Hypothalamus enlargement in mood disorders.

OBJECTIVE: The purpose of this study was to determine, in vivo, whether the hypothalamus volume is reduced in patients with mood disorders. METHODS: The cross-sectional study included 20 unmedicated (MDDu) and 20 medicated patients with major depressive disorder, 21 patients with bipolar disorder, and 23 controls. Twenty of the controls were matched to the MDDu. Seven Tesla, T1-weighted magnetic resonance images were acquired and processed using methods specifically developed for high-precision volumetry of the hypothalamus. RESULTS: An overall group difference was observed for the left hypothalamus volume corrected for intracranial volume. Planned contrasts identified that the left hypothalamus was approximately 5% larger in each patient group compared with the control group. A paired t-test with the 20 matched pairs of MDDu and controls and without correction for covariates confirmed the larger left hypothalamus volume in MDDu. CONCLUSIONS: Contrary to our expectations, the hypothalamus volume was increased in patients with uni- and bipolar affective disorders. The effect was left-sided and independent of medication status or statistical correction for covariates. Supported by emerging evidence that the stress response may be related to structural and functional asymmetry in the brain, our finding suggests a crucial role of the hypothalamus in mood disorders.

[Workload in emergency departments : A Problem for personnel and patients?] / Arbeitsbelastung in der Notaufnahme : Ein Problem für Personal und Patienten?

Apart from operating theaters, intensive care units and diagnostic services, the central emergency department is one of the areas of any hospital with a high workload, which is very susceptible to risk. The following aspects of routine daily work can lead to a great strain on the personnel working in the central emergency department: the need for quick, targeted decisions, especially for patients with life-threatening disorders, a high number of patients with insufficient available resources, dissatisfaction of patients with low treatment priority and longer waiting times and delayed inpatient admissions with long stays. Interruptions in the individual work process during activities are not uncommon but represent additional disruptive factors for employees and can lead to treatment errors. Furthermore, a workload that is permanently perceived as too high leads to psychological and physical disturbances for the team members. Suitable structural, organizational and personnel prerequisites as well as solution strategies for the central emergency department are necessary to avoid corresponding treatment errors and also as a duty of care for employees.

[Attention deficit-hyperactivity disorder (ADHD) and comorbid mental disorders : ADHD-specific self-rating scales in differential diagnostics]. / Aufmerksamkeitsdefizit­/Hyperaktivitätssyndrom (ADHS) und komorbide psychische Erkrankungen : ADHS-spezifische Selbstbeurteilungsskalen bei der Differenzialdiagnostik.

BACKGROUND: It is still unclear how well the established attention deficit-hyperactive disorder (ADHD)-specific rating scales can differentiate between ADHD symptoms and symptoms of other mental disorders. METHODS: A total of 274 patients with suspected adult ADHD were extensively examined clinically and guideline-conform in an ADHD outpatient clinic. In 190 patients the diagnosis of ADHD could be made with certainty. The patients were also subsequently assessed according to the DSM IV criteria by self-rating scales on current (ADHS-SB, ASRS, CAARS) and retrospective (WURS-K) complaints. A binary logistic regression analysis was performed in order to extract from the questionnaires, which could best distinguish the diagnosis of ADHD from other mental disorders. RESULTS: The results showed that two self-rating scales (WURS-K and ADHS-SB) were sufficient to correctly diagnose ADHD in 83% of the patients examined with a sensitivity of 94% and specificity of 56%. CONCLUSION: The ADHD-specific self-rating scales are additionally useful for the diagnostic differentiation between ADHD-specific and other psychiatric symptoms in the clinical practice and can improve the safety of the diagnosis.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]. / Internetbasierte Interventionen in der Behandlung psychischer Störungen : Überblick, Qualitätskriterien, Perspektiven.

BACKGROUND: Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available. OBJECTIVE: The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions. METHODS: A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications. RESULTS: Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders. DISCUSSION: When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

Yawning in depression: worth looking into.

Yawning often occurs during states of increased sleep propensity. Depression is associated with sleep problems and tiredness. The aim of this paper is to review the present knowledge about possible changes of yawning during an episode of major depression (MD) and to report data on yawning from an online depression forum comprising of 450,000 postings. A literature search did not reveal any study about yawning in people with MD when compared to controls. However, there is evidence for an increased frequency of yawning under the influence of antidepressants. Analysis of the depression forum postings revealed 63 people writing about increased yawning in the context of depression. However, all but one of them were treated with antidepressants; and yawning was not reported as a symptom of depression, but in most cases (N=56) as occurring as a result of treatment with antidepressants. These findings are in agreement with a tonic hyperarousal in typical depression which is reduced by all standard antidepressants. For clinicians, it would be of interest to know whether yawning is reduced in untreated depression and whether it predicts treatment outcome.

[Predictive factors of depression and its therapy]. / Prädiktive Faktoren der Depression und ihrer Therapie.

Predictive factors of for the occurrence of depressive episodes include psychosocial and biological risk factors. These factors reflect the heterogeneity and complexity of the disease. They can identify groups that would benefit from preventive measures and provide indications for suitable preventive strategies. In recent decades considerable scientific effort, for example in the field of psychiatric genetics, has been undertaken to identify predictive factors for individual antidepressant therapy response and as an aid for individual treatment decisions. However, no clinically usable conclusions could yet be drawn from the respective findings. In practice clinical factors, such as symptom cluster of the depressive disorder and specific properties of the antidepressant, individual factors and contextual factors, such as the type of treatment facility, decision support and economic aspects, are factors influencing the choice of a specific antidepressant. Early clinical improvement under antidepressant medication in the first 2 weeks of treatment is one of the best predictors for the long-term treatment outcome in patients with major depressive disorder.

[Treatment situation of long-term unemployed with psychological disorders]. / Versorgungssituation von Langzeitarbeitslosen mit psychischen Störungen.

BACKGROUND: Untreated psychiatric disorders of long-term unemployed persons represent a medical problem and a placement barrier to the labor market that can be eliminated. The objective of the study was to assess the spectrum of diagnoses and the treatment rates in a group of unemployed persons (≥ 50 years) referred by the employment exchange of the job center in Munich to a center for psychosocial coaching. METHODS: Out of 105 participants 44 (42%) showing signs of psychiatric disorders according to the patient health questionnaire (PHQ) screening were included in the evaluation. The psychiatric diagnoses were assessed by means of a fully structured diagnostic interview, the Munich composite international diagnostic interview (M-CIDI). A semi-structured interview was conducted to investigate the treatment rates and treatment compliance with guidelines. RESULTS: Affective disorders (70%) were in the foreground followed by anxiety disorders (55%, specific phobias, other and unspecified phobic anxiety disorders were excluded) and disorders due to abuse of alcohol (32%). Of the participants 61 % received no disorder-specific treatment or no treatment at all and treatment compliant with guidelines was received by 9%. CONCLUSIONS: Untreated psychiatric disorders (especially depression) or those that are not treated in compliance with guidelines represent a medical problem and a placement barrier to the labor market that can be eliminated.

Telemedicine during the COVID-19 pandemic in Germany: Results from three nationally representative surveys on use, attitudes and barriers among adults affected by depression.

Introduction: The COVID-19 pandemic has necessitated a reduction in face-to-face consultations, resulting in significant limitations in healthcare for individuals with depression. To ensure safe and adequate care, e-health services, such as telemedicine, gained a more prominent role. Governments have eased restrictions on the use of telemedicine, enabling healthcare professionals to increasingly offer video and telephone consultations. Objective: This study examines, 1) possible changes over the course of the pandemic in reported use of video and telephone consultations and intended future use of video consultations with healthcare professionals among adults with diagnosed depression; 2) their attitudes towards video and telephone consultations and perceived barriers towards using e-health after prolonged time of the pandemic; and 3) differences in results between subgroups based on sociodemographic and clinical characteristics. Methods: Three population-representative online surveys were conducted in Germany at different timepoints (t) during the COVID-19 pandemic. Respondents aged 18-69 years with a professionally diagnosed depression were included in the present analyses (t1: June/July 2020 with n = 1094; t2: February 2021 with n = 1038; t3: September 2021 with n = 1255). Results: The overall proportion of adults with depression who used video or telephone consultations did not change significantly in the time surveyed (t1: 16.51 %, n = 179; t2: 20.23 %, n = 210; t3: 18.47 %, n = 230). However, among users, reported use of video consultations with a psychotherapist increased significantly from t1 (34.83 %, n = 62) to t3 (44.98 %, n = 102, p = .023). Intended future use of VC for healthcare varied depending on the purpose of the consultation. Significant differences over time were only found for the purpose of using VC to discuss clinical findings, laboratory results and diagnostic analyses with a doctor, with higher intentions reported at t2 during lockdown in Germany. At t3, the majority of adults with depression felt that video and telephone consultations were too impersonal and considered them more as a helpful support rather than an alternative to face-to-face psychotherapy. Key barriers to using e-health were found within the societal context and the lacking support from significant others for using e-health, while knowledge and skills represented facilitators for using e-health. Conclusion: Despite ambivalent attitudes towards video and telephone consultations among adults with depression, reported use of video consultations with a psychotherapist increased during the COVID-19 pandemic.

Age effects on the P300 potential and the corresponding fMRI BOLD-signal.

Age has been reported to influence amplitude and latency of the P300 potential. Nevertheless, it is not yet fully understood which brain regions are responsible for these effects. The aim of this study was to investigate age-effects on the P300 potential and the simultaneously acquired BOLD signal of functional MRI. 32 healthy male subjects were investigated using an auditory oddball paradigm. The functional MRI data were acquired in temporal synchrony to the task. The evoked potential data were recorded during the intervals in between MR image acquisitions in order to reduce the influence of the scanner noise on the presentation of the tones and to reduce gradient artifacts. The age-effects were calculated by means of regression analyses. In addition, brain regions modulated by the task-induced amplitude variation of the P300 were identified (single trial analysis). The results indicated an age effect on the P300 amplitude. Younger subjects demonstrated increased parietal P300 amplitudes and increased BOLD responses in a network of brain regions including the anterior and posterior cingulate cortex, the insula, the temporo-parietal junction, the superior temporal gyrus, the caudate body, the amygdala and the parahippocampal gyrus. Single trial coupling of EEG and fMRI indicated that P300 amplitudes were predominantly associated with neural responses in the anterior cingulate cortex, the putamen and temporal brain areas. Taken together, the results indicate diminished neural responses in older compared to younger subjects especially in frontal, temporo-parietal and subcortical brain regions.

Does pain improve earlier than mood in depressed patients with painful physical symptoms treated with duloxetine?

INTRODUCTION: In depressed patients tricyclic antidepressants and selective serotonin and noradrenaline reuptake inhibitors can reduce not only depressive, but also painful physical symptoms. We investigated whether under treatment with duloxetine pain improves earlier than mood. METHODS: Data were obtained within a prospective 6-month multi-centre naturalistic study in adult out-patients with depressive episodes treated with duloxetine (fl exible doses: 30-120 mg/day). Pain and mood were assessed daily by visual analogue scales. For responders (n = 622) "time to 50 % pain response" and "time to 50 % mood response" were determined by counting the earliest day between day 0 and 27, at which the patient achieved 50 % improvement. RESULTS: Mean time to 50 % pain response (mean 6.3 days, SD 5.3) was significantly shorter than time to 50 % mood response (mean 7.6 days, SD 6.0, mean difference 1.3 days, SD 6.4; p < 0.0001). DISCUSSION: In duloxetine-responders to both pain and mood, self-rated pain improved slightly earlier than self-rated mood. The short temporal dissociation between pain and mood improvement might be explained by an earlier conscious perception of pain than mood changes.

Single-trial coupling of the gamma-band response and the corresponding BOLD signal.

Oscillations in the gamma-band frequency range have been described to be more closely connected to hemodynamic changes as assessed with functional magnetic resonance imaging (fMRI) than other aspects of neuronal activity. In addition, gamma-band oscillations have attracted much interest during the last few years since they are thought to play a crucial role in many aspects of brain function related to perception and cognition. It was the aim of the present simultaneous EEG-fMRI study to identify brain regions specifically involved in the generation of the auditory gamma-band response (GBR) using single-trial coupling of EEG and fMRI. Ten healthy subjects participated in this study. Three different runs of an auditory choice reaction task with increasing difficulty were performed. Brain activity was recorded simultaneously with high density EEG (61 channels) and fMRI (1.5 T). BOLD correlates of the GBR have been predicted using the single-trial amplitude of the GBR. Reaction times (p<0.001), error rates (p<0.05) and self-ratings of task difficulty and effort demands (p<0.001) were related to the level of difficulty in the task. In addition, we found a significant influence of task difficulty on the amplitude of the GBR at Cz (p<0.05). Using single-trial coupling of EEG and fMRI GBR-specific activations were found only in the auditory cortex, the thalamus and the anterior cingulate cortex (ACC) in the most difficult run. Single-trial coupling might be a useful method in order to increase our knowledge about the functional neuroanatomy of "neural ensembles" coupled by 40 Hz oscillations.

Are psychostimulants a treatment option in mania?

Mania and attention-deficit hyperactivity disorder (ADHD) show a high degree of symptom overlap and comorbidity. Clinical trials and case reports indicate that psychostimulants do not or only rarely trigger or aggravate manic episodes but can even produce rapid and pronounced antimanic effects. An explanatory model is presented here in which the sensation seeking, hyperactive behaviour observed in mania and ADHD is interpreted as an autoregulatory attempt to stabilize vigilance by increasing external stimulation. Accordingly, patients with both mania and ADHD show rapid declines to lower vigilance levels (e.g., sleep spindles in EEG) under resting conditions with low external stimulation. The "paradoxical" antimanic effect of psychostimulants possibly results from their vigilance stabilizing properties.

[Subdiagnostic depression. Are there treatments with clinically relevant effects?]. / Subdiagnostische Depressionen. Gibt es Behandlungen mit klinisch relevanten Effekten?

Minor depression, subsyndromal depression and subthreshold depression are frequent conditions in primary care which do not fulfil the criteria of a depressive disorder but are associated with functional disability, impairment of quality of life, and health care use. This paper reviews studies on the clinical evidence of pharmacotherapy, psychotherapy, and interventions to improve primary care. In this regard, whether clinical relevance of antidepressant therapies can be concluded from differences between placebo and active treatment is critically discussed. Due to lacking clinical evidence, aspects of a pragmatic therapeutic approach in those patients are presented.

[Antidepressants and suicidality. Risk-benefit analysis]. / Antidepressiva und Suizidalität. Nutzen-Risiko-Abschätzung.

Reanalyses of placebo-controlled trials reveal an increased risk of suicidal ideations or parasuicidal acts in children and adolescents under treatment with selective serotonin reuptake inhibitors (SSRI) or other antidepressants. Although no completed suicide was shown, these findings are the more important because, with the exception of fluoxetine, an evidence base for the efficacy of antidepressants is weak or lacking in this age group. For adults, there is no reason to doubt that antidepressants help to reduce suicides by shortening depressive episodes and preventing recurrence. A general and pronounced suicide-inducing effect of SSRI or other antidepressants can largely be excluded. On the other hand, in some vulnerable patients the risk of suicidal acts can increase, especially during the first days of antidepressant treatment. There is no evidence that this risk is higher with SSRI than with other antidepressants or nonpharmacological treatments. Safety in case of overdose is a strong argument favouring newer antidepressants over tri- and tetracyclic antidepressants in outpatients with unclear suicidality. The current widespread public discussions concering the risks of antidepressants is a risk in itself because confidence in treatment, compliance, and help seeking behaviour may get influenced negatively.

[Programmes against depression]. / Les programmes d'action contre la dépression.

BACKGROUND: Depressive disorders represent a major public health concern, regarding their high frequency and their important cost. Depression impair the quality of life more than any other disease, sometimes leading to suicidal ideas or behavior. Indeed, 50% of patients with severe major depression commit suicide. Numerous studies showed that depressive disorders are frequently not recognised, and regularly untreated. In France, where at least 3 millions of inhabitants are concerned, 38% of depressed patients are not using any health system. When they are asking for care, the majority of depressed patients visit their general practitioner (51%), whereas less than 10% visit a psychiatrist. Even when the diagnostic is correct, the treatment prescribed is not systematically relevant. The treatment is, for example, frequently proposed for a too short period, and sometimes the prescribed product does not have proven antidepressive efficacy. Furthermore, as incorrect informations are frequently given to patients, and as there is a general biased judgement about psychotropic drugs in the general population, the compliance is usually poor for antidepressive treatment. Therefore, only a small minority of depressed patients benefits from an adequate care. Public health information methodological asserts. To improve this situation, delivering simple and clear-cut recommendations cannot be considered as sufficiently effective, and public health interventions are required. Different programs improving the recognition of depressive disorders have already been tested in some countries with encouraging results. These programs are based on information campaigns given to the public, and the training of general practitioners about the management of depressive disorders. The "Defeat Depression" campaign in Great-Britain and the "National Depression Screening Day" in the United-States of America may represent informative examples. Restricting these programs to general practitioners only is frequently criticized, as this may reduce efficacy. A multilevel approach is crucial for the success of action programmes against depression, because synergistic effects can be expected. In Germany, the "Nürnberger Bündnis gegen Depression" project was based on four levels, and effectively reduced the suicide rate. These levels of action included "cooperation with GPs", such as training sessions based on video, and presence of a phone hotline, "public relations activities", "training sessions for multipliers", such as priests, social workers and media, and "special offers for high risk groups and self-help activities". In France, such a program is clearly required.

[Modern discussion forum "depression, suicidality"]. / Moderiertes Diskussionsforum zum Thema "Depression".

Five years ago, with the appearance on the internet of the competence network "Depression, Suicidality", a conducted discussion forum was established to serve as a platform for an internet-based self-help group. Today, the forum has more than 3,000 registered visitors, and is the largest virtual group concerned with depression in the German-speaking area. In comparison with a "real" self-help group, this virtual form offers specific possibilities to those concerned, such as, for example, 24-hour access to other sufferers. Admittedly, specific limitations must nevertheless be noted, which, among other things, have to do with the particular features of internet-based communication and the heterogeneity of the participants. Overall, this virtual self-help group represents a rational and useful addition to the existing possibilities for self help.