clinicians and therapists.

Self-selected intensity exercise in the treatment of major depression: A pragmatic RCT

Objective. The purpose of the study was to determine the therapeutic effect of physical exercise for patients with unipolar depression. Participants took part in an 8-week walking/running aerobic exercise program at a local sports club. Methods. Forty-six outpatients aged 18–65 years and diagnosed with mild to severe depression (ICD-10 criteria) were randomly assigned to an intervention group or wait list. Treatment as usual was continued. The Hamilton Rating Scale for Depression (HRSD-17) served as the main outcome measure. Secondary outcome measures were Beck Depression Inventory (BDI-II), Fitness Index (FI), and VO2 max as estimated by Urho Kaleka Kekkonen or UKK 2-km Walk Test. Results. Out of forty-six participants, 24% dropped out. Participants attended 58% of exercise sessions. All randomized participants were included in intention-to-treat (ITT) analysis. Analysis of covariance or ANCOVA showed a large reduction of depressive symptoms in HRSD-17 scores (Cohens d: 1.8; mean change 8.2, p < .0001). BDI-II (Cohens d: 0.50; mean change: 4.7, p = 0.09), FI scores (Cohens d: 0.27; mean change: 5.3, p = 0.08), and VO2 max did not change significantly. Conclusions. We observed a large and clinically significant change in HRSD-17 scores. Moderate changes in BDI-II scores without clinical significance and small changes in physical fitness assessments were observed.

Lorazepam-induced prolongation of the QT interval in a patient with schizoaffective disorder and complete AV block.

hospital for markedly elevated blood pressure with subsequent development of nonoliguric renal insufficiency. Upon admission, it was noted that a rash had been present for 2 to 3 weeks. The rash, described as erythematous plaques not involving the nose, was found bilaterally over the cheeks, forearms, scalp, chest, and back. The patient denied other symptoms associated with lupus erythematosus, including polyarthralgia, pleurisy, sun sensitivity, Raynaud’s phenomenon, and extremity paresthesias. There was no evidence of connective tissue disease in her past medical history. Her psychiatric history was remarkable for depression with psychosis, for which she received ziprasidone 20 mg daily for approximately 5.5 months.