Markku Eronen

Lamotrigine in treatment-resistant schizophrenia: A randomized placebo-controlled crossover trial

BACKGROUND There is no evidence from randomized, controlled trials that demonstrate effectiveness for any pharmacological treatment in clozapine-resistant schizophrenia. Since the introduction of chlorpromazine, all antipsychotics with proven efficacy on positive symptoms have been dopamine antagonists, but recent experimental data suggest that ketamine-induced positive schizophreniform symptoms in healthy subjects can be controlled by a glutamate antagonist lamotrigine. The hypothesis tested was that lamotrigine is more effective than placebo in the treatment of positive schizophrenic symptoms when combined with clozapine. METHODS Thirty-four hospitalized treatment-resistant patients having chronic schizophrenia participated in a double-blind, placebo-controlled, 14-week, crossover trial where 200 mg/day lamotrigine was gradually added to their ongoing clozapine treatment. Clinical assessments were made by the Positive and Negative Syndrome Scale at the beginning and end of each treatment period. RESULTS In intention-to-treat analysis, lamotrigine treatment was more effective in reducing positive (effect size.7, p =.009) and general psychopathological (effect size.6, p =.030) symptoms, whereas no improvement was observed in negative symptoms. CONCLUSIONS These results provide the first evidence from a randomized controlled trial of an effective pharmacological treatment with an anticonvulsant agent in treatment-resistant schizophrenia and indicate that both positive and general psychopathological symptoms in patients with schizophrenia can be controlled by a drug that is not a dopamine antagonist. The results are in line with previous experimental data suggesting that excessive glutamate neurotransmission contributes to the positive symptoms of schizophrenia.

The psychiatric epidemiology of violent behaviour

Abstract This paper reviews the current state of the debate on the relationship between mental disorder and violent behaviour. Starting from the discussion of methodological approaches to assessing a possible association, the most important studies carried out on the issue in recent years are discussed. Their results concur in supporting the assumption that there is a moderate but reliable association between mental disorder and violence. However, this does not imply that people with mental illness are generally more likely to commit violent acts than members of the general population. An elevated risk of violent behaviour is only evident for specific psychiatric diagnoses and symptom constellations. For schizophrenia and other psychotic disorders, a significant increase in the likelihood to commit violent acts is reported. Substance use disorders and antisocial personality disorder, however, represent a markedly higher risk for violent behaviour. The article further discusses possible determinants of violent behaviour such as psychotic symptoms and comorbidity with substance abuse and considers who is at particular risk of becoming a target of violent acts.

Increase in cerebral blood flow of right prefrontal cortex in man during orgasm

The functional anatomy of human emotional responses has remained poorly understood, mainly because invasive experiments in humans are unacceptable due to ethical reasons. The new functional imaging techniques such as positron emission tomography and single photon emission computed tomography have made it possible to study the neurophysiology of living humans noninvasively. We studied the regional cerebral blood flow with semi-quantitative 99mTc-HMPAO single photon emission computed tomography in eight healthy right-handed heterosexual males during organism. The results showed decrease of cerebral blood flow during orgasm in all other cortical areas except in right prefrontal cortex, where the cerebral blood flow increased significantly (P < 0.005).

Acute Ethanol-Induced Changes in Cerebral Blood Flow

Using high-resolution single photon emission computed tomography, the authors studied changes in cerebral blood flow (CBF) in six healthy men after the men rapidly consumed intoxicating amounts of ethanol. When the subjects were given intravenous placebo before ethanol intake, regional CBF was significantly increased over baseline in the right prefrontal cortex, but no significant change in CBF was observed when the subjects received intravenous naloxone before ethanol intake. The results indicate that euphoria occurring during acute ethanol intake is associated with activation of the right prefrontal cortex and mediated through the endogenous opioid system.

A 15-year national follow-up: legislation is not enough to reduce the use of seclusion and restraint

BackgroundSeclusion and restraint are frequent but controversial coercive measures used in psychiatric treatment. Legislative efforts have started to emerge to control the use of these measures in many countries. In the present study, the nationwide trends in the use of seclusion and restraint were investigated in Finland over a 15-year span which was characterised by legislative changes aiming to clarify and restrict the use of these measures.MethodThe data were collected during a predetermined week in 1990, 1991, 1994, 1998 and 2004, using a structured postal survey of Finnish psychiatric hospitals. The numbers of inpatients during the study weeks were obtained from the National Hospital Discharge Register.ResultsThe total number of the secluded and restrained patients declined as did the number of all inpatients during the study weeks, but the risk of being secluded or restrained remained the same over time when compared to the first study year. The duration of the restraint incidents did not change, but the duration of seclusion increased. A regional variation was found in the use of coercive measures.ConclusionLegislative changes solely cannot reduce the use of seclusion and restraint or change the prevailing treatment cultures connected with these measures. The use of seclusion and restraint should be vigilantly monitored and ethical questions should be under continuous scrutiny.

The violent female perpetrator and her victim

The aim of the present study was to examine the relationship between violent female offenders and their victims as well as the putative differences in the motives and specific psychological factors among three groups of female offenders: women who have victimised someone closely related to them, those who have victimised an acquaintance and lastly women who have victimised a stranger. More than half (N=61) of all violent female offenders hospitalised or incarcerated in Finland during the year of study were interviewed and assessed by Structured Clinical Interview II for DSM-IV (SCID-II) and Hares Psychopathy Checklist-Revised (PCL-R). In 34% of the cases the victims were persons close to the offender, in 41% the victims were acquaintances and in 25% strangers. The victims in homicide offences were more often both male and closer to the perpetrator than in assault offences. Although motives were related to interpersonal problems, self-defence and long-term physical or psychological abuse were reported by only a few women, even for the small proportion of women whose victims were intimate partners. The most frequent reason for offences stemmed from confrontational situations in connection with alcohol use. Women who victimised acquaintances and strangers were also more likely to have a history of criminality and substance abuse than women who victimised those in close personal relationships. The latter were also more likely to have an antisocial personality disorder (PD) and psychopathic characteristics. There were, however, no significant differences found between those who had experienced physical or psychological abuse in childhood or adulthood and those who had no adverse experiences. These findings suggest that the violent behaviour by females leads more often to the death of the victim, when the victim is closely related to the perpetrator. The commonly-held view that violent female offending occurs primarily as a consequence of precipitation by the victim was not supported.

The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study

Background: The containment or the prevention of actual violence is the primary justification for the use of restraint and seclusion in psychiatry. The aim of the present study was to determine the grounds for using restraint and seclusion in clinical practice in Finland, and whether these reasons have changed over a 15-year period as a result of legislative changes. Method: A structured postal survey concerning the reasons for restraint and seclusion was completed in all the Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998 and 2004. The duration of the episode as well as demographic and clinical information on the restrained and secluded patient were also reported. Results: Agitation/disorientation was the most frequent reason for the use of restraint and seclusion. The duration of the restraint and seclusion episodes was not determined by the reason for using these measures. Some differences in the reasons were found among subgroups of patients. Conclusion: Clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion, and is too open to subjective assessment and interpretations.

Neonaticides may be more preventable and heterogeneous than previously thought - neonaticides in Finland 1980-2000

SummaryNeonaticide is a sad and infrequent crime with possibly a high level of underreporting. The aim of this study was to examine the circumstances of neonaticide, and whether there are subtypes of offenders, or suggestions for prevention. The study was retrospective and register-based using comprehensive nation-wide material of all cases of suspected neonaticide during 1980–2000 in Finland. Out of the 50 suspected cases, 32 women were included in the final analyses as neonaticide offenders. Most women (91%) had concealed their pregnancy, which was not the first for 66%. Most (66%) were not quite sure why they had offended, and the most frequent (63%) method of operation was neglect. Four women were diagnosed psychotic and formed a specific group. We concluded that there might be specific subgroups of offenders – even though our small population limited conclusions. Furthermore, prevention might be heightened. We call for international joint projects for enlarged material to enable grouping, as well as education and discussion among the public and the professionals to prevent neonaticide, unify its jurisprudence and improve the treatment of the offenders.

A Comparison of General Adult and Forensic Patients with Schizophrenia Living in the Community

Schizophrenia is associated with an elevated risk for violence. The response has been to incarcerate people with schizophrenia and to increase the number of forensic beds. Most of these beds are filled by men with schizophrenic disorders with long histories of offending and of treatment in general psychiatry. Outcome from forensic, as compared to general psychiatric services, is unknown. The present study compared outcome defined as levels of positive and negative symptoms, readmission, and aggressive behavior for 248 men with schizophrenic disorders (150 discharged from forensic hospitals and 98 from general adult wards) during a two-year period after discharge from forensic and general psychiatric services. Patients were intensively assessed at discharge and four times during the subsequent two years. Illicit drug use was assessed both objectively and by self-report. More of the forensic than the general patients had failed to complete high school, had displayed a stable pattern of antisocial behavior since at least mid-adolescence, and had convictions for non-violent and violent offences. At discharge and throughout the follow-up period, general patients displayed higher levels of positive and negative symptoms than forensic patients, and more of them engaged in aggressive behavior towards others. Aggressive behavior was associated with positive symptoms and Antisocial Personality Disorder. Rates of readmission were similar for the two groups. The forensic approach that includes assessing and managing the risk of violence as well as treating symptoms of schizophrenia led to better outcome than that of general psychiatry.

Who are the restrained and secluded patients: a 15-year nationwide study

BackgroundTo find interventions for reducing the use of restraint and seclusion, it is necessary to identify who the restrained and secluded patients are. The aim of the present study was to determine which demographic and clinical groups of psychiatric inpatients are at risk of being restrained/secluded, and whether there have been changes in the restrained/secluded patients’ profiles over a 15-year period in Finland.MethodA structured postal survey concerning the demographic and clinical information of restrained/secluded patients was completed in all Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998, and 2004. The National Hospital Discharge Register was used to gather information on all psychiatric inpatients during the study weeks.ResultsOut of the variables studied (age, gender, main diagnosis, phase of hospital stay), only the main diagnosis and the phase of hospital stay were independent risk factors for restraint/seclusion, and remained constant over time. The age profile of the restrained/secluded patients was unstable over time and the risk of being restrained/secluded was not associated with gender.ConclusionRestraint and seclusion is used mainly among the acute and the most disturbed patients. Therefore, in order to reduce the use of restraint and seclusion, resources should be targeted especially to these groups.