Fighting stigma of mental illness in midsize European countries.

PURPOSE: Stigma is the most powerful obstacle to the development of mental health care. Numerous activities aiming to reduce the stigma of mental illness and the consequent negative discrimination of the mentally ill and their families have been conducted in Europe. Descriptions of many of these activities are not easily available, either because there are no publications that describe them, or because descriptions exist only in local languages. This supplement aims to help in overcoming this imbalance by providing a description of anti-stigma activities in 14 countries in Europe regardless of the language in which they were published and regardless whether they were previously published. METHODS: The review was undertaken by experts who were invited to describe anti-stigma activities in the countries in which they reside. It was suggested that they use all the available evidence and that they consult others in their country to obtain a description of anti-stigma activities that is as complete as possible. RESULTS: The anti-stigma activities undertaken in the countries involved are presented in a tabular form. The texts contributed by the authors focus on their perception of the stigma of mental illness and of activities undertaken to combat it in their country. CONCLUSIONS: Although much has been done against the stigmatization and discrimination of the mentally ill, fighting stigma remains an essential task for mental health programs and for society. The descriptions summarized in this volume might serve as an inspiration for anti-stigma work and as an indication of potential collaborators in anti-stigma programs.

Management of depression in the presence of pain symptoms.

Somatic illness is frequently associated with depression and anxiety and major depression significantly increases risk of severe medical conditions, e.g. cardiovascular illness. One of the most frequent comorbidities is that of depression and pain. Alterations in noradrenergic and serotonergic neurotransmissions in the central nervous system have been implicated in the joint pathophysiology of depression and chronic pain. Antidepressants, alone or in combination with psychotherapy, are an effective treatment option in such cases. The newer dual action antidepressants (milnacipran, venlafaxine, duloxetine) acting specifically on both noradrenergic and serotonergic neurotransmitter systems are presumably more reliable in pain management. So far, the most extensively studied drug has been duloxetine. Twelve randomized placebo-controlled trials with the total number of 4,108 patients suffering from pain associated with major depressive disorder suggested consistent analgesic efficacy of duloxetine, especially in fibromyalgia and peripheral neuropathic pain.

Sleep deprivation therapy.

Sleep deprivation is a useful therapeutic option in the treatment of depressive disorders, especially in pharmacoresistant disorders. Its therapeutic efficacy in other indications has not, however, been confirmed. According to current knowledge, application of sleep therapy requires concomitant therapy to prevent early relapses of depression. Total sleep deprivation is the classic variant of its clinical use. Partial sleep deprivation has a somewhat less pronounced antidepressant effect, and the duration of sleep deprivation rather than application timing determines its therapeutic effect. The most reliable predictors of sleep deprivation efficacy are marked diurnal fluctuations of depressive mood, patient locomotor activity, and limbic hyperactivity in the central nervous system. The mechanism of the antidepressant effect of sleep deprivation remains unknown.

Nonadherence to antipsychotic treatment in patients with schizophrenic disorders.

Adherence to treatment is a general indicator of quality and success of communication between the physician and the patient. It means the extent to which patient behaviour, in terms of taking medications, following diets, or executing life-style changes, coincides with medical or health advice. Nonadherence to antipsychotic therapy in patients with schizophrenia is far more widespread than clinicians assume. Lower nonadherence in therapy based on antipsychotics of the second generation compared with conventional medications has already been indicated by early reports. The consequences of nonadherence include exacerbation of symptoms, an increased relapse rate, psychiatric hospitalization hospitalisation, and less favourable patient prognosis. There are several factors that cause treatment nonadherence in schizophrenia: causes derived from the schizophrenic disorder itself, patient characteristics, causes associated associated with the health-care system, and the antipsychotic treatment itself.

Differences in the effect of second-generation antipsychotics on prolactinaemia: six weeks open-label trial in female in-patients.

OBJECTIVES: The main objective was to evaluate the effect of five second-generation antipsychotics (amisulpride, quetiapine, olanzapine, risperidone, and zotepine) on prolactinaemia during 6 week therapy in 433 female in-patients with mainly schizophrenic disorders. Secondary objectives included identification of dynamics of change in serum prolactin levels and correlations of changes of prolactinaemia with some demographic and clinical parameters. METHODS: The trial was a prospective, open-label, single-center one with a flexible dosing of SGAs. The therapeutic effect of SGAs was assessed by a change of scores of CGI-S and CGI-I scales from a baseline to the endpoint. Blood samples were taken in the morning under fasting condition. RESULTS: Amisulpride and risperidone increased prolactinaemia significantly in 100% of patients, as early as after week 1 of the therapy. Quetiapine and zotepine relatively reduced prolactinaemia significantly, as early as from week 1 of the quetiapine treatment. Olanzapine led to a transient mild prolactin elevation. The much lower prevalence of hyperprolactinaemia over 2 000 mIU/l differentiates olanzapine from amisulpride and risperidone. Prolactin elevation did not correlate with age, menopausal condition, therapeutic efficacy, antipsychotic daily dose, serum levels of lipids and glucose. There was significant correlation with first vs. subsequent psychotic episodes, weight, EPS and serum levels of thyroid hormones. CONCLUSION: Amisulpride and risperidone had marked and early prolactin elevating effects, requiring, therefore, more frequent monitoring of prolactinaemia and associated undesirable effects and risks than olanzapine, quetiapine and zotepine.

Treatment of bipolar depression.

Antidepressants have insufficient effect in 20-40% of patients treated for depressive disorders. This is particularly true for psychotic and agitated depression. When administered on a long-term basis, antidepressants cause a switch into mania in 25-40% of patients and induce rapid cycling. Classical antipsychotics have exhibited good therapeutic efficacy in the treatment of various forms of depression, especially psychotic and agitated forms, albeit burdened with many, above all extrapyramidal, side effects. When administered over long periods of time, classical antipsychotics may have a depressogenic effect. Second-generation antipsychotics have started to be increasingly used in this indication for a variety of reasons including: their antidepressant effect attributable to raised concentrations of catecholamines in the prefrontal cortex, their impact on serotonin transmission, their antipsychotic effect due to their mode of action including the mesolimbic blockade of dopamine D2 receptors, and the low incidence of extrapyramidal and other side effects. The following text encompasses the results of controlled trials using second-generation antipsychotics in the treatment of acute depressive disorders.

Treatment of acute agitation in psychotic disorders.

Several psychotic disorders, including schizophrenia, may be associated with symptoms of acute agitation and aggression. While drug treatment of agitation is often essential, non-pharmacological interventions, both environmental and behavioral, also play important roles in the complex management of agitated patients. The most extensively used psychotropic drugs are parenteral formulas of conventional antipsychotics and benzodiazepines. Recently, injection forms of two second generation antipsychotics, olanzapine and ziprasidone, have become available. Both drugs have shown adequate efficacy and tolerability in several double-blind trials of intramuscular administration in acutely agitated psychotic patients. Compared to conventional medication, injection forms of the new antipsychotics may have a faster onset of action and more favorable profile of adverse events. Alternative approaches to injection administration include liquid drug formula, orally disintegrating tablets and wafers, treatment initiation with high doses, or rapid dose escalation. Evidence suggests that second-generation antipsychotics should be among the first-line choices in the treatment of agitation in acute psychosis.

Escitalopram for the treatment of major depression and anxiety disorders.

Escitalopram is the S-enantiomer of the selective serotonin reuptake inhibitor (SSRI) citalopram, which contains equal amounts of the S- and R-forms in a racemic mixture. Escitalopram is the most selective SSRI, with almost no significant affinity to other tested receptors. It has been demonstrated that it is escitalopram that carries the therapeutic potential of citalopram, and has statistically superior and clinically relevant properties compared with citalopram. Escitalopram is at least as effective in the treatment of depression and anxiety as other SSRIs, as well as venlafaxine, bupropion and duloxetine. Owing to multiple metabolic degrading pathways, the clinically relevant interactions of escitalopram with other drugs are minimal. Compared with other antidepressants, escitalopram is generally better tolerated, its onset of action is relatively fast, and its use may have cost-effectiveness and cost-utility advantages. Escitalopram is an effective first-line option in the management of patients with major depression, including severe forms, and various anxiety disorders.