Highly varying concepts and capacities of forensic mental health services across the European Union.

Introduction: There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed. Methods: From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data. Results: Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous. Discussion: Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

A multinational case-control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project.

BACKGROUND: The relationship between schizophrenia and violence is complex. The aim of this multicentre case-control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence. METHOD: Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process. RESULTS: The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant. CONCLUSIONS: This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.

Long-term forensic psychiatric inpatient treatment - review of the selected literature and the analysis of data from the medium secured forensic psychiatry unit. / Wieloletnie detencje psychiatryczne ­ przeglad wybranego pismiennictwa i analiza danych z oddzialu psychiatrii sadowej o wzmocnionym stopniu zabezpieczenia.

OBJECTIVES: The aim of this study was to perform an analysis of the risk factors of long-term psychiatric detention, defined as a stay in forensic institution exceeding respectively 60 and 84 months, based on data obtained from 150 patients from medium secure forensic psychiatry unit. The discussion was preceded by an analysis of the available literature in this field. The sociodemographic factors, the course of the mental disorder, the characteristic of committed criminal acts, aggressive or self-destructive behavior and the clinical characteristic of the illness in the last 6 months of psychiatric detention were analyzed. METHODS: A pilot study was based on a retrospective analysis of data from medical records and psychiatric experts' opinions of a cross-sectional nature. Due to the variables' characteristic, the Student's t-tests, Spearman's correlation and the Kruskal-Wallis rank ANOVA were used. RESULTS: Risk of long-term hospitalization significantly correlated with factors related to the course of the last 6 months of inpatient treatment, including the mental state of patients, the occurrence of aggressive behaviors and the response to pharmacological treatment. There was no significant effect of demographic factors or coexisting addiction to alcohol and psychoactive substances. The risk of long-term psychiatric detention increased with the duration of the illness. There were no correlations with the age of the patients at the time of admission nor number of detentions. The nature of the diagnosis was also not found to be a risk factor. CONCLUSIONS: Our study is the first systematic attempt to assess the risk factors of long-term psychiatric detention in a group of patients of forensic psychiatry centers in Poland. We hope that the presented results will rise a discussion on the shape of psychiatric care in Poland and encourage further research in this area, as well as they will contribute to the optimization of the treatment process.

Neurocognition and social cognition in patients with schizophrenia spectrum disorders with and without a history of violence: results of a multinational European study.

OBJECTIVE: Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence. METHODS: Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery. RESULTS: Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group. CONCLUSIONS: These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice.

Attitudes Towards ECT: A Survey of Polish Mental Health Professionals.

BACKGROUND: Although the efficacy of electroconvulsive therapy (ECT) has been well established, the utilization rate of ECT has decreased in Poland in recent years. One of the main reasons could be the negative attitude towards ECT in the community and by mental health professionals. The aim of this study was to assess the knowledge about and attitudes toward ECT in Polish mental health professionals including psychiatrists and non-physicians: nurses, psychologists, social workers. SUBJECTS AND METHODS: Psychiatrists and other mental health professionals in two large Polish hospitals were approached to participate in the survey by completing a 28-item questionnaire. The specific hospitals have been selected due to the fact that they were located in the same province of Poland (Mazowsze), had similar catchment area and profile, provided similar mental health services with only one exception; one offered ECT while the other did not. Of the 185 questionnaires that had been distributed, 165 were completed yielding a response rate of 89.19%. The study population consists of 85 psychiatrists and trainees and 80 non-physicians. RESULTS: Psychiatrists did not differ from other mental health professionals with respect to the knowledge and attitudes toward ECT. However, there were significant differences in the attitude (9.1±3.8 vs 7.1±3.3; p<0.001) and knowledge (5.9±3.8 vs 2.8±4.1; p<0.001) scores between those professionals, who have ever worked in a psychiatric ward where they could observe ECT sessions and those who have not had such an opportunity. CONCLUSIONS: Frequent witnessing of ECT sessions seems to be the most effective educational intervention to change negative attitudes towards ECT.

Neuropathological Changes in the Brains of Suicide Killers.

BACKGROUND: Homicide combined with subsequent suicide of the perpetrator is a particular form of interpersonal violence and, at the same time, a manifestation of extreme aggression directed against oneself. Despite the relatively well-described individual acts of homicide and suicide, both in terms of psychopathology and law, acts of homicide and subsequent suicide committed by the same person are not well-studied phenomena. The importance of emotional factors, including the influence of mental state deviations (psychopathology), on this phenomenon, is discussed in the literature, but still there is relatively little data with which to attempt neuropathological assessments of the brains of suicide killers. This paper is dedicated to the issue based on the neuropathological studies performed. METHODS: We analyzed a group of murder-suicides using histochemical and immunohistochemical methods. RESULTS: The results of our research indicate the presence of neurodegenerative changes including multiple deposits of ß-amyloid in the form of senile/amyloid plaques and perivascular diffuse plaques. CONCLUSIONS: Neurodegenerative changes found in the analyzed brains of suicide killers may provide an interesting starting point for a number of analyses. The presence of neurodegenerative changes at such a young age in some murderers may suggest preclinical lesions that affect cognitive functions and are associated with depressed moods.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis.

BACKGROUND: Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period. METHODS: We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels. FINDINGS: Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings. INTERPRETATION: Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries. FUNDING: Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Longer than prison? A comparison of length of stay in a medium security hospital and prison for perpetrators of violent crimes other than homicide or attempted homicide.

BACKGROUND: Concerns have been raised that people detained in secure hospitals after a criminal act spend longer in a locked institution than people sent to prison for similar offending, but research evidence is scarce and conflicting. AIMS: To compare the length of secure hospitalisation of people convicted of crimes for which flexible sentencing is allowed with length of time in prison for people serving a prison sentence for similar crimes who were not found mentally ill. METHODS: A records-based, retrospective study was conducted comparing length of stay of all inpatients in one medium security hospital in Poland, hospitalised between 2014 and 2018, who had been convicted of any interpersonal crime other than homicide or attempted homicide, and data on all sentenced prisoners in Poland on 09.05.2018 convicted of a similar range of offences. Homicide was excluded because, in Poland, it usually attracts a fixed sentence-a life sentence until the 1970s and currently a 25-year imprisonment-so disrupting comparisons. RESULTS: Eighty-two patients completed their secure hospital stay within the study period or were still hospitalised at the census point 09.05.2018, only 10 of them women. Male patients convicted of stalking or similar threatening offence or 'mistreatment' spent, on average, almost twice as long confined to hospital than men sentenced to imprisonment spent in prison (28.8 months, respectively). By contrast, men hospitalised after sex offences were confined for over three years less than those sentenced to prison. Only bodily harm offences attracted comparable lengths of stay in hospital and prison. CONCLUSIONS: Our findings confirm significant disparities in length of time spent in a closed institution after offences of serious interpersonal violence, according to whether that institution was prison or hospital, but not all in the same direction. Next steps should explore reasons for this and relative longer-term outcomes.

Treatment resistance and prolonged length of stay among schizophrenia inpatients in forensic institutions.

Patients suffering from schizophrenia spectrum disorders are the largest group of forensic inpatients worldwide, therefore the identification of factors that influence how long service users experiencing schizophrenia spend in forensic hospitals is one of the most important research areas in forensic psychiatry. Methods: Analysis of data of 87 schizophrenia inpatients, hospitalized in a medium secure forensic unit. Results: Mental disorders among family members, alcohol or substance dependence diagnosis, the severity of the criminal behavior demonstrated by homicide/homicide attempts and features of treatment resistance as persistent psychotic symptoms and current treatment with >1 antipsychotics was proven to influence the length of stay (LoS).

Pharmacological interventions to reduce violence in patients with schizophrenia in forensic psychiatry.

BACKGROUND: The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings. METHODS: For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review. RESULTS: Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterogeneous study designs and outcomes meta-analytic methods could not be applied. CONCLUSION: Due to substantial methodological limitations it is difficult to draw any firm conclusions about the most effective pharmacological strategies to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying more rigorous methods regarding case-definition, outcome measures, sample sizes, and study designs are urgently needed.

Implementation of the European Psychiatric Association (EPA) guidance on forensic psychiatry in Poland. Current state and required measures. / Implementacja wytycznych Europejskiego Towarzystwa Psychiatrycznego (EPA) w zakresie psychiatrii sadowej w Polsce. Stan obecny i konieczne dzialania.

The article discusses the key aspects of the guidance of the European Psychiatric Association (EPA) on forensic psychiatry and the required actions to implement guidance into clinical practice. The authors pay attention to the discrepancies between the recommendations resulting from the guidance and clinical practice and current systemic solutions. The basic difficulties were discussed in relation to the implementation of the guidelines in the clinical practice in Poland as regards providing services as an expert by psychiatrists and psychologists, risk assessment and management, psychiatric therapy in detention centers, implementation of protection measures in inpatient and outpatient treatment conditions, efficiency of pharmacological and non-pharmacological interventions. We hope that discussing the content of the guidance will help to deepen the knowledge of clinicians in the field of work as court expert witnesses and persons responsible for the implementation of the preventive measure. Based on the clinical experience measures were proposed that enable implementation of the guidance, and thus improvement of the quality of care exercised over the mentally ill criminal offenders.

Factors Influencing Length of Stay of Forensic Patients: Impact of Clinical and Psychosocial Variables in Medium Secure Setting.

OBJECTIVES: Forensic psychiatric care has two, often contradictory, aims-the treatment of mentally ill offenders and the isolation of the perpetrators to ensure public safety. It is essential to ensure that any periods of liberty deprivation do not last longer than necessary to provide appropriate treatment. Therefore, identifying the factors affecting the length of stay (LoS) is one of the most important research areas in the forensic psychiatry. The literature on this subject is scarce and to date there no data available on LoS for patients in Eastern or Central European patients. METHODS: We conducted a retrospective analysis of data for 150 inpatients in a medium secure unit. Based on a literature review and clinical experience, variables potentially influencing LoS were identified and included in the analysis. RESULTS: The variables that were significantly associated with LoS included duration of mental illness; severity of index offense; whether a crime was committed as a result of hallucinations or during drug treatment discontinuation; if the index offenses was a continuous crime (crimes committed over an extended period of time); persistent psychosis; multiple antipsychotic treatments; as well as a diagnosis of schizophrenia and schizoaffective disorder. CONCLUSIONS: Our findings are highly consistent with observations made by other researchers. However, contrary the majority of previous studies our project incorporates data concerning the clinical presentation of patients. For example, we demonstrate that variables measuring treatment resistance might be one of the crucial determinants of LoS, which is a novel research finding.

Polish Experiences of Safety Measures Involving Forensic Psychiatric Inpatients Implemented During the SARS-CoV-2 Pandemic.

The SARS-CoV-2 pandemic has made it necessary for us to adapt our healthcare systems to a very different sort of reality. This clearly also applies to psychiatric services. The restrictions and safeguards associated with the pandemic particularly concern adherence to social distancing and medical treatment safety procedures. The implementation of these procedures is generally complicated by conditions of forensic psychiatry where, in line with demands made by courts, the treatment and isolation of mentally unwell offenders must be carefully managed. In most countries, forensic psychiatric treatment is an inpatient service where patients are kept in restricted and cramped spaces, making social distancing difficult to implement as patients participate in compulsory group therapeutic activities. As a result, it is necessary to introduce unique recommendations relating to patient safety and treatment adapted to the realities of forensic psychiatry. All this requires the implementation of additional restrictions, over and above those arising from the essential aspects of forensic psychiatry. In this paper, we present and discuss the Polish guidelines for forensic psychiatric care during the SARS-CoV-2 pandemic, developed as a result of discussions on essential measures introduced to reduce the spread of the virus and the unique needs of the forensic patient population.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol.

BACKGROUND: The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant. METHODS: The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study. DISCUSSION: Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise. TRIAL REGISTRATION: Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

Symptomatic differences and symptoms stability in unipolar and bipolar depression. Medical charts review in 99 inpatients. / Obraz psychopatologiczny i powtarzalnosc wystepowania objawów w chorobie afektywnej jednobiegunowej i chorobie afektywnej dwubiegunowej. Analiza dokumentacji 99 pacjentów.

OBJECTIVES: Misdiagnosis of bipolar disorder may result in a non-optimal treatment, higher servicecosts and increase in the patient's suffering and risk of suicidal behavior. Lack of clinically approved and suitable for widely use biomarkers of BD led clinicians to focus on clinical course and symptomatology of depression in BD. The aim of this study was the retrospective evaluation of symptomatic differences and symptoms stability between MDD and BD patients during three subsequent depressive episodes in the inpatient setting. METHODS: Retrospective chart review of 99 patients with diagnosis of MDD and BD during three subsequent depressive episodes. Chi-squared test and logistic regression was used to analyze the symptomatic profile. Cohen's kappa value used to estimate symptoms stability. RESULTS: Statistical differences were observed in the case of 7 out of 22 depressive symptoms. Somatization (pain and non-pain complains), psychomotor agitation and pathological guilt were more frequent in MDD patients. Anhedonia, attention deficit, and suicidal ideation were more frequent in BD group. In MDD group relatively highest symptom stability was observed for somatization, middle insomnia, early wakening, and attention deficit. In BD group relatively highest symptom stability was observed for delusions, somatization (pain and non-pain complains), initial and middle insomnia, memory disturbance, psychomotor retardation, and pathological guilt. CONCLUSIONS: The observed symptomatic differences may be an additional factor of MDD/DB differential diagnosis. Lower than previously reported symptoms stability highlights the need to evaluate more than one depressive episode in differential diagnosis.

External factors influencing length of stay in forensic services - a European evaluation. / Czynniki zewnetrzne wplywajace na dlugosc pobytu w osrodkach psychiatrii sadowej ­ badanie europejskie.

OBJECTIVES: A growing number of patients whose length-of-stay in forensic services is aboveaverage length are identifiable in several European countries. Forensic services are situated within a particular sociocultural setting. Accordingly, this trend to increased admission length cannot be solely attributed to patient characteristics. This is the first known study exploring the influence of external factors on length-of-stay in forensic services. METHODS: Representatives from 16 European countries, members of the international COST project, focused on forensic psychiatric service, analyzed their respective forensic services using a structured tool. Responses were combined and analyzed using thematic analysis. RESULTS: Four themes described the factors influencing length-of-stay: care and treatment pathways; resources; legal and systemic impact; and sharing expertise. CONCLUSIONS: Findings suggest multidisciplinary consideration of the whole care pathway is required to address increased length-of-stay. Further research is required to support development of evidence-based standards applicable across Europe, and improve outcomes for patients at risk of increased length-of-stay in forensic services.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders.

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Elevated hydroxylactam of hemopyrrole level in urine in perpetrators of extremely violent acts diagnosed with psychosis. / Podwyzszone stezenie hydroksylaktamu hemopyrolu u psychotycznych sprawców czynów szczególnie agresywnych.

OBJECTIVES: Hydroxylactam of hemopyrrole (HPL) is an abnormal side product of porphyrin biosynthetic pathway, which may have a devastating impact on the behavior. The link between an aggressive behavior and an increased HPL level was postulated in the 1960s. Further researches concerning HPL brought contrary results and did not clarify its function and possible role in the pathogenesis of aggression. In our research we hypothesize that a heightened level of HPL may correspond to an extreme aggressive behavior in subjects diagnosed with psychosis. METHODS: We performed an analysis of HPL level in urine samples, collected from 36 male subjects diagnosed with a mental illness who presented an extreme aggressive behavior. The control group included 22 male subjects, matched with age. RESULTS: The variable HPL/creatinine quotient differs significantly between the study group and the control group. CONCLUSIONS: We used successfully proprietary method for marking HPL level in urine, developed for the purposes of the project. The results of our study indicate that in a group of subjects with a history of an extreme aggressive behavior a corrected level of HPL may be elevated, compared to subject without history of extreme aggressive behavior. Further studies are needed to evaluate the reasons of HPL elevation and its clinical implications in this group of patients.

Alpha Wavelet Power as a Biomarker of Antidepressant Treatment Response in Bipolar Depression.

There is mounting evidence of a link between the properties of electroencephalograms (EEGs) of depressive patients and the outcome of pharmacotherapy. The goal of this study was to develop an EEG biomarker of antidepressant treatment response which would require only a single EEG measurement. We recorded resting 21-channel EEG in 17 in-patients suffering from bipolar depression in eyes-closed and eyes-open conditions. The EEG measurement was performed at the end of a short washout period which followed previous unsuccessful pharmacotherapy. We calculated the normalized wavelet power of alpha rhythm using two referential montages and an average reference montage. The difference in the normalized alpha wavelet power between 10 responders and 7 non-responders was most strongly pronounced in link mastoid montage in the eyes-closed condition. In particular, in the occipital (O1, O2, Oz) channels the wavelet power of responders was up to 84 % higher than that of non-responders. Using a novel classification algorithm we were able to correctly predict the outcome of treatment with 90 % sensitivity and 100 % specificity. The proposed biomarker requires only a single EEG measurement and consequently is intrinsically different from biomarkers which exploit the changes in prefrontal EEG induced by pharmacotherapy over a given time.

[Effectiveness of ketamine in depressed patients resistant to ECT or rTMS therapy]. / Skutecznosc zastosowania ketaminy u pacjentów z depresja oporna na leczenie elektrowstrzasowe lub rTMS.

OBJECTIVES: In the last decade several authors described a robust and clinically relevant alleviation of depressive symptoms after infusions of the uncompetitive N-methyl-D-aspartate (NMDA) glutamate receptor antagonist - ketamine. In the majority of published reports ketamine was administrated to patients with depression resistant to pharmacotherapy, but not to ECT. We present a series of 5 subjects suffering from multimodal treatment-resistant depression (including ECT or rTMS and various medications) treated with intravenous infusions of ketamine in a subanesthetic dose of 0.5 mg/kg in the naturalistic setting. To the best of our knowledge it is the first report on ketamine infusion in patient resistant to antidepressants and r TMS METHODS: Two subjects have been diagnosed with MDD, one with BD, two with severe depressive episode. The efficacy and possible adverse events were monitored using psychometric scales. Basic life parameters and ECG were observed. RESULTS: Ketamine's infusions showed transient antidepressant efficacy. Improvement rate in our group was significant lower than in previously reported. Ketamine was generally well tolerated. We noted transient BP variations and appearance of mild and transient dissociative symptoms. Low early response rate may be correlated with resistance to previous multimodal treatment, high rate of somatization and anxiety comorbidity or heterogeneity of our group. CONCLUSIONS: Our findings do not support the use of ketamine infusions as the monotherapy in the subgroup of patients with multimodal treatment resistant depression.