The negative impact of vitamin D on antipsychotic drug exposure may counteract its potential benefits in schizophrenia.

AIMS: Patients with schizophrenia frequently show insufficient vitamin D levels, which are associated with somatic comorbidity and may contribute to psychopathology. For many reasons, vitamin D supplementation may be indicated for this patient cohort. However, there is growing evidence for a vitamin D-mediated increase of drug metabolism by induction of cytochrome P450 (CYP) 3A4. Hence, this study aimed to assess vitamin D's impact on both antipsychotic drug concentrations and psychopathology in a non-interventional manner. METHODS: Totals of 107 serum concentrations of different antipsychotic drugs (amisulpride, aripiprazole, clozapine, olanzapine, quetiapine and risperidone), 80 serum concentrations of vitamin D and psychopathological assessments were obtained from 80 patients with schizophrenia. The impact of Vitamin D on antipsychotic drug concentrations and symptomatology was assessed using a generalized linear model, path and correlation analyses. RESULTS: We observed a negative relationship between vitamin D and dose-adjusted antipsychotic drug concentrations, which was particularly pronounced for drugs which are predominantly metabolized via CYP3A4 (i.e., aripiprazole and quetiapine). A path analysis suggested a relieving effect of vitamin D on symptomatology which was, however, counteracted by its negative impact on antipsychotic drug levels. Finally, patients with vitamin D levels above the median exhibited a significantly higher proportion of therapeutically insufficient dose-normalized drug concentrations of aripiprazole and quetiapine. CONCLUSION: Despite vitamin D's potential benefits on physical and mental health, clinicians should be aware of its negative impact on blood concentrations of antipsychotics metabolized by CYP3A4 in patients with schizophrenia. Therefore, when considering its supplementation, therapeutic drug monitoring should be applied to guide dose adjustment.

Exploring the neural correlates of (altered) moral cognition in psychopaths.

Research into the neurofunctional mechanisms of psychopathy has gathered momentum over the last years. Previous neuroimaging studies have identified general changes in brain activity of psychopaths. In an exploratory meta-analysis, we here investigated the neural correlates of impaired moral cognition in psychopaths. Our analyses replicated general effects in the dorsomedial prefrontal cortex, lateral prefrontal cortex, fronto-insular cortex, and amygdala, which have been reported recently. In addition, we found aberrant brain activity in the midbrain and inferior parietal cortex. Our preliminary findings suggest that alterations in both regions may represent more specific functional brain changes related to (altered) moral cognition in psychopaths. Furthermore, future studies including a more comprehensive corpus of neuroimaging studies on moral cognition in psychopaths should re-examine this notion.

Electroconvulsive therapy against the natural will: Some concerns.

In recent years, the scientific interest in "Electroconvulsive therapy (ECT) against the patient's natural" will has grown. Several publications have reported mostly positive outcomes in cases, where ECT has been implemented against the patient's natural will. The author's findings primarily indicate the effectiveness of ECT in non-consenting patients, which confirms earlier findings. All author's overall presumption turned out to be mainly positive. Within the discussion on involuntary ECT treatment, we missed disadvantageous arguments, which also need to be considered for a balanced judgement. By bringing up the following viewpoint, would like to contribute to a balanced decision making process in cases where involuntary ECT is a legal treatment option.

[Conflict of interest in continuing medical education - Studies on certified CME courses]. / Interessenkonflikte in der ärztlichen Fortbildung - Untersuchungen an zertifizierten Online-Fortbildungsangeboten.

OBJECTIVES: Although the problem of conflict of interest in medical education is discussed intensively, few valid data have been published on how to deal with the form, content, funding, sponsorship, and the influence of economic interests in continuing medical education (CME). Against this background, we carried out an analysis of data which had been documented for the purpose of certification by a German Medical Association. A central aim of the study was to obtain evidence of possible influences of economic interests on continuing medical education. Furthermore, strategies for quality assurance of CME contents and their implementation were to be examined. METHODS: We analyzed all registration data for courses certified in the category D ("structured interactive CME via print media, online media and audiovisual media") by the Bavarian Chamber of Physicians in 2012. To measure the effects of conflict of interest, relationships between topics of training and variables relating to the alleged self-interest of the organizer/sponsor (for example, drug sales in a group of physicians) were statistically verified. These data were taken from the Bavarian Medical Statistics 2012 and the GKV-Arzneimittelschnellinformation. RESULTS: In 2012, a total of 734 CME course offerings have been submitted for 51 medical specialties by 30 course suppliers in the Bavarian Medical Association. To ensure the neutrality of interests of the CME courses the course suppliers signed a cooperation treaty ensuring their compliance with defined behavior towards the Bavarian Medical Association concerning sponsorship. The correlation between course topics and drug data suggests that course suppliers tend to submit topics that are economically attractive to them. There was a significant correlation between the number of CME courses in a specific field and the sales from drug prescriptions issued by physicians in the respective field. CONCLUSIONS: The results show that neutrality of interests regarding continuing medical education is difficult to achieve under the current framework for the organization, certification, and especially the funding of CME events in Germany. The cooperation agreement between the Bavarian Medical Association and training applicants is taken as an example of how legal certainty can be ensured. Based on the findings described below, suggestions and strategies to strengthen assessment expertise of course participants have been developed and elaborated.