Non-adherence to psychotropic medication assessed by plasma level in newly admitted psychiatric patients: Prevalence before acute admission.

AIMS: Non-adherence or partial adherence to psychotropic medication is found in 18-70% of patients. Many previously used methods for the assessment of adherence (e.g. questionnaires, pill counts, and electronic systems), however, might underreport actual rates of non-adherence to medication. The aim of this study was to quantify adherence using plasma level. METHODS: We conducted a 6-week prospective study of all consecutive admitted patients at the Paracelsus Medical University of Salzburg, Clinics of Psychiatry and Psychotherapy, who had been treated with antipsychotics/antidepressants prior to admission (pre-medication dosage in 161 of 233). Plasma drug levels were determined and compared with expected levels based on known preadmission dosing regimens and average pharmacokinetic data. RESULTS: Seventy-three percent of the patients had actual plasma levels clearly below or above the intended level. Significantly more patients with schizophrenia (66%) did not take the medication as prescribed, when compared with patients with affective disorders (47%) or those with other psychiatric diagnoses (41%). Only 27% (44 of 161) of the patients had plasma level in the expected range based on the dosage. CONCLUSION: The risk of partial adherence or non-adherence is expected in two-thirds of patients with schizophrenia, half of patients with affective disorders, and approximately 40% of patients with other psychiatric diagnoses. Given that admitting psychiatrists could not provide an accurate assessment of patient adherence, it is strongly suggested that clinical judgment be supplemented with the actual monitoring of adherence - and further optimization of pharmacotherapy - by means of therapeutic drug monitoring.

Hippocampal neurogenesis and antidepressive therapy: shocking relations.

Speculations on the involvement of hippocampal neurogenesis, a form of neuronal plasticity, in the aetiology of depression and the mode of action of antidepressive therapies, started to arise more than a decade ago. But still, conclusive evidence that adult neurogenesis contributes to antidepressive effects of pharmacological and physical therapies has not been generated yet. This review revisits recent findings on the close relation between the mode(s) of action of electroconvulsive therapy (ECT), a powerful intervention used as second-line treatment of major depression disorders, and the neurogenic response to ECT. Following application of electroconvulsive shocks, intricate interactions between neurogenesis, angiogenesis, and microglia activation, the hypothalamic-pituitary-adrenal axis and the secretion of neurotrophic factors have been documented. Furthermore, considering the fact that neurogenesis strongly diminishes along aging, we investigated the response to electroconvulsive shocks in young as well as in aged cohorts of mice.

[Reliability and concordance validity of a German version of the Young Mania Rating Scale (YMRS-D)]. / Relabilität und Übereinstimmungsvalidität der deutschen Version der Young Mania Rating Scale (YMRS-D).

OBJECTIVE: The Young Mania Rating Scale (YMRS) is the most widely used assessment tool for severity of manic symptoms in bipolar patients. While the original English version has been translated to various different languages, a validated German translation of YMRS has not yet been available. METHODS: We translated the original English version to German (YMRS-D) and tested its use in clinical practice in 81 manic inpatients at two different psychiatric hospitals in Austria. The interviews were carried out by eight experienced and trained psychiatrists in random pairs of two interviewers. In order to assess concordance validity of YMRS-D, all patients were simultaneously rated using the Clinical Global Impression Rating Scale, Bipolar Version (CGIBP), by one of three experienced senior raters. RESULTS: Inter-Rater Reliability was assessed calculating the Intra-Class Correlation Coefficient and showed high values (between 0.79 and 0.97, all p<.001) in all items of the German Rating Scale. Internal Consistency analysis of the scale yielded a value of .74 (Cronbach's Alpha). Spearmans rank correlation coefficient for the total scores of CGI-BP and YMRS-G was high (0.91, p<.001), suggesting good concordance validity of YMRS-D. Sensitivity to change was assessed in a subgroup of 20 patients by comparing YMRS-D and CGI-BP total scores at inclusion and at an additional interview three weeks later which showed a highly significant correlation (r = -0,953; p<.0005). CONCLUSIONS: The German version of YMRS seems to be a valid, reliable and useful tool for the assessment and quantification of manic symptoms.

Paroxetine with pindolol augmentation: a double-blind, randomized, placebo-controlled study in depressed in-patients.

Pindolol, a 5-HT1A autoreceptor antagonist, given in combination with selective serotonin reuptake inhibitors (SSRIs), may enhance and/or accelerate the therapeutic efficacy of SSRIs. Fifty patients, meeting ICD-10 criteria for major depressive disorder or bipolar depression, were enrolled in our randomized, placebo-controlled, double-blind trial. One group received paroxetine plus pindolol (2.5 mg t.i.d.), and the other group received paroxetine plus placebo. The proportion of patients with sustained response (>or=50% reduction of baseline HAM-D 17 score maintained until the endpoint; p=0.252) and the proportion of patients with remission (HAM-D 17

Influence of age and gender on risperidone plasma concentrations.

There is limited information on gender- and age-specific effects on plasma concentrations of risperidone and its active metabolite, 9-hydroxyrisperidone. The present study investigated dose- and weight-adjusted plasma concentrations of risperidone and its metabolite in three age groups (45 years, 45-60 years, over 60 years). Gender-specific differences were examined in the whole sample and for the premenopausal subgroup. One hundred and twenty-nine patients (18-93 years) were included in the study, 52 (40%) male and 77 (60%) female. Concentrations of risperidone and 9-hydroxyrisperidone were measured at steady-state by high-performance liquid chromatography with electrochemical detection (HPLC-ED). When total plasma concentrations (risperidone plus 9-hydroxyrisperidone) were adjusted for daily maintenance dose (ng/mL/mg C/D ratio), significant differences between all age groups were found. We found a mean increase of the C/D ratio by 34.8% per decade in patients older than 42 years. No significant sex-related differences in the average plasma concentrations were observed for the whole sample and for the premenopausal subgroup. This study shows clear evidence of higher risperidone total plasma concentrations for patients over 40 years of age. This linear increase (over 30% per decade) may then lead to an increased incidence of adverse effects in elderly patients.

Propofol and methohexital as anesthetic agents for electroconvulsive therapy: a randomized, double-blind comparison of electroconvulsive therapy seizure quality, therapeutic efficacy, and cognitive performance.

BACKGROUND: Propofol is often used as an anesthetic agent for electroconvulsive therapy (ECT). Whether the relatively short seizure duration, resulting from the medication, deteriorates the seizure quality and therapeutic outcomes, or whether propofol might be associated with small but significant post-ECT cognitive impairments, is still a subject of controversy. The purpose of our study was to test these hypotheses in comparison with methohexital. MATERIALS AND METHODS: In a double-blind, controlled study, 50 patients with severe major depression who were to be treated with ECT were randomly assigned to anesthesia with propofol (120.9 +/- 50.0 mg) or methohexital (83 +/- 26.3 mg) and were observed for 2 months. The 2 drugs were compared on the basis of electroencephalography-registered seizure duration, mean blood pressure, as well as pulse frequency, seizure efficacy index, and postictal suppression. Systolic and diastolic blood pressure, and seizure duration and quality were recorded consecutively during ECT treatments. Changes in depressive symptoms and cognitive functions were measured at 5 time points, pre-ECT, after the third to fifth ECT, post-ECT treatment, and at a follow-up examination 2 and 8 weeks after the last ECT treatment. RESULTS: Patients on propofol showed a significantly lower increase in blood pressure post-ECT (P < 0.001), their seizure duration was comparable to patients on methohexital (P = 0.072), and seizure quality was significantly superior, as was measured by the Postictal Suppression Index (P = 0.020), and comparable to the methohexital group as measured by the Seizure Efficacy Index (P = 0.160). The improvement of depressive symptoms and the improvement in cognitive functions were similar in both groups (with the exception of the results from 2 cognition tests). CONCLUSIONS: Propofol, as compared with methohexital, results in a more moderate increase in blood pressure and shorter seizure duration. The seizure quality did not differ significantly between the 2 groups. We detected a tendency toward improved cognitive performance after anesthesia with propofol as compared with methohexital, but with statistical significance in only 2 cognition trials. Therefore, propofol is a safe and efficacious anesthetic for ECT treatment.

Electroconvulsive Therapy in Acute Life-Threatening Catatonia with Associated Cardiac and Respiratory Decompensation.

A 61-year-old white female patient with known endogenous depression developed acute life-threatening catatonia. Associated cardiac and respiratory insufficiency prevented drug therapy. The patient was successfully treated with ECT.