P. M. Judith Haffmans

Bright light therapy and melatonin in motor restless behaviour in dementia: A placebo-controlled study.

The purpose of this study was to evaluate the effects of bright light therapy combined with melatonin on motor restless behaviour in dementia.

Tryptophan Depletion Affects Heart Rate Variability and Impulsivity in Remitted Depressed Patients with a History of Suicidal Ideation

BACKGROUND Depression is a major risk factor for cardiovascular disease. An important risk factor for cardiovascular disease, low heart rate variability, often has been found in depressed patients and has been associated with impulsivity. The present study investigated whether experimental lowering of serotonin would decrease heart rate variability and increase impulsivity in remitted depressed patients, in particular in those patients with disturbed impulse control. METHODS Nineteen patients in remission from depression received high-dose and low-dose acute tryptophan depletion in a randomized, counterbalanced, double-blind crossover design. Heart rate variability and impulsivity were assessed during each acute tryptophan depletion session and during a baseline session. Suicidal ideation during past depression was used as an index for individual differences in impulse control. RESULTS High-dose acute tryptophan depletion led to a larger increase in depressive symptoms than did low-dose acute tryptophan depletion. High-dose acute tryptophan depletion decreased heart rate variability and increased impulsivity and anxiety, but only in patients with a history of suicidal ideation. Symptom effects of high-dose acute tryptophan depletion correlated with low heart rate variability at baseline. CONCLUSIONS Depressed patients who have problems with controlling impulsivity might be more at risk for developing cardiovascular disease, possibly related to increased vulnerability to impaired 5-hydroxytryptamine function.

Monoamine oxidase inhibitors in resistant major depression: A double-blind comparison of brofaromine and tranylcypromine in patients resistant to tricyclic antidepressants

In a double-blind study the selective monoamine oxidase-A inhibitor brofaromine was compared with the classical MAOI tranylcypromine in 39 patients with major depression resistant to treatment with tricyclic antidepressants. Concerning efficacy no significant differences were found. Ten out of 22 patients responded to brofaromine and 5 out of 17 patients to tranylcypromine. Adverse effects favoured brofaromine. Although orthostatic hypotension occurred in both groups, severe decrease in blood pressure and dizziness occurred significantly more with tranylcypromine. Both MAOIs caused a decrease in stage 4 and REM sleep and an increase in REM latency. In most patients receiving tranylcypromine REM sleep was completely abolished.

THE EFFECTS OF SODIUM VALPROATE ON DISTURBED BEHAVIOR IN DEMENTIA

responders and nonresponders concerning the mean dose. Determination of plasma levels of sodium valproate was performed in 6 patients (4 responders; 2 nonresponders). A positive relation was found between dose and plasma levels. Remarkably, plasma levels in 3 out of 4 responders were below the therapeutic window in epilepsy. The effects of sodium valproate in the 23 patients are shown in Table 1. In 26% of the patients, the disturbed behavior was completely abolished. Response defined as a long-term reduction of the type of disturbed behavior lasting until discharge was seen in 520/0 of the patients. No differences could be found in response between the various types of dementia nor between the stages of dementia. The apparent sex difference can largely be explained by the higher incidence of physical aggressive behavior in males in this study (M = 8; F = 1). This type of behavior showed the best response with sodium valproate. The effects of sodium valproate related to the various types of disturbed behavior are presented in Table 2. Restless behavior and physically aggressive and verbally aggressive behavior showed a good response. Two types of disturbed behavior were seen in 8 men and 2 women. Six of them were full responders. Two men had 3 types of disturbed behavior. In both cases, sodium valproate was effective on all 3 types of disturbed behavior.

Hypnotics as concurrent medication in depression : a placebo-controlled, double-blind comparison of flunitrazepam and lormetazepam in patients with major depression, treated with a (tri)cyclic antidepressant

The addition of benzodiazepine hypnotics to a treatment with tricyclic antidepressants has received little systematic study. In a double-blind placebo-controlled design, the effects on mood and on sleep of two benzodiazepine hypnotics (lormetazepam and flunitrazepam) were studied in patients with major depression who were also treated with maprotiline or nortriptyline. After 4 weeks of combined treatment, lormetazepam resulted in a significantly greater decrease in the score on the Hamilton Depression Subscale than placebo, while there was a non-significant trend in favour of lormetazepam in comparison with flunitrazepam. With respect to sleep EEGs, lormetazepam resulted in a significantly greater suppression of REM sleep. The differences between lormetazepam and flunitrazepam may be partly explained by the shorter half-live of lormetazepam.

Lithium augmentation of venlafaxine : An open-label trial

The authors conducted an open-label study of the efficacy and tolerability of venlafaxine and of lithium augmentation in outpatients with depression who were not responding to venlafaxine. Outpatients aged 18 to 70 years were eligible if they had a minimum baseline score of 16 on the 17-item Hamilton Rating Scale for Depression (HAM-D). Patients were started on venlafaxine 37.5 mg twice daily for 1 week. For weeks 2 through 4, the dose of venlafaxine was increased to 75 mg twice daily, and for weeks 5 through 7, the dose was further increased to 75 mg three times daily. At the end of the 7-week treatment period, patients with a <50% decrease in their HAM-D scores from baseline were given lithium carbonate 600 mg once daily. The dose of lithium carbonate was adjusted to maintain plasma levels in the range of 0.6 to 1.0 mmol/mL. Efficacy was assessed with the 17-item HAM-D, Montgomery-Asberg Depression Rating Scale, and the Clinical Global Impressions Scale. Data were analyzed on an intent-to-treat basis. At the end of the 7-week treatment period, 35% of patients showed a > or = 50% decrease in their HAM-D scores from baseline. Lithium augmentation was initiated in 23 patients. The results showed that the addition of lithium was well-tolerated and led to a further decrease in the HAM-D scores, with eight patients responding and two of them presenting a remission. The addition of lithium to venlafaxine was found to be a well-tolerated strategy in treatment-resistant patients.

Characteristics, prevalence, risk factors, and underlying mechanism of hyponatremia in elderly patients treated with antidepressants: A cross-sectional study

OBJECTIVES The aims of this study were to describe the characteristics of hyponatremia in elderly users of antidepressants, to determine the prevalence and risk factors for hyponatremia, and to identify the underlying mechanisms. STUDY DESIGN Cross-sectional study (March 2007-April 2009) with prospectively collected data. Patients were older than 60 years, used antidepressants, and had a complete geriatric assessment. MAIN OUTCOME MEASURES Serum sodium and antidiuretic hormone levels, serum osmolality, urine sodium level, and urine osmolality were measured. The prevalence of hyponatremia (serum sodium <135 mM) as an adverse reaction to an antidepressant (AR-AD), defined with Naranjos algorithm, was calculated. Hyponatremic patients were compared to normonatremic patients with regard to gender, age, weight, history of hyponatremia, hyponatremia-associated medications and disorders, and type and duration of antidepressant use. RESULTS Of 358 eligible patients, 345 were included. The prevalence of hyponatremia as an AR-AD was 9.3%. Risk factors were a history of hyponatremia (adjusted OR 11.17, 95%CI 2.56-40.41), weight<60 kg (adjusted OR 3.47, 95%CI 1.19-10.13), and psychosis (adjusted OR 3.62, 95%CI 1.12-11.73). Non-suppressed ADH was found in a minority of hyponatremic patients. CONCLUSIONS In elderly patients, the prevalence of hyponatremia as adverse reaction to all types of antidepressants was 9%. Patients with previous hyponatremia, weight <60 kg, and psychosis were at risk. Beside SIADH, the nephrogenic syndrome of inappropriate antidiuresis, in which ADH secretion was normal, is postulated as an underlying mechanism. This has consequences for treatment of antidepressant-induced hyponatremia with vasopressin receptor antagonists.

Interpersonal and Social Rhythm Group Therapy for Patients with Bipolar Disorder

This article describes Interpersonal and Social Rhythm Therapy (IPSRT) adapted for use in a group setting for patients with bipolar disorder. In a preliminary efficacy study, we studied the pre-post group treatment effect on affective symptoms. One-year pre-post findings in the IPSRT group indicated that this modality was effective in reducing depressive symptoms and might reduce the number of hospital admissions. Also, group IPSRT increased stability of the social rhythm, which is thought to be important in reducing recurrence of manic and depressive episodes. These findings suggest that group IPSRT could be an additional treatment option for patients with bipolar disorder who continue to have mood episodes despite adequate pharmacotherapy and psychoeducation.

Is aggressive behaviour influenced by the use of a behaviour rating scale in patients in a psychogeriatric nursing home

To study the influence of the introduction of a behaviour rating scale on reported incidence and management of aggressive behaviours in patients in a psychogeriatric nursing home.

Effect of a program of diverse activities on disturbed behavior in three severely demented patients.

The effects of a daily program of various activities on disturbed behavior were studied prospectively in three patients with severe dementia. Prior to the study, patients had not responded to treatment with benzodiazepines and/or neuroleptics. The study consisted of three periods, each lasting for 4 weeks: i.e., baseline, intervention, and follow-up. During each period, behavior was assessed by means of observation scales: GIP, SDAS, and CGI. Psychotropic medication was held as constant as possible. During intervention, the patients took part in a program of activities, including group, musical, physical, and social activities. During baseline and follow-up, patients followed the regular ward activities. The patients showed different responses, probably related to personal interests. Possible implications for the treatment of patients with dementia, complicated by disturbed behavior, and suggestions for future research are discussed. The enthusiasm of the nursing staff dealing with these patients was a promising result.