Relationship Between Anesthesia Depth and Quality of Seizures in Patients Undergoing Electroconvulsive Therapy: A Prospective Observational Study.

OBJECTIVES: Electroconvulsive therapy under general anesthesia is an established treatment for mood disorders, such as therapy-resistant depression. As most anesthetic drugs used for induction of anesthesia increase the seizure threshold, adequate depth of anesthesia without diminishing the therapeutic efficacy of interventions is crucial. The aim of this study was to investigate whether anesthesia depth as assessed by Narcotrend (NCT) monitoring correlates with maximum seizure quality. METHODS: An observational study was performed in psychiatric patients undergoing multiple interventions of electroconvulsive therapy. Seizure quality of each attendance was assessed evaluating electroencephalogram end point, electromyogram end point, postictal suppression index, the midictal amplitude, and a 3-step overall graduation. Narcotrend was used to assess anesthesia depth according to index-based electroencephalogram findings. Measurements were obtained before induction of anesthesia, before stimulation, and after arousal. Data were analyzed by means of linear mixed models and generalized estimating equations models. RESULTS: A total of 105 interventions in 12 patients were analyzed. Anesthesia depth before stimulation was significantly associated with seizure quality (standardized ß = 0.244, P = 0.010), maximum sustained coherence (ß = 0.207, P = 0.022), and electroencephalogram duration (ß = 0.215, P = 0.012). A cutoff value of 41 or greater versus 40 or less for the NCT index was found appropriate to differentiate between good and less satisfactory overall seizure quality. CONCLUSIONS: Anesthesia depth index assessed by NCT monitoring was positively associated with seizure quality. Narcotrend monitoring may be useful in assessment of optimal anesthesia depth before stimulation.

Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment.

Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called "late onset" patients (LOBD), and the elder patients with a long-standing clinical history, the so called "early onset" patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970-2021 using the MeSH terms "bipolar disorder" and "aged" or "geriatric" or "elderly". The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.

Combined Processing of Facial and Vocal Emotion in Remitted Patients With Bipolar I Disorder.

OBJECTIVES: Bipolar disorder (BD) is associated with impairments in facial emotion and emotional prosody perception during both mood episodes and periods of remission. To expand on previous research, the current study investigated cross-modal emotion perception, that is, matching of facial emotion and emotional prosody in remitted BD patients. METHODS: Fifty-nine outpatients with BD and 45 healthy volunteers were included into a cross-sectional study. Cross-modal emotion perception was investigated by using two subtests out of the Comprehensive Affective Testing System (CATS). RESULTS: Compared to control subjects patients were impaired in matching sad (p < .001) and angry emotional prosody (p = .034) to one of five emotional faces exhibiting the corresponding emotion and significantly more frequently matched sad emotional prosody to happy faces (p < .001) and angry emotional prosody to neutral faces (p = .017). In addition, patients were impaired in matching neutral emotional faces to the emotional prosody of one of three sentences (p = .006) and significantly more often matched neutral faces to sad emotional prosody (p = .014). CONCLUSIONS: These findings demonstrate that, even during periods of symptomatic remission, patients suffering from BD are impaired in matching facial emotion and emotional prosody. As this type of emotion processing is relevant in everyday life, our results point to the necessity to provide specific training programs to improve psychosocial outcomes. (JINS, 2019, 25, 336-342).

Efficacy of Continuation/Maintenance Electroconvulsive Therapy in the Treatment of Patients With Mood Disorders: A Retrospective Analysis.

OBJECTIVE: The aim of the study was to contribute evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) going beyond the existing literature by examining longer-term outcomes from a single center. METHODS: We conducted a retrospective observational cohort study for a 14-year period, in which a group of 27 individuals with mood disorders, as defined by International Classification of Diseases-10, were examined and received acute ECT, followed by c/mECT. Mirror-image comparison of individual data sets, 5 years before and after c/mECT, was conducted for the number and mean duration of hospitalizations, as well as inpatient days per year. Statistical analysis was performed using general equation estimation modeling. RESULTS: In 27 patients (63% female, mean ± SD age = 54.3 ± 11.7 years) experiencing either from bipolar (41%) or unipolar (59%) mood disorder, with most patients presenting with a depressive episode at hospital admission (93%), c/mECT was initiated after a successful course of acute ECT in addition to treatment as usual. In a 5-year period before and after starting c/mECT, we observed a significant decline in the mean number of hospitalizations per year (0.64 vs 0.32, P = 0.031), the average number of inpatient days per year (23.7 vs 6.1 days, P < 0.001), and the mean duration of hospital stays (41.6 vs 22.1 days, P = 0.031). CONCLUSIONS: The findings provide further support for the efficacy of c/mECT as an augmentation therapy to psychopharmacological treatment in patients experiencing mood disorders, who have responded to acute ECT. Further studies, however, using a controlled study design and larger sample sizes are needed.

Bupropion Maintenance Treatment in Refractory Bipolar Depression: A Case Report.

BACKGROUND: The optimal duration of antidepressant treatment in bipolar depression appears to be controversial due to a lack of quality evidence, and guideline recommendations are either vague or contradictive. This is especially true for second line treatments such as bupropion that had not been subject to rigourous long term studies in Bipolar Disorder. CASE PRESENTATION: We report the case of a 75 year old woman who presented with treatment refractory bipolar depression. Because of insufficient response to previous mood stabilizer treatment and refractory depressive symptoms, bupropion was added to venlafaxine and lamotrigine. From there onwards, the patient improved continuously without experiencing deterioration of depression or a switch into hypomania. Our patient being on antidepressants for allmost four years experienced an obvious benefit from longterm antidepressant administration. CONCLUSION: Noradrenergic/dopaminergic mechanisms of action may play a more prominent role in bipolar depression, and may still be underused as a therapeutic strategy in the acute phase as well as in long-term maintenance in at least a subgroup of bipolar patients. There is still a lack of evidence from RCTs, but this case report further supports antidepressant long-term continuation and the usefulness of a noradrenergic/dopaminergic antidepressant in the acute and maintenance treatment of bipolar disorder.

[Lithium treatment in patients with impaired kidney function: Between Scylla and Charybdis]. / Lithiumtherapie bei eingeschränkter Nierenfunktion: Zwischen Skylla und Charybdis.

Introduction In quite a few patients with bipolar disorder there is no real alternative to lithium treatment despite impaired kidney function. Is it possible to continue lithium treatment despite kidney malfunction by changing dosage and/or frequency of administration? Case Report We report on a 65-year-old woman suffering from bipolar-I disorder who had been on lithium treatment for many decades. While on lithium, the glomerular filtration rate (GFR) decreased constantly. A decision had to be made whether to switch to a more tolerable o.d. administration or to taper off lithium. Conclusion With a single dose at bedtime, the serum levels remained stable; however, kidney function unfortunately did not improve. A relevant increase of GFR above the level of 60 mL/min/1,73 m2 was only achieved after a 50% dose reduction leading also to a substantial decrease of lithium serum levels. A kidney protective lithium application in patients with reduced renal function is like sailing between Scylla and Charybdis.

Child and adolescent psychiatry patients coming of age: a retrospective longitudinal study of inpatient treatment in Tyrol.

BACKGROUND: Mental illness is a common phenomenon at all ages. Various independent studies have shown that psychopathology is often expressed on a continuum from youth to adulthood. The aim of our study was to demonstrate a) the frequency of admission of former child and adolescent psychiatry inpatients (CAP-IP) to adult inpatient mental health facilities, and b) a potential longitudinal diagnostic shift. This is the first Austrian study designed to shed light on these issues. METHODS: Nearly 1000 inpatient cases at a specialized child and adolescent care center were analyzed. These cases were then tracked using data matching with registry data from adult psychiatric institutions. Overall, our observational period was 23 years. RESULTS: 26 % of our sample of former CAP-IP used psychiatric inpatient mental health services as adults, thus indicating chronicity or reoccurrence. In line with previous literature, there were patients who stayed in the same diagnostic category as well as patients with a diagnostic shift from childhood to adulthood. CONCLUSIONS: Childhood and adolescence is a very important period for early intervention and prevention of mental illness. Our findings support the notion of the continuity of psychopathology from youth into adulthood.

[«The child is father of the man¼ - review of literature on epidemiology in child and adolescent psychiatry]. / «The Child is Father of the Man¼ - Review von relevanten Studien zur Epidemiologie in der Kinder- und Jugendpsychiatrie.

One of the goals of epidemiological research is to describe the frequency and patterns in the distribution of diseases among certain groups of a statistical population. According to the literature available, mental disorders in children and adolescents are a common phenomenon worldwide. This article provides a review of the most important and recent international studies on the magnitude, on patterns of distribution, on the course and on gender differences of psychiatric disorders in children and adolescents. Additional data from scientific textbooks are added to the original articles.

Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder.

OBJECTIVES: Outcome in bipolar disorder (BD) is multidimensional and consists of clinical and psychosocial domains. Difficulties in affect recognition and in emotional experience are a hallmark of BD, but there is little research investigating the consequences of this deficit on the psychosocial status of patients who are in remission. METHODS: This cross-sectional study examined the relationship of facial affect recognition and treatment outcomes in terms of psychopathology, quality of life, and psychosocial functioning in remitted BD patients compared to healthy volunteers. RESULTS: Altogether, 47 outpatients meeting diagnostic criteria for bipolar I disorder according to DSM-IV and 45 healthy control subjects were included in the study. Patients were particularly impaired in the recognition of facial expressions depicting disgust and happiness. For patients, the most frequently observed misidentifications included disgusted faces misrecognized as angry expressions, fearful faces misrecognized as disgusted or surprised expressions, surprised faces misrecognized as fearful expressions, and sad faces misrecognized as fearful or angry expressions. Regarding emotional experience, shame, guilt, sadness, fear, lifelessness, loneliness, and existential fear were experienced more intensely by patients. CONCLUSIONS: These findings demonstrate deficits in experiencing and recognizing emotions in BD patients who are in remission and underscore the relevance of these deficits in the psychosocial context.

Does a Lack of Awareness of Cycloid Psychosis Hamper Adequate Treatment for Patients Suffering From This Disorder? A Case Report.

Categorial systems of nosology are based on a cross-sectional enumeration of symptoms with a predefined cut-off, but hardly capture rapid fluctuations of manifestation nor longitudinal characteristics, e.g., cyclicity. Especially with disorders presenting with an admixture or frequent change of psychotic and affective symptoms, diagnostic specifity of the DSM and ICD diminishes. In those instances, alternative concepts as cycloid psychosis might display more accurately the very characteristics and course of a mental disorder and help to tailor individualized treatments. Karl Leonhard described three major subtypes of cycloid psychosis: anxiety-happiness psychosis, confusion psychosis, and motility psychosis, all showing a pleiomorphic symptom profile resembling intraphasic switching of poles. Here we present the case of a 59-year-old woman suffering from cycloid psychosis as defined by the criteria of Perris. Between 2013 and June 2019, the patient was admitted 35 times for compulsory treatment. A frequent change of diagnoses, ranging from adjustment disorder to complex PTSD, and from unipolar depression to "pseudoneurotic schizophrenia," resembles the puzzling manifestations. Most of the time the patient was labeled as schizoaffective disorder despite never displaying clear psychotic core symptoms. Despite treatment with different antipsychotics including LAI the cumulative length of hospitalization increased steadily from 74 days in 2014 to 292 days in 2017. When reviewing the case in 2017 the longitudinal pattern of her disorder and the diverse acute manifestations were finally conceptualized as a cyclic on-off of an atypical psychosis. After starting lithium to pre-existing LAI antipsychotics and valproic acid, the number of days per year spent in inpatient care sharply dropped to 136 in 2018. We propose to reconsider cycloid psychosis as a useful clinical concept whose descriptive value, validity and utility for treatment decisions should be further evaluated. Lithium alone or in addition to valproic acid may act on cyclicity as a core symptom of cycloid psychosis as well as of bipolar disorder, even in the absence of major affective symptoms.

[Women seek for help - men die! Is depression really a female disease?]. / Frauen suchen Hilfe - Männer sterben! Ist die Depression wirklich weiblich?

Prevalence rates of depression in females are about two to three times higher as compared to men. Biological evidence seems to support these data. Genderspecific suiciderates, closely linked to depressive illness, however raise doubts about the genderspecific epidemiological data of depression as males commit suicide three to ten times more often than females. The sociomedical concept of "male depression" delivers an explanation. A gender bias in diagnose as well as a reduced male helpseeking behavior and dysfuntional stress coping in males might be reasons for the reported low prevalence-rates of depression in males. Depression might hide behind addictive- and risk-behavior as well as irritability. As these symptoms differ from the classic depressive symptoms they might not be detected and identified as such. Validated rating scales which specifically assess male symptoms of depression, as well as peer-education programs for colleagues might change current depression rates in males.

[Depressive symptoms and the Idiopathic Parkinson's Syndrome (IPS): a review]. / Depressive Symptome und das Idiopathische Parkinson Syndrom (IPS): Ein Review.

The prevalence of the Ideopathic Parkinson's Syndrome sums up to 2% and ranks second in the list of neurodegenerative diseases. Beside psychotic, cognitive and behavioural symptoms that go along with the IPS, the authors focus on epidemiology, pathogenesis as well as diagnosis and therapy of depressive symptoms seen in the context of IPS. Metaanalytic data on the prevalence of depressive symptoms sum up to 31%. As depression in IPS relies on a complex interaction of psychological and biological causes the clinical picture is difficult to assess because symptomatology differs from classical depression. Dopamine agonists as well as antidepressants present the mainstay in biological therapeutic interventions. A therapeutic algorithm based on theoretical considerations is presented.

The use of (newer) antipsychotics in bipolar inpatients over a 17-year observation period.

Antipsychotics (AP) are commonly used in the treatment of bipolar disorder. They cover a broad spectrum of indications including acute psychotic, manic and depressive symptoms, and maintenance treatment. This study evaluates the changes in prescribing patterns of first-generation antipsychotics (FGA) and second-generation AP at Innsbruck University Hospital for the treatment of bipolar inpatients between 1999 and 2016. In this retrospective chart review, we included adult patients with a diagnosis of bipolar affective disorder (ICD 9: F296; ICD 10: F31) who were admitted as inpatients at the Department for Psychiatry and Psychotherapy between 1999 and 2016 for more than 7 days. The study was approved by the local ethics committee. The complete medical histories were searched retrospectively for the prescription of psychotropic medications at the time of discharge, with a special focus on APs. We found a significant increase in the use of atypical AP, mainly attributable to the prescription of quetiapine for all types of episodes, followed by aripiprazole for manic and as add-on therapy for depressive episodes. The prescription rate of clozapine decreased significantly. The prescription rate of FGA showed a small but not significant decrease for the treatment of manic and mixed episodes, and a significant decrease for depressive episodes. These trends apparently mirror in part the evidence base for the use of AP, but also illustrate that clinicians still appreciate the effectiveness of FGA despite their inferior tolerability profile.

Quality of life in stabilized outpatients with bipolar I disorder: Associations with resilience, internalized stigma, and residual symptoms.

OBJECTIVES: Improving Quality of Life (QoL) is an important objective in the treatment of bipolar disorder. The aim of the current study was to examine to which extent resilience, internalized stigma, and psychopathology are correlated to QoL. METHODS: We recruited 60 outpatients diagnosed with bipolar I disorder according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, symptoms were quantified by the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS) and internalized stigma by the Internalized Stigma of Mental Illness (ISMI) scale. In order to assess QoL and resilience, the Berliner Lebensqualitätsprofil (BELP) and the Resilience Scale (RS-25) were used in both patients and control subjects. RESULTS: Despite presenting with a very mild symptom level and relatively low internalized stigma, patients with bipolar I disorder indicated significantly lower QoL and resilience as compared to healthy control subjects. In patients, QoL correlated significantly with resilience, internalized stigma, and residual symptoms of depression. No significant correlations were observed between QoL and residual manic symptoms. LIMITATIONS: The cross-sectional design and the relatively small sample size limit the generalizability of our results. Furthermore, levels of resilience and internalized stigma may change over the course of the illness and have different impacts on the long-term outcome of patients with bipolar disorder. CONCLUSION: Our results show that QoL of patients suffering from bipolar I disorder, even when only mildly ill, is strongly associated with the degree of resilience and internalized stigma, and that particularly residual depressive symptoms have a negative impact on QoL. In addition to drug treatment, psychotherapeutic approaches should be applied to strengthen resilience, to reduce internalized stigma, and, ultimately, to improve quality of life.

[Is there a rationale in combining anticonvulsants for bipolar patients?]. / Rationale für eine Kombinationstherapie von Antikonvulsiva bei bipolaren Störungen.

High recurrence rates, chronicity and severity as well as high incidence rates of therapy refractory of bipolar disorder, different clinical manifestations of episodes, and psychiatric comorbidities demand combined drug treatment strategies. Polypharmacy is reported in more than 40 % of bipolar in- and out patients. The aim of this paper is to evaluate the incidence of combined mood stabilizer prescriptions and to delineate preclinical and clinical rationales for these treatment options. Over the last decade frequency of combination therapies with 2 or more anticonvulsants increased from 4.5 to more than 12 %. On the background of the dynamic complexity and being aware of potential side effects of such therapy paradigms, the authors provide a rationale for a thoughtful anticonvulsant combination therapy, considering the preclinical findings from epilepsy research, and clinical trials in bipolar disorder.

[Child and adolescent bipolar disorder]. / Bipolar Affektive Störungen im Kindes- und Jugendalter.

The onset of bipolar disorders before the age of 10 is rare. First manifestation occurs most frequently between the age of 15 to 30. Children of a parent with bipolar disorder are at a fivefold risk for developing a bipolar disorder. Therefore, an elaborate family-history is essential for the assessment of potentially manic or depressive symptoms in children and adolescents. Basically, for all age groups the same diagnostic criteria according to ICD 10 are applied. Due to the differing symptoms for children and adolescents the finding of a diagnosis is considerably harder than for adults. Manic episodes before the age of 10 are characterized by increased activity, more risk taking behaviour and elevated emotional instability. In adolescents, however, behavioural disturbance with antisocial behaviour and drug-abuse are more common. Thus, typical misdiagnosis as ADHD or conduct disorders for children and adolescents are frequent. Aggravating the complexity, in up to 90 % both differential-diagnosis may occur as comorbid disorders. Furthermore, psychotic symptoms are more common than in adults and dysphoria is more likely than euphoric or depressive mood. Asymptomatic intervals rarely exist, whereas "ups" and "downs" in rapid succession are prevailing (rapid cycling). An early diagnosis, leading specific treatment, is essential for the prognosis of bipolar disorders. Additionally, structural (CCT or MRI) and laboratory examination are essential to expel endocrine or brain-organic diseases. Besides psychotherapeutic and psychoeducative methods, always including parents and attached persons, the psychopharmacological treatment is a major part of a multimodal treatment. The available substances partly have been in use for years and are appropriate for youngsters. These include mood stabilizers like lithium, divalproex and carbamazepine, which provide besides their acute antimanic effects also relapse-prophylactic properties. In addition atypical antipsychotics like risperidone, olanzapine and quetiapine have gained more and more importance in the treatment of manic states in children and adolescents during the last years. However the use of antidepressants in children and adolescents should be considered with great caution due to arguable efficacy and potentially severe adverse effects, i.e. amplification of suicidal ideation.

[Psychotherapeutic interventions in bipolar disorder: a review]. / Psychotherapeutische Interventionen bei Bipolaren Erkrankungen: Eine Ubersicht der Literatur!

The treatment of bipolar disorders is a demanding task involving patients, therapists and relatives. As bipolar disorders are associated to multiple psychosocial disturbances, the management of a bipolar disease should focus on psychosocial interventions. Despite an exploding literature on this topic, psychopharmacological interventions applied as a monotherapy have shown unsatisfactory outcomes. In order to enhance outcome, psychotherapy, such as cognitive behavioural therapy (CBT), psychoeducation, a modified form of interpersonal psychotherapy (IPSRT) or family focussed psychotherapy (FFT) were investigated. When used in conjunction with pharmacotherapy, these interventions may prolong time to relapse, reduce symptom severity, and increase medication adherence. These combinations are currently considered being the golden standard in the treatment of bipolar disorders. Psychotherapeutic interventions as an add-on strategy exert better effects when patients are euthymic at entry. Prevention of manic episodes seems to be more successful as compared to the prevention of depressive episodes. There are currently no hints for a method specific efficacy. Efficacy of psychoeducation seems to be rather short lived. Currently not yet evaluated booster-sessions might help. More data are needed in order to identify patients with a putative good response to psychotherapeutic interventions.

[Are there substantial reasons for contraindicating antidepressants in bipolar disorder? Part II: facts or artefacts?]. / Sind Antidepressiva in der Behandlung der bipolaren Depression obsolet? Teil II: Harte Fakten oder Artefakte?

After having dedicated the first part of this article to the prevalence and impact of depressive symptoms in the context of bipolar disorders, the authors now delineate advantages and disadvantages of antidepressants in bipolar depression. A literature search was performed using PubMed, and Mesh Database using the keywords, bipolar disorder, antidepressants and depression. Additional information was gained by cross-referencing from papers found in the data base. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. In contrast to the worldwide uniformly used guidelines in the treatment of mania, there is a controversial discussion, on the use of antidepressants in bipolar disorder. Whereas European guidelines exert a more allowing attitude towards the use of antidepressants, currently published US-guidelines do explicitly not recommend antidepressants in the treatment of bipolar depression, unless depression is severe. In fact, antidepressants are yielded to destabilize the disease by triggering switches into mania and to increase cycle acceleration. Despite that, antidepressants, in addition to, or without mood-stabilizers, are broadly used in clinical practice in acute or maintenance therapy. Literature of the use antidepressants as first line treatment in bipolar depression is too sparse to favour or to refute such a therapy. In order to prevent from affective side effects, antidepressant substances like tricyclics should be avoided. Instead substances like SSRI or bupropion with less affective side effects should be used. If antimanics are added, SSRI or bupropion seem to exert switch rates on placebo level. Specific subtypes of bipolar disorder, such as mixed episodes, rapid cycling courses, seem to be extensively associated to antidepressants induced switch phenomena. Antidepressants should be avoided in this sample of patients. Bipolar-II-subtype seems to be associated with low switch-rates, independent from the used substance class. Patient-specific features, such as comorbidities, a history of mania, early beginning, psychotic features, a positive genetic load) seem to negatively influence the onset of antidepressant induced affective side-effects. An extended assessment of the individual medical history is therefore warranted. Literature on the use of antidepressants in maintenance is virtually absent. The authors present current literature and guidelines of recent treatment recommendations in bipolar depression.

[Are there substantial reasons for contraindicating antidepressants in bipolar disorder? Part III. The alternatives!]. / Sind Antidepressiva in der Behandlung der bipolaren Depression obsolet? Teil III: Die Alternativen!

After having described depressive symptoms along the course and different subtypes of bipolar disorder the authors focus on pharmacological alternatives to antidepressant medication in bipolar depression. In doing so, they review the newest literature on efficacy of antidepressants and compare effect size of the different alternatives like antipsychotics and mood stabilizers to those of antidepressants. Efficacy of antidepressants in bipolar depression is still discussed controversially, as scientific evidence, is as far as available, weak. Severity of depressive symptoms should define, wether or not antidepressants in comparison to alternative agents like antipsychotics or mood stabilizers should be implemented. According to a balanced analysis of pro's and con's antidepressants may be used in minor to medium depressive symptoms as well. For clinical safety reasons, and not due to scientific evidence, an antimanic agent should be implemented in addition to an antidepressant. Because of clinical wisdom, in patients with mixed episodes or rapid cycling antidepressants should be avoided.

Trends in the pharmacological treatment of patients with schizophrenia over a 12 year observation period.

In this study we evaluated whether our efforts to promote evidence-based guidelines for the psychopharmacological treatment of patients with schizophrenia have led to measurable changes of treatment practice in our hospital by investigating three primary hypotheses: 1) Polypharmacy has become less common in recent years, 2) Conventional neuroleptics have been replaced by second generation antipsychotics; and 3) Dosing regimes have changed towards lower doses. We have therefore collected data from the clinical records of all in-patients with ICD-9/ICD-10 diagnoses of schizophrenia hospitalized at the Department of Psychiatry of the Medical University Innsbruck in the years 1989, 1995, 1998 and 2001. Data from 1989 to 1998 showed a significant decrease in the use of two or more antipsychotics given simultaneously. Contrary to our hypothesis, there was a significant increase in polypharmacy between 1998 and 2001. The predominant use of second generation antipsychotics became standard in schizophrenia treatment. In this context the decrease of concomitant anticholinergic medication is notable. Doses of conventional antipsychotics like haloperidol as well as doses of risperidone decreased whereas doses of other second generation antipsychotics increased. All in all, the pharmacological management of schizophrenia patients is increasingly in tune with current treatment guidelines.