REM density is associated with treatment response in major depression: Antidepressant pharmacotherapy vs. psychotherapy.

Major depression is one of the most common psychiatric illnesses. Interestingly, a few studies have indicated the existence of depression subgroups, which respond differently to the available treatment options. Previously, sleep abnormalities have been suggested to indicate amenability to different treatment regimens. Thereby, especially REM-sleep parameters seem to play a prominent role, and REM-sleep dysregulation has been repeatedly discussed as a potential endophenotype of depression. With that said, estimating therapy outcome in order to choose the best line of treatment is of utmost importance to patients suffering from depression. The present study looks deeper into these clues by investigating the capability of polysomnographic sleep parameters to predict treatment response in depressed patients to either pharmacotherapy or psychotherapy. Moderately to severely depressed patients (n = 38) were randomly assigned to either psychotherapy (i.e. interpersonal psychotherapy) or pharmacotherapy (i.e., monotherapy with selective serotonin reuptake inhibitors, SSRI, or selective serotonin noradrenalin reuptake inhibitors, SSNRI). Prior to treatment, all patients underwent polysomnography in the sleep laboratory. After treatment, responders and non-responders of both treatment groups were compared regarding their baseline sleep parameters. Higher baseline REM density, i.e. the amount of rapid eye movements during REM sleep, predicted better response to antidepressant pharmacotherapy. In the psychotherapy group, the effect seemed reversed but was not statistically significant. No other sleep parameter predicted treatment response. Our findings support the notion that REM-sleep dysregulation is indeed indicative of a distinct endophenotype of depression and that pharmacotherapy with SSRI/SSNRI might be superior to psychotherapy in these patients.

[On the Situation of Inpatient Forensic Psychotherapy in Germany - Results of a Survey in Forensic Psychiatric Institutions]. / Zur Situation stationärer forensischer Psychotherapie in Deutschland ­ Ergebnisse einer Umfrage in Maßregelvollzugseinrichtungen.

The Federal Constitutional Court has emphasized the necessity of psychotherapy for offenders. Little is known about the actual situation of this field of work. Thus, an online survey was initiated.The survey was conducted through an online portal. The heads of forensic psychiatric facilities have been asked to participate by completing a questionnaire.The elicitation provided data from 27 institutions. A large part of patients receive psychotherapeutic treatment. Psychotherapy is predominantly shaped by psychologists. The majority of institutions apply approaches derived from behavioral therapy. To a large extent, manualized and modular procedures are being used; most of them in group settings. One problem stems from personnel deficiencies, leading to psychotherapy not taking place on a regular basis or not being performed in accordance to the guidelines of treatment programs.The prior allegation - impositions of forensic measures being characterized by custodial detention - is no longer valid for a high number of forensic psychiatric services.

Eye Movement Desensitization and Reprocessing Versus Treatment as Usual in the Treatment of Depression: A Randomized-Controlled Trial.

Eye movement desensitization and reprocessing (EMDR) is a well-established treatment for post-traumatic stress disorder. Recent research suggested that it may be effective in treating depressive disorders as well. The present study is part of a multicenter randomized-controlled trial, the EDEN study, in which a homogenous group of 30 patients was treated to test whether EMDR plus treatment as usual (TAU) would achieve superior results compared to TAU only in a psychosomatic-psychotherapeutic inpatient treatment setting. Both groups were assessed by the Beck Depression Inventory-II (BDI-II) and the Global Severity Index and depression subscale of the Symptom Checklist 90-Revised. The EMDR + TAU group improved significantly better than the TAU group on the BDI-II and Global Severity Index, while a marginally significant difference favoring the EMDR + TAU group over the TAU group was found on the depression subscale. In the EMDR + TAU group, seven out of 14 patients improved below nine points on the BDI-II, which is considered to be a full remission, while four out of 16 in the TAU group did so. These findings confirm earlier suggestions that EMDR therapy may provide additional benefit in the treatment of depression. The present study strengthens the previous literature on EMDR therapy in the treatment of depression due to the randomized-controlled design of the EDEN study.

[Does the Youth Psychopathic Traits Inventory (YPI) identify a clinically relevant subgroup among young offenders?]. / Identifiziert das Youth Psychopathic Traits Inventory (YPI) eine klinisch bedeutsame Untergruppe junger Straftäter?

Objective: Does the Youth Psychopathic Traits Inventory identify one or more high-risk subgroups among young offenders? Which recommendations for possible courses of action can be derived for individual clinical or forensic cases? Method: Model-based cluster analysis (Raftery, 1995) was conducted on a sample of young offenders (N = 445, age 14­22 years, M = 18.5, SD = 1.65). The resulting model was then tested for differences between clusters with relevant context variables of psychopathy. The variables included measures of intelligence, social competence, drug use, and antisocial behavior. Results: Three clusters were found (Low Trait, Impulsive/Irresponsible, Psychopathy) that differ highly significantly concerning YPI scores and the variables mentioned above. The YPI Scores Δ Low = 4.28 (Low Trait ­ Impulsive/Irresponsible) and Δ High = 6.86 (Impulsive/Irresponsible ­ Psychopathy) were determined to be thresholds between the clusters. Conclusions: The allocation of a person to be assessed within the calculated clusters allows for an orientation of consequent tests beyond the diagnosis of psychopathy. We conclude that the YPI is a valuable instrument for the assessment of young offenders, as it yields clinically and forensically relevant information concerning the cause and expected development of psychopathological behavior.

Assessing paedophilia based on the haemodynamic brain response to face images.

OBJECTIVES: Objective assessment of sexual preferences may be of relevance in the treatment and prognosis of child sexual offenders. Previous research has indicated that this can be achieved by pattern classification of brain responses to sexual child and adult images. Our recent research showed that human face processing is tuned to sexual age preferences. This observation prompted us to test whether paedophilia can be inferred based on the haemodynamic brain responses to adult and child faces. METHODS: Twenty-four men sexually attracted to prepubescent boys or girls (paedophiles) and 32 men sexually attracted to men or women (teleiophiles) were exposed to images of child and adult, male and female faces during a functional magnetic resonance imaging (fMRI) session. RESULTS: A cross-validated, automatic pattern classification algorithm of brain responses to facial stimuli yielded four misclassified participants (three false positives), corresponding to a specificity of 91% and a sensitivity of 95%. CONCLUSIONS: These results indicate that the functional response to facial stimuli can be reliably used for fMRI-based classification of paedophilia, bypassing the problem of showing child sexual stimuli to paedophiles.

A young woman who killed 5 of her own babies: A case of multiple neonaticide.

Neonaticide is a rare form of homicide. It is generally classed as manslaughter but differs from other forms of homicide in many respects. The factors favouring its occurrence and the legal position of neonaticide in Germany are discussed. The case is presented of a mother who committed five neonaticides within 8 years. While she was a caring mother for her two oldest children, she killed the five subsequent offspring immediately after giving birth. In the scarce literature on neonaticides, a case of multiple offending is particularly rare. Similarities to, and differences from, other cases of neonaticide in the literature are considered. The psychodynamic context of the offences is examined in order to identify contributing features which could be used to help prevent future occurrences.

The (in)consistency of changes in brain macrostructure in male paedophiles: A combined T1-weighted and diffusion tensor imaging study.

Thus far, four studies have used magnetic resonance imaging (MRI) to test for differences in brain structure between paedophilic (i.e. sexually attracted to pre-pubescent children) and teleiophilic (i.e. sexually attracted to adults) men, revealing divergent results. To re-examine this issue, we acquired high resolution structural T1-weighted and diffusion MRI scans of the brain in 24 paedophilic and 32 teleiophilic men. We performed voxel-based morphometry (VBM) of the T1-weighted images and tract-based spatial statistics (TBSS) of the diffusion tensor imaging data to search for grey and white matter differences between groups. In contrast to previous studies, less than half of the individuals in our paedophilic group had a record of sexual offences against children, as subjects were partially recruited from two outpatient facilities of a child sexual abuse prevention project for self-acknowledged paedophiles. After adjustment for multiple comparisons and controlling for important confounding factors, we did not find any significant grey or white matter differences between the paedophilic and teleiophilic subjects. Together with the inconsistencies in the literature, these results argue against consistent structural differences at the macroanatomical scale between paedophiles and teleiophiles.

Eye movement desensitization and reprocessing (EMDR) therapy in the treatment of depression: a matched pairs study in an inpatient setting.

BACKGROUND: Depression is a severe mental disorder that challenges mental health systems worldwide as the success rates of all established treatments are limited. Eye Movement Desensitization and Reprocessing (EMDR) therapy is a scientifically acknowledged psychotherapeutic treatment for PTSD. Given the recent research indicating that trauma and other adverse life experiences can be the basis of depression, the aim of this study was to determine the effectiveness of EMDR therapy with this disorder. METHOD: In this study, we recruited a group of 16 patients with depressive episodes in an inpatient setting. These 16 patients were treated with EMDR therapy by reprocessing of memories related to stressful life events in addition to treatment as usual (TAU). They were compared to a group of 16 controls matched regarding diagnosis, degree of depression, sex, age and time of admission to hospital, which were receiving TAU only. RESULTS: Sixty-eight percent of the patients in the EMDR group showed full remission at end of treatment. The EMDR group showed a greater reduction in depressive symptoms as measured by the SCL-90-R depression subscale. This difference was significant even when adjusted for duration of treatment. In a follow-up period of more than 1 year the EMDR group reported less problems related to depression and less relapses than the control group. CONCLUSIONS: EMDR therapy shows promise as an effective treatment for depressive disorders. Larger controlled studies are necessary to replicate our findings.

Psychopathy, intelligence and conviction history.

The current study examined the relationship between psychopathy, intelligence and two variables describing the conviction history (length of conviction and number of prior convictions). It was hypothesized that psychopathy factors (interpersonal and antisocial factors assuming a 2-factor model or interpersonal, affective, lifestyle and antisocial factors assuming a 4-factor model) would be related in different ways to IQ scores, length of conviction and number of prior convictions. Psychopathy and IQ were assessed using the PCL:SV and the CFT 20-R respectively. Results indicated no association between interpersonal psychopathy features (Factor 1, two-factor model), IQ and the number of prior convictions but a positive association between Factor 1 and the length of conviction. Antisocial features (Factor 2, two-factor model) were negatively related to IQ and the length of conviction and positively related to the number of prior convictions. Results were further differentiated for the four-factor model of psychopathy. The relationship between IQ and psychopathy features was further assessed by statistically isolating the effects of the two factors of psychopathy. It was found that individuals scoring high on interpersonal features of psychopathy are more intelligent than those scoring high on antisocial features, but less intelligent than those scoring low on both psychopathy features. The results underpin the importance of allocating psychopathic individuals to subgroups on the basis of personality characteristics and criminological features. These subgroups may identify different types of offenders and may be highly valuable for defining treatment needs and risk of future violence.

Sleep and cognition at baseline and the effects of REM sleep diminution after 1 week of antidepressive treatment in patients with depression.

It has been hypothesized that non-rapid eye movement (NREM) sleep facilitates declarative memory consolidation, and rapid eye movement (REM) sleep is particularly important in promoting procedural learning. The aim of this study was to examine the effects of pharmacological REM sleep suppression on performance in different neuropsychological tasks. For our baseline, we chose 41 moderately depressed patients (age range 19-44 years), who were not taking antidepressants. In the morning after polysomnography, we tested memory recall and cognitive flexibility by assessment of verbal and figural fluency, a shift of attention task and the Trail Making Test B. After recording baseline values, patients were assigned randomly to one of three treatment groups: medication with citalopram; medication with reboxetine; or exclusive treatment with psychotherapy. Retesting took place 1 week after onset of treatment. The main results were: (1) an association of slow-wave sleep with verbal memory performance at baseline; (2) a suppression of REM sleep in patients taking citalopram and reboxetine; (3) no differences regarding neuropsychological performance within the treatment groups; and (4) no association of REM sleep diminution with decreases in memory performance or cognitive flexibility in patients treated with citalopram or reboxetine. In line with other studies, our results suggest that there are no negative effects of a decrease in REM sleep on memory performance in patients taking antidepressants.

Changes in CREB phosphorylation and BDNF plasma levels during psychotherapy of depression.

BACKGROUND: The cyclic adenosine monophosphate response element-binding proteins (CREB) and their interaction with brain-derived neurotrophic factor (BDNF) are essential elements in signal transduction pathways important for cellular resilience and neuroplasticity. They play a decisive role in the concept of altered neuroplasticity in major depression. We have previously demonstrated that the increase in phosphorylated CREB (pCREB) in T lymphocytes is significantly associated with clinical improvement in patients treated with antidepressants. In the present study, we focused on patients treated only with psychotherapy to exclude direct pharmacological actions. In addition to pCREB, we also measured the BDNF plasma levels. METHODS: pCREB in T lymphocytes was determined by Western blot; the BDNF plasma levels with solid-phase ELISA. Psychopathology was evaluated with the Hamilton Rating Scale for Depression (HAMD). Thirty patients meeting DSM-IV criteria for major depressive episodes (MDE) were recruited into this 6-week study. They received interpersonal psychotherapy (IPT) twice weekly. RESULTS: After 6 weeks of IPT, 17 patients responded (reduction of > or =50% of baseline HAMD); after 1 week of treatment pCREB increased significantly compared to the nonresponder group. Measurement of the BDNF plasma levels revealed no differences between the responder and nonresponder groups. Furthermore, the correlations between BDNF plasma levels and pCREB were not significant. CONCLUSIONS: The early increase in pCREB is related to treatment response and does not depend on pharmacological interventions or BDNF plasma levels. For the first time, cellular biological markers could be associated with response to psychotherapy.

The prevalence of mental disorders in a German sample of male incarcerated juvenile offenders.

The current study investigated the prevalence of mental disorders among incarcerated juvenile offenders in Germany and sought to identify clinically relevant subgroups. In sum, 149 newly incarcerated male juvenile delinquents (M age = 19 years) were included. Diagnostic tools included the German version of the Structured Clinical Interview for DSM-IV and the Psychopathy Checklist-Screening Version. The most prevalent diagnoses in the sample included conduct disorders (81%), Cluster B personality disorders (up to 62%), and substance-related disorders (up to 60%). Moreover, psychopathic features were found among 21% of the participants. Cluster analysis distinguished three subgroups among this group of young offenders. The most problematic consisted of juveniles with multiple psychopathology, including antisocial traits, personality pathology, higher scores on the Psychopathy Checklist, as well as multiple substance abuse. Study outcomes are discussed in light of their implications for the development of effective treatment for juvenile offenders.

Predictive validity of the psychopathy checklist: screening version for intramural behaviour in violent offenders-a prospective study at a secure psychiatric hospital in Germany.

OBJECTIVE: To consider the extent to which the presence of psychopathy, as indicated by the psychopathy checklist: screening version (PCL:SV), can predict intramural behaviour in offenders with mental disorders serving compulsory treatment at a German forensic psychiatric hospital. METHOD: The PCL:SV was used with 48 offenders detained at a forensic psychiatric hospital in Germany. In a prospective design, objective and subjective measures of behaviour were compared for those identified as high and low scorers on the PCL:SV. Data were obtained from hospital records of disciplinary incidents (objective) and from interviews with case managers and therapists (subjective), according to predefined criteria and in standardized forms. RESULTS: The hospital records of the high scorers indicated they had been involved in significantly more disciplinary incidents than low scorers. Their behaviour was also rated significantly more negative by therapists than the low scorers. CONCLUSION: Numeorus studies found the psychopathy checklist (PCL) score to be a reliable predictor of recidivism in offenders after release. The present study has demonstrated that the PCL score has also predictive validity for intramural behaviour problems in individuals serving compulsory treatment at a forensic psychiatric hospital. As a result, we recommend the routine use of the PCL with offenders starting a period of compulsory detention to identify those at increased risk for problem behaviour.

Are there age-related effects in antisocial personality disorders and psychopathy?

We investigated possible age differences in the frequency of antisocial personality disorder (ASPD), and of psychopathy according to Hare's criteria and its constituent features: In a cross-sectional study 226 male violent offenders, detained in adult or youth custody, were investigated using the Psychopathy Checklist Screening Version (PCL:SV) and the SCID II Interview. Their ages ranged from 18 to 59 years. Total PCL:SV score was negatively correlated with age. ANOVA showed that total PCL scores for three age groups differed significantly. Both effects were due entirely to Factor 2 of the PCL. Factor 1 was not related to age. The frequency of ASPD was also lower among older prisoners. The relationship with age was similar to that of PCL:SV Factor 2. These results point to age-related effects in psychopathy and suggest that different aspects of psychopathy follow different developmental courses. The results of our group comparison suggest that the different subfacets of psychopathy are not stable over time to the same extent. In order to make statements about the course of intraindividual development, however, longitudinal studies would be required.

Sleep in major depression: relation to memory performance and outcome after interpersonal psychotherapy.

BACKGROUND: Earlier findings suggest both a link between sleep and memory consolidation and a relationship between abnormal sleep at baseline and poor treatment outcome in major depression after interpersonal psychotherapy (IPT). METHODS: Pre-treatment polysomnography was examined in 32 patients with a major depressive episode (mean age = 39.5 years, 20 women). Declarative memory was tested by the Rey-Osterrieth Complex Figure Test and a paired associative word list and procedural learning was assessed by a mirror tracing skill. All patients were treated with IPT according to the manual and did not receive any antidepressant medication. Twenty-three patients took part in a minimum of 12 sessions of IPT. Remission was defined as 2 consecutive weeks with a score <8 on the Hamilton Rating Scale of Depression. RESULTS: Declarative visual memory performance was associated with total sleep time and total amount of rapid eye movement sleep. In IPT remitters (n = 14), there was a trend towards a decrease in rapid eye movement density (first period) and a significant decrease in delta power in pre-treatment sleep in comparison to non-remitters (n = 9). Treatment outcome after IPT was also associated with declarative memory performance at baseline (as a trend). CONCLUSIONS: Further indications of a role of sleep in memory processes and of the importance of specific sleep parameters as markers for a positive treatment response to psychotherapy were found.

The relationship between DSM-IV cluster B personality disorders and psychopathy according to Hare's criteria: clarification and resolution of previous contradictions.

This study examines the relationship between DSM-cluster B personality disorders (PDs) and psychopaths according to Hare's criteria as detected by the Psychopathy Checklist (PCL:SV) in 299 violent offenders. To clarify some contradictions among several previous studies on this issue, individual cluster B PDs were looked at alone, excluding any cases of comorbidity with other PDs of this cluster. We found highly significant relationships between antisocial and borderline PD and Factor II of the PCL and a highly significant correlation between narcissistic PD and Factor I of the PCL. These results were to be expected from the theoretical basis of the development of the PCL and provide a contribution to the construct validity of the PCL, which until now has not been validated on such a large sample in Germany.

Psychopathy checklist score predicts negative events during the sentences of prisoners with Hare psychopathy: a prospective study at a German prison.

OBJECTIVE: This study examined the predictive validity of the German translation of the Psychopathy Checklist-Screening Version (PCL-SV) for negative events during the course of the prison sentence of German prisoners. METHOD: Using the PCL-SV, we investigated 145 offenders in a German prison at the start of their sentences. We then compared the extreme groups identified by the PCL-SV--the high and low scorers--using a prospective design with respect to negative events and factors during the course of the sentences. This involved the standardized collection of data on both objective records of disciplinary incidents and subjective impressions from prison staff on the basis of operationalized criteria. RESULTS: The high scorers were involved in significantly more disciplinary incidents and were also rated significantly less favourably by prison staff than the low scorers. CONCLUSION: Until now, the PCL has only been shown to predict recidivism following release from prison. The results of our study show that the PCL also has predictive validity for problems during the course of the sentence. It is therefore recommended that the PCL be used routinely at the start of the prison sentence to estimate the likelihood of subsequent difficulties.

Kiel psychotherapy project for violent offenders Towards empirically based forensic psychotherapy -- disturbance profiles and risk of recidivism among incarcerated offenders in a German prison.

This study reports on a psychotherapy project for violent offenders. The project was established at a German prison by the Psychiatric and Psychotherapeutic Department at the University of Kiel. The overall aim of this project is to develop a scientifically based psychotherapy programme for violent offenders. As a first step the project's systematic initial diagnostic procedures are presented. These procedures are carried out when new prisoners join the project to provide an empirical basis for the planning of therapy. Data are presented for the 60 prisoners who have so far taken part. These show high prevalences for some psychiatric disorders, namely substance related disorders (33% dependency, 55% abuse), personality disorders (58% had at least one personality disorder) and psychopathy according to Hare's criteria (13%). The data also indicate that only a basal level of self-motivation existed to take part in psychotherapy (65% precontemplative). It is apparent that violent offenders constitute a heterogeneous group as far as mental disturbances are concerned. The data suggest that a psychotherapy programme for violent offenders needs to include both targeted interventions to raise motivation and, for those with substance-related and/or personality disorders, disturbance-specific interventions.

[Signals for the initiation of structured diagnostic procedures for depression in primary health care. A practice-relevant evaluation of international guidelines]. / Signalsituationen für den Beginn einer strukturierten Depressionsdiagnostik in der Allgemeinarztpraxis--Eine praxis-kritische Einschätzung internationaler Leitlinien.

BACKGROUND AND OBJECTIVES: Almost every tenth patient of a general practitioner (GP) suffers from depression. However, only 20-25% of these patients are correctly diagnosed during a GP consultation. How do international guidelines for depression in primary care initiate structured diagnostic procedures for depression? METHODS: We performed a systematic literature search on guidelines for the diagnosis of depression with focus on primary care. The quality of the guidelines was rated according to base of evidence, existence of pilot studies, data on implementation, presentation and specificity for primary care settings, and conflict of interest. We also screened whether and how the guidelines comment on the initiation of structured diagnostic procedures for depression. RESULTS: Of the 22 identified guidelines, only 15 address primary care. Only 3 of these were tested in pilot studies, 3 provided data on implementation, 9 were evidence-based. The best guideline (6 out of 6 criteria met) is available in Dutch and established for The Netherlands only. We ranked the guidelines from NHG, VHA and ICSI as very good in terms of methodological quality. They present 'red flags' that initiate structured diagnostic procedures by 'opportunistic screening'. This is followed by the application of a self-rating instrument and an ICD-10-based diagnostic checklist identifying up to 98% of all patients with depression in a given consultation time of 10 minutes on average. CONCLUSION: Based on these criteria a national diagnostic depression guideline should, from our point of view, explicitly include keys such as "red flags" for the initiation of structured diagnostic procedures.

[Interpersonal psychotherapy (IPT) in depressions]. / Interpersonelle Psychotherapie (IPT) bei Depressionen - Ein Modell für Evidence-based Medicine in der Psychotherapie -

Evidence-based medicine gains more importance within psychotherapy as well, although some problems occur in trying to follow the principles of evidence-based-medicine in the field of psychotherapy very strictly. The Interpersonal Psychotherapy (IPT) for depression, which has been developed more than 30 years ago may be taken as an example for evidence-based-psychotherapy: the concept was built on empirical observations and manualised. Further on it was evaluated in many clinical trails that showed the good efficacy and later effectiveness. IPT reaches a high level of evidence and is to be seen as well-established psychotherapy. Psychotherapy research tries to point out the effectiveness for different subtypes of depressive disorders. Moreover it is investigated which connection exist between therapy outcome and neurobiological changes in the central nervous system.