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Electroconvulsive therapy (ECT) is a clinically well-established, evidence-based procedure for the treatment of particularly severe or treatment-resistant psychiatric and neuropsychiatric disorders. A considerable number of patients who require ECT are unable to provide informed consent due to their medical condition. Both international and national studies show that restrictive laws and legal rulings can hinder or even prevent the use of ECT in patients lacking the capacity to provide informed consent or in cases of nonvoluntary treatment (coercive treatment). Patients with indications for ECT who lack the capacity to consent constitute a vulnerable group, often with no viable alternative therapy available. The decision to administer ECT to individuals lacking the capacity to consent, particularly as a nonvoluntary treatment, is highly complex in terms of legal and medical ethics aspects because depending on the circumstances, both administering and withholding ECT can profoundly impact the patient's fundamental rights. The available evidence shows that patients initially treated against their will exhibit good overall response rates, with equally high retrospective and prospective approval for therapy compared to patients who initially consented to treatment.Together with the medical ethics considerations the authors conclude that the use of ECT should adhere to the same ethical and normative standards as all other medical interventions. This also applies to cases involving involuntary treatment. Adopting a more restrictive approach to ECT compared to other medical measures is neither medically nor ethically justified. Structural and legal barriers restricting access to necessary treatment for patients with severe and potentially life-threatening conditions should be critically reviewed and, when possible and necessary, removed.

Albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, orforglipron and semaglutide are glucagon-like peptide‑1 (GLP-1) receptor agonists. Tirzepatide targets not only GLP‑1 but also glucose-dependent insulinotropic peptide (GIP) receptors and retatrutide is a triple GLP‑1, GIP and glucagon receptor agonist. The GLP‑1 receptor agonists increase insulin release but suppress glucagon release. They slow down the emptying of the stomach and thus prevent blood sugar spikes. They reduce appetite and food intake. In the brain GLP‑1 receptor agonists lead to a better glycemic control and they appear to have anti-inflammatory and neuroprotective effects. It has been reported that GLP‑1 receptor agonists reduce oxidative stress and apoptosis, lower the risk of ischemia and promote neurogenesis. The GLP‑1 receptor agonists can also influence dopaminergic signal transduction in the nucleus accumbens. Therefore, they could modify the effect of cocaine, alcohol and nicotine. Preliminary investigations provide indications of the therapeutic benefits of GLP‑1 receptor agonists for people with dementia, eating disorders, psychopharmacologically induced weight gain, depression, anxiety and substance use disorders. Typical accompanying adverse reactions are gastrointestinal side effects, such as nausea, vomiting, diarrhea, eructation and gastroesophageal reflux. More severe side effects include pancreatitis, allergic reactions, renal function disorders and possibly an increased risk of thyroid cancer.

Background: The care of mentally ill people should be carried out in a timely, needs-based and community-based manner. The structure of the outpatient care is a cornerstone in achieving this goal. Against this background, this study presents the development of psychotherapeutic care in Saxony.

Methods: Data on outpatient psychotherapy between 2014 and 2023 from the medical register of the Saxony Association of Statutory Health Insurance Physicians were retrospectively evaluated and mapped using geodata analyses. Publicly available data from the Saxony geodatabase were used to analyze distances between local districts in Saxony and the private practices.

Results: The number of psychotherapists in private practice increased between 2014 and 2023, particularly in rural regions. The number of psychotherapists for adults increased from 761 to 1224. In 2023 all psychotherapeutic practices for adults were within 20 km of all districts in Saxony so that the provision of care improved with respect to the spatial coverage. In contrast, the availability of pediatric and adolescent psychotherapists and specialists in the child and adolescent sector as well as for adults has improved only slightly.

Discussion: The number of practices for psychotherapy has improved in urban and rural areas; however, there is a lack of data to reliably assess the coverage of needs. An analysis of the need for psychotherapeutic treatment is therefore urgently required.

Background: Disorders of sexual function are a frequent comorbidity of depression and have complex interactions on psychological, sexual and relationship qualities.

Objective: To determine the prevalence of sexual functional disorders in depressed patients, the effects of antidepressant drugs and development of treatment recommendations.

Material and method: Evaluation of the current literature and discussion of fundamental studies.

Results: Depression and sexual dysfunction frequently affect each other in complex ways which makes it important to address interpersonal relationship dynamics and to include these in the therapy. The use of serotonergic antidepressants can greatly increase the risk for sexual dysfunction by up to 27 times. In addition to (couples) therapeutic interventions, reducing the dose or switching medications to, e.g., bupropion or using additive medications can also be treatment options.

Conclusion: Despite the shame associated with the topic, it is crucial for therapists to address sexual topics early and openly. Relationship dynamics should be considered during therapy. If antidepressant medications are used it is recommended to provide a more detailed clarification for patients about their potential sexual side effects and their limited treatment options before starting the medication.

Background: More than a decade ago disulfiram lost its approval for use in Germany. Nonetheless, a considerable number of psychiatric hospital outpatient departments as well as practicing physicians continue to prescribe it. These professionals have formed the "Network for Alcohol Aversive Pharmacotherapy" (NAP) to maintain a high quality of this treatment approach.

Objective: To describe the current use of disulfiram with respect to patient numbers and characteristics, side effects, and use of concomitant multimodal treatment forms.

Material and methods: Since 2019 the NAP has conducted an annual retrospective survey among its members regarding the aforementioned parameters.

Results: From 2019 to 2023 a total of 1579 treatment cases were described by 33 centers, 152 patients reported a total of 241 drinking events, 26 of them resulting in hospitalization but none causing complications or permanent harm. The most frequent side effects, in descending order, were unpleasant body odor (2.5%), fatigue, male sexual dysfunction, mildly elevated liver enzymes, allergic skin reactions and polyneuropathy (0.8%). More than one quarter of the patients suffered from comorbid depression, and approximately 5% from ADHD, borderline or other personality disorders, trauma-related disorders and anxiety disorders, respectively. Of the patients 33% were treated with antidepressants and 12% with sedating antipsychotics. Various forms of concomitant group therapy were offered to 66% of the patients.

Conclusion: Treatment with disulfiram is legally possible, generally well-tolerated and safe. It is offered in most treatment centers as part of a comprehensive treatment plan that includes multimodal treatment of comorbid psychiatric disorders.

Background: Blinded placebo treatment arms in clinical trials often achieve up to 80% of the clinical improvements of the verum groups. Apparently, the majority of the effects found in the antidepressant groups in clinical trials are due to factors that are not specific to antidepressant treatment. This article reviews the factors that contribute to the high effectiveness of placebo interventions for antidepressants.

Methods: A narrative literature review is presented with particular emphasis on placebo effects in antidepressant clinical trials.

Results: There is a particularly strong placebo effect in depression compared to other mental disorders. The magnitude of this effect can be modulated by helpful versus nonhelpful instructions, by patient participation in the decision-making process but also by personal attention, especially if the clinician is perceived as competent and warmhearted. The occurrence of subtle side effects can also reinforce placebo effects. Placebo effects are not only reflected in subjective patient-reported outcome variables but are also evident in neurochemical changes in the body.

Conclusion: Clinicians essentially contribute to the effectiveness of antidepressant treatment through their own behavior. At the same time, the relatively small overall difference between verum and placebo treatments for depression leads to the necessity of a critical evaluation of the cost-benefit ratio, adapted to the individual case. Study designs for the evaluation of antidepressants are required that better reflect the complex interactions between the genuine drug effects and placebo effects.

Background: Antidepressant pharmacotherapy often does not result in the desired effect despite adequate duration and dose. Better evidence on second-step strategies is needed.

Objective: Overview of the current evidence for various pharmacological second-step strategies after nonresponse to antidepressant monotherapy.

Material and methods: Summary of recent systematic reviews with meta-analyses of the group of authors on pharmacological second-step treatment.

Results: A meta-analysis showed no advantage of switching to a second antidepressant compared with continuing the previously ineffective monotherapy. Another two meta-analyses showed no benefit of increasing the dose of selective serotonin reuptake inhibitors (SSRI). For serotonin and noradrenaline reuptake inhibitors (SNRI) and tricyclic antidepressants (TCA) in each case a meta-analysis showed no clear advantage of increasing the dose. Another two meta-analyses showed a superiority of a combination therapy consisting of a reuptake inhibitor (SSRI, SNRI, TCA) with a presynaptic alpha‑2 autoreceptor antagonist (e.g., mirtazapine) compared with an antidepressant monotherapy.

Conclusion: In accordance with the recommendations of the German national treatment guideline, in the event of nonresponse to antidepressant monotherapy, the combination of two antidepressants is preferable to repeated switching of the antidepressant.

Background: The prescription of antidepressants has been steadily increasing in Germany and worldwide for decades; however, there are no indications that this leads to an improvement in public mental health.

Objective: The question is investigated whether antidepressant pharmacotherapy, when administered over a long period of time, can adversely affect the course of depressive disorders.

Material and method: A selective literature search was carried out in the PubMed and ScienceDirect (since 1969) databases. In addition to the keyword "antidepressants", the search included the terms "tolerance", "withdrawal", "relapse", "loss of effectiveness" and "treatment resistance".

Results: If antidepressant treatment is stopped, the interval until the next episode of illness decreases compared to the inter-episode interval before initiation of drug treatment and the faster the antidepressant is stopped, the shorter the interval becomes. The relatively high frequency of relapses during ongoing treatment suggests that tolerance to the effects of the drugs has developed. In some cases, treatment resistance must also be considered to be a biological (counter)reaction of the brain to the intervention.

Conclusion: The literature summarized in this narrative review indicates that long-term antidepressant drug treatment can have an adverse effect on the course of the disease in some patients. The undisputed benefits of acute antidepressant drug treatment are offset by potential risks when taken chronically or when discontinued, which are probably due to adaptive brain changes. This must be taken into account when initiating any antidepressant pharmacotherapy.