Psychiatry in selected countries of Central and Eastern Europe: an overview of the current situation.

OBJECTIVE: To review the current status of psychiatry in selected countries of Central and Eastern Europe: Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Russia, Slovakia, and Slovenia. METHOD: A group of psychiatrists from the region evaluated the status of psychiatry at the end of 2004 based on data from their countries and information available on WHO homepages. RESULTS: There is a shift from traditional in-patient facilities towards out-patient and community services as evidenced by a decreasing number of hospital beds. Economic pressures affect the financing of psychiatric services, and reimbursement for novel psychotropics. Political changes were followed by updated legislation. Psychiatric training, pre-, postgraduate and continuous medical education, are gradually being transformed. Scientific output as measured by publications in peer-reviewed journals has been significantly lower than in the West. CONCLUSION: The major changes in the period of transition documented in the review pose new challenges for psychiatry.

[Efficacy and tolerance of risperidone in various doses (report of a study)]. / Ucinnost a snásenlivost risperidonu pri ruzném dávkování (sdelení z praxe).

Risperidone was compared in 2 double blind studies with haloperidol and perphenazine in schizophrenic psychoses. According to the maximal daily dose achieved the risperidone group was divided in 4 subgroups and the risperidone efficacy and tolerability in these groups were compared both mutually and in relation to the baseline. With all doses a good global antipsychotic efficacy has been observed. There were no statistically significant differences in influencing of productive or negative symptoms with exception of significantly more pronounced reduction of productive catatonic symptoms with 2 < max < or = 5 mg in comparison with doses higher than 15 mg daily. Extrapyramidal symptoms were less frequent with lower doses: with 2 < max < or = 5 mg significantly lower occurrence of increased muscle tonus and tremor was found than with higher doses. With maximal daily doses above 10 mg antiparkinson drugs had to be applied in more patients and in the case of trihexyphenidyl this difference reached a statistically significant level.

[Effectiveness of clonazepam in depressive disorders]. / Ucinnost clonazepamu v indikaci depresívní poruchy.

Clonazepam was administered to 55 patients with depressive disorder (DSM-III-R) in average minimal and maximal doses of 2.40 and 6.54 mg/day for 21-28 days. Complete remission was achieved in 60% patients (Serejskij AB, drop of global HAMD and FKD score by more than 50%), in particular in case of concurrent anxiety. A marked antidepressive effectiveness of clonazepam was suggested also by a drop of the total HAMD and FKD score already after the first week of treatment. All items of the HAMD and FKD scale were significantly positively influenced with the exception of agitation, somatic anxiety, insight, paranoidity, obsession respectively hypochondriasis and paranoidity. No correlation was found between the effect of clonazepam and sex, the patients' age, duration of the depressive disorder, period of the index episode and severity of depression. As to undesirable effects, the authors recorded fatigue and sleepiness (40%) and hypotension (20% of the patients), in particular at the onset of treatment and after larger daily doses. In 3/10 bipolar patients a switch to hypomania was observed.

[Paroxetine in the treatment of depressive disorders (pilot study)]. / Paroxetin v lécbe depresívních poruch. (Pilotní studie).

In an open study, 42 depressive patients (according to DSM-III-R) were administered paroxetine at mean minimal and maximum doses of 21 and 48 mg once daily in the morning. Treatment resulted in complete remission as defined by Serejsky in 57%, and 55% of patients were rated, according to CGI, as improved. Global HAMD and FKD scores significantly dropped compared to baseline values and responders and non-responders differed significantly as early as seven days of treatment, although the onset of the antidepressive effect was not clinically apparent before 2 weeks of treatment. Significant reductions were seen in all items except paranoidity and weight loss and hypochondria using the FKD scale. A substantial reduction in suicidal ideation and tendencies was also noted in the group of non-responders, a finding supporting a non-specific anti-suicidal effect of paroxetine, which was therapeutically significantly more successful in women than in men. Side effects occurring in 10% and more percent of treated subjects included fatiguability, sweating, tremor, dry mouth, obstipation and nausea.

[Antidepressives of the 3rd, 4th and 5th generation]. / Antidepresiva III., IV. a V. generace.

Antidepressants are classified into five generations. Preparations of the first generation affect various neurotransmitter systems and are therefore associated with many undesirable effects (e.g. tricyclic antidepressants, maprotiline). The second generation of antidepressants is already devoid of anticholinergic action and their adrenolytic and antihistaminic effects are weaker (e.g. mianserine, mirtazapine, trazodone). The antidepressant action of preparations of the third generation is mediated only by one of the three main neurotransmitter systems for depression (5-HT, noradrenaline, dopamine) and does not affect muscarine, histamine and adrenergic cerebral systems (e.g. SSRI, ipsapirone, viloxazine, reboxetine, bupropione). Recently antidepressants of the fourth generation were synthetized which influence only the serotonin, and noradrenaline or dopamine system (e.g. milnacipran, befloxatone). The fifth generation of antidepressants foresees the exclusive action on 5-HT, noradrenaline and dopamine systems of the CNS in varying ratios (e.g. venlafaxine, cericlamine).

[Citalopram (Seropram) in tablet and infusion forms in the treatment of major depression]. / Citalopram (seropram) v tabletové a infuzní forme v lécbe velkých depresí.

Citalopram i.v. and oral had a reliable antidepressive and anxiolytic effect in 101 hospitalized patients, as apparent from the achievement of complete remission in cca 60% of the patients with major depression after four weeks follow-up. Treatment with citalopram by the intravenous or oral route was most successful in anxious or inhibitory depressions, while atypical forms with hypochondriac or obsedant features responded better to infusions. The global score of HAMD and FKD scales and typical symptoms of depression such as a pathic decreased mood, anhedonia, feelings of guilt, lack of interest, anxiety and suicidal thoughts were positively reduced. The following were not affected: loss of appetite, loss of weight, anosognosia, paranoidity, and hallucinations. The clinical onset of the therapeutic effect was on average apparent on the 10th-12th day of therapy, significantly sooner when the intravenous route was used. The authors did not find significant differences in the therapeutic results in patients under and above 60 years and in those with a mild or severe depression. As regards subjective preference and preference by relatives, infusions were unequivically preferred as they had, no doubt, also a psychological effect. As to the incidence of undesirable effects, the authors did not detect a difference between the two routes of administration of citalopram, which was well tolerated and 50% of the patients did not report any side-effects and the rare ones recorded were not more frequent than in 20% of patients.

[Citalopram in depression (results of an open multicenter study in phase IV of the clinical trial)]. / Citalopram u depresí (Výsledky otevrené multicentrické studie v rámci IV. etapy klinického hodnocení).

249 depressed patients were treated by 35 psychiatrists in an open multicenter trial during 6 weeks with citalopram. The protocol enabled that naturalistic treatment conditions could be kept. The results were rated with the help of the Clinical Global Impression (CGI) scale. The treatment was successful in 77% of the patients. 5 patients dropped out because of adverse effects, 8 patients did not finish the trial due to insufficient efficacy. In 160 patients (64.2%) no adverse effects were registered. Transient mild headaches in 8.4% and nausea in 4% were the most frequent adverse events. The best effects were observed in patients who were rated as moderately ill (82.8% ameliorated) at pretreatment. Nevertheless, also 66.7% of those rated as severely ill before the treatment improved substantially. In patients treated with higher doses than 20 mg/day, the improvement rate was not higher than in those treated with 20 mg daily.

Double-blind comparison of risperidone and haloperidol in schizophrenic and schizoaffective psychoses.

A double-blind eight-week study was carried out to compare the efficacy and safety of risperidone in relation to haloperidol. Sixty-two inpatients suffering from acute schizophrenic or schizoaffective psychoses diagnosed according to ICD-9 were treated with risperidone 2-20 mg daily or haloperidol 2-20 mg daily. The mean total BPRS scores were reduced from 45.5 to 32.4 in the risperidone group and from 43.1 to 28.5 in haloperidol group. There were no significant differences between the two treated groups with regard to the total BPRS score and the percentage of remissions achieved. No statistically significant difference was found between the groups in any of the factors or items except guilt feeling (p < 0.02), anxiety (p < 0.005), and factor I--anxiety/depression--(p < 0.02) in favour of haloperidol. Risperidone had the benefit of a lower incidence of extrapyramidal side-effects.

[Intraindividual comparison of haloperidol decanoate and oxyprothepine in maintenance therapy in schizophrenic psychoses]. / Intraindividuální srovnání dekanoátu haloperidolu a oxyproteinu v udrzovací lécbe schizofrenních psychóz.

In an open intraindividual comparison of haloperidol and oxyprothepine decanoates there was a tendency in favour of haloperidol decanoate. At the end of 9 months' maintenance treatment there were no statistically significant differences in the global BPRS score, CGI and individual BPRS items with exception of paranoidity. No differences in the occurrence of rehospitalizations and ambulatory relapses were found. As for side effects with haloperidol decanoate a higher occurrence of akathisia and a lower mean weigh increase (2 kg v. 4 kg) were observed and twice more pts had no side effects in comparison with oxyprothepine decanoate, but also these differences were not statistically significant. Taking into consideration the differences found (even if not statistically significant) and the individual reactivity, it seems to us advantageous to have a broader choice of depot neuroleptics.

[Alternative therapy in the acute phase of endogenous depression--antiepileptics and new benzodiazepines and their comparison]. / Alternativy lécby akutních fází endogeních depresí--antieplieptika a novejsí benzodiazepiny a jejich srovnání.

The average therapeutic effect of classical tricyclic antidepressants and antidepressants of the second and third generation varies between 60-70%. Moreover, tricycklic antidepressants are associated with undesirable effects mostly anticholinergic and "cardiotoxic", which may be a contraindication in particular in patients with multiple diseases and in older age groups. The authors compared two new alternative therapeutic procedures, represented by new highly effective benzodiazepines and anticonvulsants, as regards the therapeutic effect and side-effects. From this comparison ensues that their general therapeutic effect is on average comparable with the effect of tricyclic antidepressants, however, in the spectrum of their undesirable symptoms the anticholinergic effects are absent. Recent benzodiazepines have a better effect on depressions where anxiety and agitation are in the foreground. Their effect on depressive core symptoms is more marked, as compared with anticonvulsants. The most frequent side-effects are fatigue, somnolence and vertigo. Anticonvulsants have a balanced effect in different syndromological forms of depression. Undesirable effects are mostly gastrointestinal. In the authors' trials it did not lead to hypomania.

[The status of fluvoxamine among the antidepressive agents]. / K postavení fluvoxaminu ve skupine antidepresiv.

Fluvoxamine was administered in an open trial of 50 hospitalized patients with major depression of the melancholic type (DSM-III-R) for an average period of 24.56 days in mean minimal and maximal daily doses of 100-311 mg orally after a wash-out interval of 1-14 days. Treatment achieved complete improvement in 54% and partial improvement in 16% of the patients, significantly more frequently in women than in men. The antidepressant effect of fluvoxamine was confirmed also by a statistically significant reduction of the global HAMD and FKD score, starting on the 7th day of the trial. The therapeutic effect was clinically apparent during the second week of treatment. The best therapeutic effect was achieved in anxiety depressions (65%), to a lesser degree inhibitory depressions (50%) and atypical ones (46%), as apparent from the value of Náhunek's antidepressive index 0.88 which suggests a significant anxiolytic effectiveness of fluvoxamine. Fluvoxamine had a positive effect on the majority of HAMD and FKD items, incl. a depressive mood, anxiety, feelings of guilt, anhedonia, reduced interest and ability, obsession, depressive thoughts and suicidal tendencies. Reduced motor activity, loss of appetite, insight, somatic symptoms, paranoidity and hypochondria were less influenced. At the onset of treatment the preparation did not reduced insomnia and thus in 72% patients hypnotics were added. In the course of fluvoxamine therapy no suicidal attempts were observed although 34 (68%) of the patients initially admitted had suicidal thoughts. Fluvoxamine is well tolerated by patients; as to side-effects gastrointestinal complaints were most frequent (in 28% of the patients).

[70 years of educational, research and therapeutic-preventive activity at the Psychiatric Clinic of Brno University]. / 70 let pedagogické, výzkumné a lécebne-preventivní cinnosti psychiatrické kliniky Brnenské Univerzity.

The Medical Faculty of the Masaryk University in Brno and thus also the psychiatric department was established by act no. 50 of January 28, 1919 in the newly founded Czechoslovak Republic. Records on care of the mentally sick in municipal hospitals, later in the hospital of the brethren of mercy and finally in the municipal hospital in Pekarská street date to the 16th century. After establishment of the mental asylum in Brno--Cernovice in 1863 in the provincial hospital a department comprising 46 beds for mental patients proceeded with its activities and after the foundation of an independent Czechoslovak State it was transformed into a psychiatric and later psychiatric and neurological department. Despite the modest conditions heads, of the department, Prof. Dr. K. Belohradský, Prof. Dr. H. Procházka and Prof. Dr. M. Krivý, managed to maintain a high clinical standard of patient care, teaching and research oriented above all on organic psychoses, examination of the cerebrospinal fluid and concurrent supporting psychotherapy. After closure of the Czech universities the department was transformed into a ward. After the Second World War the combined psychiatric and neurological department was headed by Prof. Dr. K. Popek. The first head of the separate psychiatric department in 1948 was Prof. Dr. Z. Lauterer, who was also appointed in 1954 the first head of the independent chair. He was followed by Prof. Dr. J. Hádlík whose chief merit was that the activities of the department were transferred to the new modern building in Brno-Bohunice and that a department of medical psychology was attached to the chair. Subsequently Prof. Dr. K. Náhunek, DrCc. founded and contributed towards the success of the Brno school of psychopharmacology. At present the authors try to ensure the scientific and professional development, to improve under--and postgraduate training and in collaboration with other research institutes to raise the scientific standard of the discipline.

[Results of treatment of schizophrenic and schizoaffective patients with sulpiride (Eglonyl Alkaloid) in comparison with perphenazine (Perfenazin Spofa)]. / Výsledky lécby schizofrenních a schizoafektivních nemocných sulpiridem (Eglonyl alkaloid) ve srovnání s perfenazinem (Perfenazin Spofa).

In a three-week crossover controlled the authors administered alternately sulpiride and perphenazine with an intermittent placebo interval, to 40 hospitalized patients with acute exacerbation of schizophrenic and schizoaffective psychosis. According to evaluation recommended by Serejský significantly more complete remissions type AB were achieved especially in schizodepressive patients given sulpiride. The global score of BPRS and FKP scales after administration of the two tested neuroleptic drugs differed: sulpiride had a more favourable effect on depression, emotional withdrawal, reduced affectivity, slower motor activity, worry about the somatic state and hallucinations, while perphenazine gave better results in patients with reduced compliance, lack of cooperation, hostility and excitation. Sulpiride is well tolerated by the patients. Pharmacological parkinsonoid was observed only in cca half the patients, as compared with perphenazine and therefore also the need of correction by antiparkinsonian drugs was significantly smalled. The low incidence of extrapyramidal, hypnosedative and autonomous undesirable effects gave sulpiride the optimal position in our classification of 16 tested neuroleptic drugs. In one third of the patients no undesirable side--effects were observed.