Pain complaints are frequent in psychiatric and primary care settings. Furthermore, in pain clinic, depression and pain disorders are common comorbidities. On the other hand, several antidepressants are effective in the management of chronic pain and in alleviating pain complaints in depressed patients.

In this lecture, we summarize the current knowledge with regard to the use of antidepressants in chronic pain conditions and in pain as a somatic complaint in depression. We review the pharmacological mechanisms and the neurobiological substrate of these properties.

To give arguments for the recognition of antidepressants as useful tool to treat pain in depression and depression in chronic pain patients, and to provide information about the right choice of an antidepressant in chronic pain.

The monoaminergic system participates both in the regulation of mood and in the modulation of pain. Antidepressants have several properties modulating monoamines. Some of these properties are critical to understand the mechanisms of action of these compounds in chronic pain and in alleviating pain as a somatic symptom in depressed patients. The discussion about whether antidepressants alleviate pain acting on mood or pain transmission is a matter open to discussion, however there is no doubt about the utility of these drugs in pain. Recent studies in modified genetic animals reinforce the idea the not only monoamines but also other neurotransmission systems underlie these effects.

Bipoler Depression in it's acute psase is a very distressing state for the suffering patient & a chalanging job for the Psychaitrist to treat to alliavete in a reasonable period of time.

In acute state Bipolar patients, mostly women in their middle age, moderately overweigted often presents with a crying state or even with potent suicidal ideation that continiue to go on inspite of treatment with pharmacological treatments.

Here is an attempt to search for a remedy to these set of patients.

72 acutely ill Bipolar depressed patient were assigned with 3 treatment regimens, after their diagnosis was confirmed on the criteria of DSM-4 TR.

There age group were 46 to58 years with a median age 52 years. There were 12 Ist episode depressive phase and 60 patients both male 24 & women 36 are recurent sufferers.The Study was conducted in the O.P.D patiends attending Calcutta Pavlov Hospital during 2008-09.

1st. group receive only Fluoxotine & olanzapin combination for 6 weeks.

2nd group recieve FLuox+Olanzapin +lithium carbonate in 900 mg/day dose.

3rd group recieve Lith. carobonate+Olz.+fluoxotine +Lamotrigine in 25-50mg/d.

The 1st group with a combo of olanzapin+Fluoxotine were the least responsive.

They were evaluated in the Psychologist table usinng ASPER-Montigegmy Depression rating scale.

Allthe groups shows improvement in different items of the scale.

3rd group using a tripple drug Combo therapy do the best.

Is a poly combo drug therapy or E.C.T or +Psychotherapy combo a best answeer to these criticaly depressed BPD patients.

Patients with untreated obstructive sleep apnea often report depressive symptoms, such as low mood, loss of interest and reduction of drive. In this study we examined the frequency of significant depressive symptoms amongst patients with untreated obstructive sleep apnea over a one year period.

From January to December 2008 we screened 1260 consecutive patients with untreated obstructive sleep apnea (AHI > 9) seen at our Center for Sleep Medicine were screened for depression. Based on self-administered questionnaires, patients with significant depressive symptoms were defined as having either a BDI II score ≥ 14 or WHO-5 ≤ 13. Additionally, severity of depression was rated based on BDI II scores.

Depressive symptoms were reported frequently. Based on BDI-II, 27.9% of patients report significant depressive symptoms. Of these, 46.2% were mild, 35.9% moderate and 17.9% severe. In addition, 52.6% of patients self-reported feeling unwell based on their WHO-5 scores.

Significant depressive symptoms measured by standardised self-rating scales were detected in over a quarter of our patients with untreated sleep apnea. It remains unknown whether treatment of OSA alone abolishes depressive symptoms, or whether depressive mood may reduce the compliance with treatment. Patients may need an interdisciplinary approach to initial treatment.

Patients with Bipolar Affective Disorder have high rates of somatic comorbidity and it's necessary to know the characteristics of these patients to develop preventive and therapeutic strategies.

To describe twelve patients diagnosed with BAD admitted to a Brief Hospitalization Unit.

Evaluation by a questionnaire which recorded sociodemographic data (sex, age, marital status, education, occupation, employment status); medical management indicators (average stay, number of previous admissions and if re-entering during the study); previous treatments (antipsychotics, antidepressants and benzodiazepines); somatic background (presence of cardiovascular risk factors that contrasted with taking blood pressure, BMI calculation, ECG and complete analytical) and consumption of toxic substances.

58.33% are women with a mean age of 41.91 years and 58.33% in single cases. 58.33% has secondary education, although the 41.66% isn’t working.

The average stay of admission is 20.83 days. 50% had between 1 and 4 more admissions and 33.33% re-enters.

25% doesn’t take medications. Of the rest, 77.77% taking neuroleptics, being the most common option with 57.14% treatment with quetiapine. The 88.88% takes mood-stabilizing and the 44.44% benzodiazepines.

No patient has altered the glucose profile. The 8.33% has high blood pressure control and 25% altered lipid profile. The average BMI is 28.64

The 66.66% smoke. The 33.33% consumed alcohol and cannabis on 16.66%.

Patients with BAD have high proportions of cardiovascular risk factors and important consumption of toxic substances. Reflected the impact of the disease in the sociolabour field and the need for many hospital admissions because of the chronic course and poor therapeutic adherence.

Clinico-psychopathological with the data verification to SCL-90-R, statistic - Mann-Whitney U-test, Spearmen Rank Order Correlations, Wilcoxon Matched Pairs test. Among patients BD, as opposed to the patients RD, the stronger direct correlation interconnection of “depression” and “somatization”, “obsessivness” is defined (r 0,62-0,81). Compared indications of depression level and basical “index of symptoms’ evidence” (p>0,05) in droups, the patients BD as opposed to the patients RD at p< 0,05 the indications of “anxiety” (2,08&1,67), “somatization” (1,97&1,68), “obsessivness” (1,76&1,4) are higher. These data may show the “residual manic equivalent” in the form of somatization, obsessivness symptoms in the structure of the BD depression, its atypical type and differential - diagnostic symptoms with depression in RD structure is identified. The effectiveness of hospital complex therapy of BD patients is estimated. During 56 days the patients got Seroquel therapy in a dose 150-600 mg/day, group behavioral therapy, sociotherapy. Up to the 10th day of the treatment the indications of “anxiety” (p< 0,05), “depression” (p< 0,05), up to 14th day “somatization” (p< 0,05), up to 21st day “obsessivness” (p< 0,05) were reduced. After hospital complex therapy patients got supporting Seroquel therapy in a dose 50-200 mg/day. In catamnesis in 6 months 11 patients were examined, their state was defined as “stably positive”. These data indicate that the complex therapy of bipolar depression of the II type patients, including Seroquel is effective.

The purpose of this study was to evaluate the antidepressant duloxetine in depressive patients with pain.

The sample: 28 patients (18 female and 10 male, mean age 53,85) were diagnosed with major depressive disorder (MDD) according to ICD 10. They were assessed with HAMD17 items in baseline and at 14, 28, 42, 56 days, CGIS at baseline, 28 and 56 days, CGII at 28 and 56 day.

Patients received duloxetine (Cymbalta) 60-120 mg/day. All treated patients had a good evolution with a significant improvement on HAMD score. Total score HAMD 17 items was: baseline - 21,9; 14 days - 19,9; 28 days - 17,1; 42 days - 13,1; 56 days - 11,6. At item 13 -diffuse muscle aches in arms or legs the mean score was 1,65 at baseline, and 0,75 at 56 days. The evolution of CGIS was: mean 4,2 in baseline and 1,9 at 56 days. Significant improvement was noted at 56 days: 13/28 (46,42%) were much improved and 15/28 (53,58%) were very much improved. We noted mild nausea at 10 patients, mild restlessness at 7 patients, mild dizziness at 5 patients at the beginning of the treatment.

1. 1) Our results suggest that duloxetine is a safe and effective treatment for depression.

2. 2) The concomitant action for different aches is very important for depressive patients with pain.

3. 3) Coexistence of depression with physical pain negatively affects the performance in daily activity and quality of life; in such cases the first treatment option could be duloxetine.

To identify the frequency and clinical features of DM and mania with delirium.

We reviewed all admissions to our acute inpatient unit with mania, hypomania or mixed affective state, in 2006 and 2007. Cases with delirious features and cases with a working diagnosis of DM, were reviewed in detail. The three groups (no delirium, delirious features and DM) were compared for general demographic and clinical variables, as well as features specifically associated with DM (e.g., catatonia; nakedness; inappropriate toileting; unexplained fever, etc).

We found 100 patients with mania, hippomania or mixed affective state. 14 had medically unexplained delirium, 4 of them with a final diagnosis of DM. DM cases (but not non-DM mania cases with delirious features) had extremely long durations of stay, acute onset, hypertermia, catatonia, autonomic instability, anarchic sleep, shouting/coprolalia, delirium persisting for over a week, and were more likely to receive ECT. Moreover, in three of them DM occurred in most manic/mixed affective episodes.

DM is a rare occurrence in bipolar disorder. It has typical clinical features and may be recurrent.

Resistant depression is a long-term, disabling illness. The aim of this study was to compare the efficacy of antidepressant monotherapy (ADM) and combinations of antidepressants (CAD) in the treatment of resistant patient (≥1 unsuccessful antidepressant treatment) in current clinical practice.

We reviewed chart documents of resistant patients hospitalized at Prague Psychiatric Center for major depressive disorder (DSM IV) and had finished at least 4 - weeks of treatment with ADM or CAD. Clinical status was assessed using MADRS, CGI and BDI-S at baseline, after 2 weeks and in the end of treatment in the framework of regular evaluation during the hospitalization. Response to treatment was defined as a reduction of MADRS score ≥ 50%.

Results: We analyzed 78 inpatients (CAD=27, ADM=51). Both groups were equal in baseline characteristics (number of previous treatments, severity of depression etc.) and in the length of index treatment. The CAD group was superior to ADM group in the MADRS score reduction (14.6 vs 10.2 pts, p=0.02) and the proportion of responders (67% vs. 39%, p=0.03) in the end of treatment. The post-hoc effect size of CAD compared to ADM was moderate (Cohen's d=0.54).

Conclusion: The results of this study suggest that combinations of antidepressants may be more effective than a monotherapy in patients with resistant depression.

This study was supported by a grants from Internal Grant Agency of Ministry of Health of Czech Republic No. NS 10368-3 and a grant from Ministry of Health of Czech Republic MZ0PCP2005.

Absence of social support has its role in the etiology and maintaining of depression, showing inability of the depressive subjects to built and to sustain interpersonal relationships, and to mobilize social support at the time of crisis. The objective of our investigation was to establish the level of social support in the patients suffering from dysthymic disorder, in the course of the disorder.

The sample participants included 40 patients who fulfilled DSM-IV criteria for the dysthymic disorder (mean age 40.65, SD 3.70), and 40 corresponding healthy controls (M 37.50, SD 8.05). The following instruments for assessment of social support were used: Social Support Index, Family Hardiness Index, Family Coping Coherence Index, Relative and Friend Support (McCubbin, et al., 1982,1986).

The dysthymic disorder patients compared to the healthy controls, had statistically significant lower values (p< 0.001) of Social Support Index, Family Hardiness Index, Family Coping Coherence Index and of Relative and Friend Support.

In the course of the disorder, those suffering from dysthymic disorder compared to the healthy controls, had a significantly lower level of social support, indicating absence of a reparative role of social support in maintaining the psychological well-being.

This SERENITY study was designed to investigate the effectiveness of atypical antipsychotics (AAPs) as defined by the three areas of patient functioning, efficacy and tolerability in general practice.

Between January 2007 and June 2008, 252 patients were enrolled, as planned, in this non-interventional study in Belgium. Inclusion criteria were patients 18-65 years old, willing and able to participate, diagnosed with Schizophrenia or Bipolar Disorder and currently in a manic episode and for whom the general practitioner (GP) decided to prescribe an AAP.

Patient demographics, selection criteria, psychiatric and medical history and condition were assessed at Visit 1. Additional psychotropic drugs, name and dose of AAP, the QoL questionnaire Q-LES-Q-16, the Sheehan Disability Scale (SDS) for patient wellbeing, the Clinical Global Impression (CGI) and Patient Global Impression of Change (PGIC) scores for clinical efficacy and tolerability were assessed at Visit 1 (day 0), Visit 2 (week 4) and at Visit 3 (week 8).

A mean change of 24.62 was observed in the Q-LES-Q results. The SDS total score decreased substantially with a mean change of -9.26. Number of days lost, and the number of unproductive days, at work or school decreased with a mean change of -1.88 and -2.31, respectively. CGI-S scores decreased by a mean -1.92 and the CGI-I and PGIC scores also decreased. A weak but positive correlation was seen between the medication satisfaction and the efficacy, tolerability and patients’ well-being.

This study indicates that GP-based management of antipsychotic treatment is effective in the community.

The UNIQUE study assessed the effect of Quetiapine fumarate augmentation on the overall depression status of patients with major depressive disorder and who did not respond to any acute treatment with selective serotonin reuptake inhibitors (SSRIs) or selective noradrenalin reuptake inhibitors (SNRIs) and naïve to any atypical antipsychotics.

Between March 2006 and November 2007, 39 male and female patients, aged 18-65, were enrolled into this four-week, open label, non-comparative, multicentric, phase II prospective study. Treatment with Quetiapine fumarate began at enrolment, with a titration to a target dose of 300mg. The following scales were completed during all five visits: Montgomery-Asberg Depression Rating Scale (MADRS); Clinical Global Impression (CGI); Brief Psychiatric Rating Scale (BPRS); Sheehan Disability Scale (SDS).

All questionnaire mean scales were significantly reduced (Friedman P< 0.0001) at the end of the study from baseline: MADRS 16.9 (12.8-21.0); CGI 1.94 (1.52-2.37); BPRS 10.3 (6.7-13.6); SDS 8.5 (5.6-11.5). Response, defined as a reduction in MADRS total score >50% was observed in 45.9% of the 37 patients completing at least 2 weeks of the study and 37.8% were considered in remission e.g. MADRS total score ≤ 12 at visit 5.

Quetiapine fumarate augmentation improved the overall depression status of patients resistant to SSRI or SNRI treatment.

Progressive hepatolenticular degeneration or Wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterised of hepatic and neurological disorders due to the accumulation of copper in organs such as the liver or the basal ganglia. The manifestations of Wilson's disease are multiple and sometimes insidious, which makes the diagnosis very complicated.

A clinical case was followed and reviewed to illustrate the psychiatric symptoms in Wilson's disease.

A 23-year-old male came to the emergency room presenting insomnia, logorrhea, euphoria, irritability and a slight tremor in the upper limbs. Symptoms started two weeks before. The previous year, he was diagnosed of bipolar disorder after a manic episode which required inpatient treatment with risperidone and lithium. During the actual hospitalization, the tremor increased progressively and affected all four limbs and his head. He was then examined by neurology and an ophthalmology service, who ordered some specific complementary exams. Low levels of ceruloplasmin and serum copper and high levels of urinary copper confirmed the diagnosis of Wilson's disease. Treatment with copper chelants was introduced and the psychiatric symptoms and the analyses got better in several weeks.

Even a typical presentation of a psychiatric syndrome can be part of the spectrum of an organic illness. So an organic etiology should always be considered in the differential diagnosis, as sometimes it is possible to be treated.

In recent years increased indices of bipolarity in treatment-resistant depression were found. The objective of the study was to assess and compare Mood Disorder Questionnaire (MDQ) positive screen between patients with treatment-resistant (TR) depression and non-treatment-resistant (NTR) depression and identify significant predictors of MDQ positive screen.

The population studied included patients aged 18-65 who had a diagnosis of first or recurrent major depressive disorder. Each psychiatrist included 5 consecutive patients, from all the patients he is treating, where the depressive episode was assessed as treatment-resistant (study group) and 5 consecutive patients with a non-treatment-resistant episode (control group). The symptoms of bipolarity were assessed by the MDQ. A positive screen of MDQ showing the features of bipolarity requires seven or more items be endorsed, at least several of the items co-occurred, and the symptoms caused at least moderate psychological impairment. One thousand and fifty-one patients entered the study: 570 in treatment-resistant group and 481 in non-treatment-resistant group.

The percentage of patients having MDQ positive screen was significantly higher in the treatment-resistant than in the non-treatment-resistant group (13.7% vs. 5.6%, respectively, p< 0.001). Significant predictors of MDQ positive screen identified in logistic regression were: family history of bipolar disorder (OR=4.04, p< 0.001), early onset of first major depression (< 20 years) (OR=3.27, p=0.001), and incomplete last remission (OR=3.11, p< 0.001).

Our results may suggests bipolar diathesis in treatment- resistant depression.

To estimate the association between obesity, central obesity and depression in a population sample of Greek type 2 diabetic patients.

A total of 200 patients with type 2 diabetes were enrolled in the study. They were stratified according to sex, obesity and central obesity (BMI≥30 Kgr/m2, waist>102cm in men and >88cm in women). Beck Depression Inventory II scale was used to establish the presence of a depressive disorder (DD).

The frequency of DD among the whole population was 31.5% (34.6% for the female vs. 26% for the male patients, p=0.207). BMI was statistically significant increased in depressive diabetic patients compared to non depressive diabetics, in the total (p=0.003), in women (p=0.013), but not in men (p=0.200). In addition, DD rates were statistically significant increased in diabetic patients with central obesity compared to those without central obesity, in the total (p=0.011) and in men (p=0.014). In female diabetic patients, DD was not related to central obesity (p=0.489).

Our data support a strong association between type 2 diabetes and depression in Greek patients. A significant association between obesity and depression is also observed in type 2 diabetic patients. Increased BMI is strongly related to depressive type 2 diabetic women, while central obesity is more related to depressive type 2 diabetic men.